Visiting Friends And Relatives Istm Donegal 29.08.09

Visiting friends and relativesVisiting friends and relativesDr Peter Dr Peter NooneNoone, ISTM Donegal,29, ISTM Donegal,29thth

August 2009August 2009

Presenter

Presentation Notes

Visual flight rules Honda VFR and of course Valley free radio in the States�

What the future holds?What the future holds?

•

Many of the infectious disease challenges that face Ireland are determined by international factors,

•

National approaches to ID in low incidence countries is complex,

•

What information do we need to guide practice and target health needs,

•

Opportunities presented.

Factors Factors Push Factors•

Not enough jobs •

Few opportunities •

"Primitive" conditions •

Desertification •

Famine/drought •

Political fear/persecution •

Poor medical care •

Loss of wealth •

Natural Disasters •

Death threats •

Slavery •

Pollution •

Poor housing •

Landlords •

Bullying •

Poor chances of finding courtship

Pull Factors•

Job opportunities •

Better living conditions •

Political and/or religious freedom •

Enjoyment •

Education •

Better medical care •

Security •

Family links •

Industry •

Better chances of finding courtship

Evolution of Migration Flows, 1960 Evolution of Migration Flows, 1960 -- 20052005

Source: United Nations - Trends in Total Migrant Stock, http://esa.un.org/migration

Net Migration Rates 2008Net Migration Rates 2008

Net migration rates

for 2008: positive (blue), negative (orange), stable (green), and no data (grey).

http://en.wikipedia.org/wiki/Net_migration_rate

Av number of annual migrants Av number of annual migrants 20002000--20052005

UN Pop division, World Bank, IMF , http://www.nytimes.com/ref/world/20070622_CAPEVERDE_GRAPHIC.html#

Presenter

Presentation Notes

Nearly 190 million people, about three percent of the world’s population, lived outside their country of birth in 2005. A look at the flow of people around the globe. Circle are proportional to the number of people. Small 250k, larger 1 million.

The territory size shows the number of The territory size shows the number of international immigrantsinternational immigrants that live there. that live there.

World mapper, www.sasi.group.shef.ac.uk/

Presenter

Presentation Notes

Three percent of the world population in 2000 were born in a territory different to where they now live: one hundred and seventy-four million people have moved to a new territory. The United States receives the highest number of international immigrants (people born in another territory and no longer resident there), however Andorra has highest proportion of immigrants living within its borders. Four out of every five people in Andorra are international immigrants. In the Philippines and Guyana, territories experiencing some of the lowest immigration, only one person in every 500 is an international immigrant.

Territory size shows the relative levels of Territory size shows the relative levels of net net immigrationimmigration (immigration less emigration).(immigration less emigration).

Social and Spatial Inequalities Group www.sasi.group.shef.ac.uk/

Presenter

Presentation Notes

Richer territories tend to experience net immigration (greater immigration than emigration). Just under half of the 200 territories mapped currently experience net immigration. Those territories with net emigration (greater emigration than immigration) have size zero on this map. Regions experiencing the highest net immigration are North America, Western Europe and the Middle East. Together these three regions account for 79.5% of world net immigration. The United States alone receives 37.1% of the world net total. The Social and Spatial Inequalities Group aims to conduct interdisciplinary research which contributes to an evidence base for policy development aimed at reducing social inequalities.

Territory size shows the relative quantity of Territory size shows the relative quantity of net net emigrationemigration in all territories (emigration less in all territories (emigration less

immigration).immigration).

Presenter

Presentation Notes

> 0.5 of the territories in the world are currently experiencing net emigration. More people are leaving them than are coming to them. Territories with net emigration generally are poorer than those with net immigration. Mexico is the country with the highest net emigration, with a net loss of 8.8 million people in 2000. Mexico is in North America, the region whose territories have the largest net immigration. The United State's high immigration rate is linked to Mexican emigration. Were the United States and Mexico combined to be one territory then this movement of people would not be recorded as immigration nor emigration.

Immigration, emigration and netImmigration, emigration and net--migration in Ireland, 1987 migration in Ireland, 1987 -- 20032003

Source: Central Statistics Office (CSO); Dublin

Presenter

Presentation Notes

2006

Mixing bowl Mixing bowl Western Europe's desirability as an immigrant destination is risWestern Europe's desirability as an immigrant destination is rising ing

while Latin America's draw is declining. while Latin America's draw is declining.

