What do we mean by those 'Visiting Friends and Relatives' (VFRs)?

This is a large group of travellers that sometimes need special advice

They may be temporally living in a foreign country for study, research work, short-term employment or expatriates returning to their country of origin for short visits to visit friends and relatives.

On return, the traveller may encounter different or unexpected climate changes, infection risks and environmental hazards to which they have become unaccustomed while abroad. They may also travel to other areas en route that they have not been to previously, such as Saudi Arabia for a pilgrimage.

Descendants of those who have migrated earlier.

These travellers may obtain their travel advice from their parents or grandparents based on when they were living there. It may now be out of date or inappropriate for those who have not grown up in the country being visited and gained some immunity to infections such as hepatitis A and typhoid.

They may also experience cultural and environmental adaptation problems similar to those who have no historical connection with the countries they are visiting.

Often a false distinction is made between 'immigrants' (those who have migrated to live and work in countries) and 'expatriates' (those from the UK or similar countries who have migrated to live and work abroad).

Arriving to visit relatives in the Indian subcontinent

The term `Visiting Friends or Relatives' is sometimes used to refer only to those travelling to resource-poor countries, in particular, those in Central and South-East Asia or Africa.

  • Many studies among these groups are usually based only on recorded numbers of infections, such as malaria and typhoid, diagnosed in the laboratory after being brought back into their traveller's home country

  • These infections most common in travellers, including 'VFR's, who did not consider or think it necessary to seek advice on how to prevent these infections before departure.

Some other travellers may not immediately be thought of as being in the VFR category but can experience similar problems, for example:

Those from eastern European countries returning for home visits where infections such as HIV infection. hepatitis A and tick-borne encephalitis, for example, are more common in these regions.

Those going from Europe to countries in the Southern Hemisphere such as Australia or South Africa (and vice-versa). They may unexpectedly arrive during an influenza outbreak because in the country they are visiting it is winter (the influenza season) while in their home country it is summer.

Why is it important to identify those in the VFR category?

They may be leaving a country where they are familiar with their surroundings, living in excellent accommodation, receive regular weather forecasts, be aware of infection risks and know good 'public health and safety' practices are in place.

  • They think they are familiar with the health risks since they lived there in the past, but these have changed.

  • Their day-to-day lifestyle and precautions taken against illnesses may have changed.

  • Their susceptibility to illness may have changed, which might include their general health and immune status (see below) .

  • Advice may have been sought in advance from friends and relatives which is inappropriate and this can lead to a false sense of security. .

How should health advisors respond?

They need to be aware that some of those visiting friends or relatives only seek advice when they find they need a vaccination certificate to enter the country they are visiting. The consultation is an opportunity to discuss some of the other risks they might encounter.

  • Advice on infections, climate differences or road accidents, for example, will be the same as for any other groups of travellers.

In the excitement of the visit, the need to remain aware of infection risks, now unfamiliar, may not be considered. These travellers may also have lost immunity, which they had gained previously due to repeated exposure in their country of origin.

  • This means reminding them that as well as considering vaccines and chemoprophylaxis, personal lifestyle changes may be necessary (see also mini-courses 4 and 5).

Advisors should also bear in mind, when children are travelling, that visits abroad are sometimes undertaken for female genital mutilation (see mini-course 2 for further advice)

Environmental issues

Accommodation, food, water and living conditions when staying with relatives may be predictable and easily supervised.

  • However VRFs are likely to venture elsewhere and also travel overland to and from airports involving overnight stays. When away from the security of staying with the relatives, care over food and water hygiene can become confusing and other measures to avoid infections, for example against mosquito bites, be forgotten.

  • There is likely to have been a substantial increase in traffic on the roads with corresponding dangers and an increase in accidents. Official road safety regulations may not be followed, even more so than in the traveller's home country.