1870-71 1890-91 1910-11 2000-01

Europe

Germany 0.5 0.9 1.9 8.9

France 2.0 3.0 3.0 10.0

United Kingdom 0.5 0.7 0.9 4.3

Denmark 3.0 3.3 3.1 5.8

Norway 1.6 2.4 2.3 6.3

Sweden 0.3 0.5 0.9 11.3

New world

Australia 46.5 31.8 17.1 23.6

New Zealand 63.5 41.5 30.3 19.5

Canada 16.5 13.3 22.0 17.4

United States 14.4 14.7 14.7 11.1

Argentina 12.1 25.5 29.9 5.0

Brazil 3.9 2.5 7.31

Source: Williamson and Hatton, 2005.1Number of foreign nationals in 1900.

(share of foreign(share of foreign--born population in percent)born population in percent)

Definition:Definition:•

Asylum Seeker: is a person who has submitted an application for protection under the Geneva Convention and is awaiting for asylum to be decided by Minister for Justice, Equality and Law Reform,

•

Refugee: 1951 UN Convention relating to refugees, ‘a person who has a well-bounded fear of prosecution for reasons of race, religion, nationality, membership of a particular social group or political opinion; is outside the country they belong or normally reside in; and is unable or unwilling to return home for fear of persecution.http://www.ria.gov.ie/coming_to_ireland_as_an_asylum_seeker/

Presenter

Presentation Notes

The law governing refugees and the processing of claims for refugee status in Ireland is set out in the Refugee Act, 1996 as amended by section 11(1) of the Immigration Act, 1999, by s.9 of the Illegal Immigrants (Trafficking) Act, 2000, by s.7 of the Immigration Act, 2003 and in the Orders, Regulations and Directions made under that Act. A Programme Refugee is defined in s. 24 of the Refugee Act, 1996 (as amended) as “a person to whom leave to enter and remain in the State for temporary protection or resettlement as part of a group of persons has been given by the Government and whose name is entered in a register established and maintained by the Minister for Foreign Affairs, whether or not such a person is a refugee within the meaning of the definition of 'refugee' in s.2.” These are persons who are invited to Ireland by the Government usually in response to a humanitarian crisis and at the request of the UN High Commissioner for Refugees. In general, they have the same rights as Convention refugees.

International statusInternational status•

Exceptional leave to remain, replaced on 1.04.03:–

Humanitarian protection, awarded to those refused refugee status. Cannot return to country of origin as face serious risk to life or person because of the death penalty, unlawful killing, torture, inhuman

or

degrading treatment or punishment. After 3 yrs can apply ILR.

–

Discretionary leave, awarded where refused refugee status and not fill criteria for HP above, but other reasons exist.

–

White list countries (s.94 of Nationality, Immigration & Asylum Act 2002), application from these countries clearly unfounded unless

specific evidence to the contrary produced.

•

IMMIGRATION, RESIDENCE AND PROTECTION BILL 2008

Presenter

Presentation Notes

Indefinite leave to remain Illegal asylum seeker, no such thing, 1951 UN convention on refugees

VFRsVFRs

“Immigrants who are ethnically and/or racially distinct from the majority population of their country of residence and who return to their homeland to visit friends and/or relatives”

Centers for Disease Control and Prevention. Health information for international travel 2005–2006: the “yellow book.”

Philadelphia, PA: Elsevier, 2006.

VFRsVFRs

•

People who are travelling from higher- income country of residence to their

country of origin (low-income country).

•

May include children of foreign-born parents—

“second-generation”

immigrants

whose family originated in the country visited.

VFRsVFRs account for a account for a

disproportionate fraction of disproportionate fraction of

total travellers and diseasetotal travellers and disease

Does the VFR traveller have distinct Does the VFR traveller have distinct health risks?health risks?

•

Epidemiology

•

Risk exposure

•

Health care provided–

Use of travel health services,

–

Adherence to advice

Presenter

Presentation Notes

Is this a destination risk issue rather than the reason for travel determining the risk. There is evidence that VFRs are over-represented as travellers to SEA & SSA and the relative high proportion of dse prevalence In the group maybe reflection of greater exposure to and not increased likelihood of dse. Risk relate to their economic status, access/use of services, medical seeking behaviour, rather than travel assoc risk.

The travel pattern exposes VFR The travel pattern exposes VFR to higher health risk both to higher health risk both

qualitatively and quantitativelyqualitatively and quantitatively

UK travellersUK travellers

•

61.4 million visits abroad by UK residents in 2003, •

2/3 to destinations in the European Union (EU).

•

Visits to Indian sub-continent, and SSA/SA increased by 15% and 19% respectively,

•

UK residents primarily travelled for holidays,•

Since 1996, visits by VFRs

has increased on

average by nearly 8% each year, •

In 2003 VFR trips 2nd

most popular travel reason,

overtook business travel visits for the first time.

Visits abroad by UK residents 1996Visits abroad by UK residents 1996--20052005

VFR UK dataVFR UK data

•

Of all visits abroad made by UK residents in 2007, 18% (12,214,367) were for VFR travel and of those, a significant number travelled to countries with high prevalence of malaria, typhoid, paratyphoid, and hepatitis A.

VFRs as proportion of total travellers

•

In UK ethnic groups represent 6.7% of total population but 20% of total travellers,

•

Source: Behrens RH, Hospital Tropical Dse, London,

•

In U.S. immigrants constitute 20% of the total population but 40% of international travellers,

•

Source: US census bureau 2001: US Dept of commerce, 2003.

Characteristics of VFR travelCharacteristics of VFR travel

•

VFRs

and relatives experience excessive rates of travel- related morbidity and mortality.

•

No pre-travel care common-

patient and clinician barriers to

care, pre-existing health beliefs, incomplete childhood shots.

•

Travel patterns of VFRs

traveling to high-risk destinations.

•

Susceptibility to infectious and non-infectious illnesses

increased-

multiple preexisting medical problems & extremes

of age.

•

ID differ in etiology & severity from other travellers.

Disproportionate Risk IDs in Disproportionate Risk IDs in VFRsVFRs

•

Lack of awareness of risk •

<30% have a pre-travel health-care advice,

•

Financial barriers to pre-travel health care, •

Clinics are not geographically convenient,

•

Cultural and language barriers with providers, •

Lack of trust in the medical system,

•

Greater last-minute travel plans and longer trips, •

Travel to high-risk destinations, accommodation, local lifestyle, food and water precautions, bed nets…

•

Health beliefs “immune.”

↓

vacc

HAV, typhoid and use of malaria chemoprophylaxis v other travellers.

VFRVFR’’ss an Asian Airport Surveyan Asian Airport Survey

•

2101 respondents 419(19.9%) were VFRs.•

18.1% of VFRs

sought pretravel

advice, only

6.9% from TM specialist v 36.8% of tourists.•

None of VFRs

got Hep A, B or rabies vaccines

v 5.5%, 4.8% and 0.9% of tourist travellers respectively, (None had malaria prophylaxis).

•

VFRs

0.38 (95% CI 0.20-0.70) less likely to get pre-travel health advice than tourist travellers.

FC04.04 Wilder Smith A et al, VRS –an Asian Airport Survey, 10th

ISTM Vancouver 2007.

MalariaMalaria•

In 2006, >50% of imported malaria cases in U.S. civilians occurred among VFRs.

•

GeoSentinel, ISTM and CDC sentinel surveillance data, VFRs x 8 more likely to get malaria than tourist travellers.

•

UK data shows VFR travellers to West Africa x10 develop malaria than tourists.

•

The vast majority of malaria cases associated with VFR travel had not taken any (or appropriate) chemoprophylaxis.

•

Many VFRs assume they are “immune”; most VFRs, who left their countries of origin years ago, immunity waned and is no longer protective.

MalariaMalaria

•

In UK in 2007 the majority of VFR cases with falciparum

malaria were of Black African

ethnicity/descent and acquired infection in countries of their ethnic origin or descent (mainly Ghana, Nigeria, Uganda);

•

The majority of VFR cases with vivax

malaria were of ISC ethnicity and had acquired their infection in countries of their ethnic origin or descent (mainly India and Pakistan.

Travel-associated malaria, E&W, NI: 2007 (N=691)

UK MalariaUK Malaria

Malaria IrelandMalaria Ireland

Malaria IrelandMalaria Ireland•

The notified malaria cases ROI by 62% in 2005.

•

In 2007 country recorded for 54 cases, majority from SSA; a smaller number of cases from Asia and South America.

•

Reason for travel recorded for 53 cases. 72%(38/53) of these cases were VFRs

in 2007.

•

New entrants accounted for a further 6 cases.

•

Other travel reasons were holidays (n=5), business (n=1), armed services (n=1), other (n=2), not specified (n=18).

•

P.falciparum, ~70% of notified cases (n=50).

•

7 P. vivax, 5 ovale, 3 malariae and 6 not specified.

•HPSC http://www.hpsc.ie/hpsc/A- Z/Vectorborne/Malaria/Publications/AnnualReportsonMalaria/File,3476,en.pdf

Malaria ROIMalaria ROI

Other InfectionsOther Infections•

In the U.S, >75% of typhoid cases occur in VFRs, mostly from SEA and Latin America; 90% of paratyphoid A cases are imported from SEA as well. Steinberg E, et al Typhoid fever in travelers: who should we vaccinate?,AmSoc Trop Med Hyg: 2000;60.

•

VFR children <15 years of age are at highest risk of hepatitis A, and many are symptomatic. In a British study, most cases were acquired in South Asia. Behrens RH, et al, Risk for British travelers

of acquiring

hepatitis A [letter]. BMJ. 1995;311:193

•

TB annual incidence in Dutch Travellers 2.7-3.3% per person per yr v 0.01% in resident Dutch population, Coblens, Lancet 2000;356-461.

•

Other diseases, such as hepatitis B, cholera, and measles, occur more commonly in VFRs following travel.

Presenter

Presentation Notes

Typhoid cases ROI 2004-2007 respectively: 5, 5, 9, 9. Paratyphoid cases ROI 2004-2007 respectively: 4, 0, 1, 4.

TB USTB US

Presenter

Presentation Notes

TB cases are now concentrated in foreign born cases migrating to rich countries because of decrease in rates of TB in indigenous population. TB cases in migrants exceeded that in the indigenous population for the first time in 2002.

Hep AHep A

Laboratory reports of hepatitis A, England,Wales, and Northern Ireland: 1998 –

2007

Presenter

Presentation Notes

The total number of hepatitis A laboratory reports in E&W, and NI has decreased in recent years; travel-associated cases have also decreased in line with the total. In 1998, 131 (11% of the total) cases of hep A were reported to be associated with travel abroad compared to 21 (5%) in 2006 and 15 (4%) in 2007. It is not evident, whether this is a true decrease, as travel history reporting for hep A is incomplete,

VFR KidsVFR Kids•

US airport study 2005, travellers to India, (294/1302, 23% travelling with kids, 66% got pre-travel health advice, 57% received meds/vacc.

FC04.05 Graham et al, Are Travellers

with Kids better prepared, ISTM Vancouver 2007.

•

French prospective cohort study, n=374 kids<6yrs consulting over 4/12. Africa main destination, mean duration 42/7. Sorge

F et al, Children Morbidity-Prospective Controlled Cohort Study, FC04.06, ISTM Vancouver 2007,

–

Ill any cause RR 2.0–

RR fever =2.1 (95% CI=1.2-5.2),

–

Malaria incidence was 5% in those visiting endemic areas,–

Those aged 10-20mths increased morbidity 3 (1.2-7.6),

–

Travel rural area increased risk 2.7(1.3-5.5),–

Travel <45 days reduced risk child morbidity OR 0.3(0.14-0.6).

InfxnsInfxns in in VFRsVFRs

•

Cholera excess in VFRs, CDC 78% of 160 cases 1992-1994 occurred in VFRs. Mahon BE et al, Reported cholera in the U.S, 1992-1994: a reflection of global changes in cholera epidemiology. JAMA. 1996;276:307-312,

•

Meningococcal meningitis most cases in 15 countries in SSA meningitis belt, mainly in dry season. Hajj/Omra

pilgrimages

•

Weekly Epidemiologic Report. 2003;133:294-296. also Leake

JA et al Early detection and response to meningococcal disease epidemics in SSA: appraisal of the WHO strategy. Bull World Health Organ. 2002;80:342-349.

•

70,000 deaths due to rabies occur worldwide annually, the majority in SEA and ISC, almost 50% of deaths occur in children. World Health Organization fact sheet No. 99.

•

June 2001.

Presenter

Presentation Notes

For travel to the Hajj/Omra and is recommended for any traveler to sub-Saharan endemic areas during the dry season or during ongoing epidemics. It should be considered year round for VFRs due to their increased contact with local populations. In developing countries, 60% of animal bites occur in or around the home, increasing VFR risk. An animal wound, even a lick or scrape, should be extensively cleaned with soap and water. Immigrants visiting friends and relatives should avoid contact with dogs, cats, monkeys, bats, rodents, raccoons, and other animals, even if they do not seem to be behaving strangely or appear ill. Pre-exposure rabies vaccination should be a serious consideration in VFRs traveling for more than 30 days, especially children; however, vaccination cost is significant.

STDSTD’’ss

•

Surinamese and Antillean immigrants in Amsterdam, 47% of men and 11% of women travelling back home acquired a sexual partner, Kramer MA et al, Sex Transm

Infect. 2005 December; 81(6): 508–510. doi: 10.1136/sti.2004.014282.

•

SSA Africans living in London, 40% of men and 205 of women acquired a new sexual partner while travelling abroad. Fenton KA, et al, AIDS 2001;15:1442-5.

•

Men of 47% with local sexual partner, 36% had unprotected sex, assoc Surinamese origin OR 11, 1.72-104, Hx

STI OR

12.51, 3.75-46.95.•

Women, of 11% with local sexual partner, 50% unprotected sex, assoc with >1 partner in last 5 yrs, OR 13.57-250.2, Kramer MA et al, Sex Transm

Infect. 2005 December; 81(6): 508–510

Presenter

Presentation Notes

2/3rds (14077 of 21273) of heterosexually acquired HIV infections in Western Europe in 1979-2002 were in persons from ‘epidemic countries’. Hamers FF, Lancet 2004;364:83-94. Based on molecular Epidem study 0.5 of Surinamese and antillean HIV infected persons in the Netherlands had been infected during a homeland visit. (Op de Coul EML, et al AIDS 2001; 15:2277-86.)

UK DataUK Data•

For typhoid/paratyphoid, majority of VFR cases 2007 were ISC ethnicity (mainly India, Pakistan, and Bangladesh).

•

Factors for disproportionate burden of typhoid, paratyphoid, and malaria in VFRs

were not seeking

travel advice before their trip/not taking adequate prevention measures.

•

VFR cases of enteric fever less likely to have sought health advice before travel than non-VFR cases, particularly those non-UK born.

Travel-associated cases of enteric fever by reason for travel: 2007 (N=305)

Laboratory reports of Salmonella Typhi and Paratyphi,E&W, NI: 1998 – 2007

Travel Immunisation acceptanceTravel Immunisation acceptance

•

VFR’s

predominantly female and younger than business travellers,

•

Visit for longer,•

91% plan to stay with friends or relatives,

•

72% had an mean annual household income <$60k,

•

Lower acceptance rates of HAV, HBV, typhoid, Rabies, TdaP.

Diener

T, Abbas Z, Martin D, Travel Imms

Acceptance rates among VFRs

compared to business travellers and those travelling for work and study abroad, ISTM Vancouver.

Drogheda clinic experienceDrogheda clinic experience

Travel consult

Student

Pastor

Mature student

Lecturer

Labourer

IT Engineer

Infant

Houseperson

Fitter/Welder

Doctor

Child

Care assistant

Administrator

Accountantoc

cupa

tion

302520151050

Count

1

29

1

1

1

1

1

5

7

1

7

15

4

2

2

Fig 2. Occupations of VFR Travellers

3.85%5.13%

1.28%

11.54%

44.87%

5.13%

5.13%

5.13%

6.41%

11.54%

Togo

Saudi Arabia

Pakistan/Kuwait

Pakistan

Nigeria

Kenya

India

Ghana

Egypt

Dem Rep Congo

Destination

Fig 1. Destination of VFR Clinic Attendees, 2003-2006

Noone

P, Callaghan M, “Audit of needs of VFR Travellers attending an Irish travel medicine clinic”

British Travel Health Association Journal, May 2008; 11: 46-51. (presented as poster at NECTM, Helsinki, 22-24th May “08)

Drogheda experience 2003Drogheda experience 2003--20062006

•

VFRs

: 78/1470(5.3%) of all consultations, •

mean trip duration was 4.8 weeks (SD 2.9).

•

mean stay in Southern Africa was 4.5, v 5.6 weeks elsewhere. •

Consultations a mean 4.3 (SD 3.8) weeks before departure.

•

Malaria

prophylaxis was declined by 13% of VFRs. •

Hepatitis A and typhoid vaccines uptake was 97.2%, 91% respectively overall and 100%, 88% in children respectively.

•

3 VFRs

declined yellow fever vaccine. •

Rabies vaccine uptake was low at 2% overall.

•

12 (44%) VFRs

travelling home for over 30 days declined hepatitis B vaccine.

•

VFRs

cancelled/missed 26(25%) of appointments v 206(12.3%) appointments overall, OR 2.4(95% CI 1.5-3.8).

BarriersBarriers

•

Barriers to the delivery of preventive travel-related medical services exist at many levels, including;–

the systems level (low insurance coverage),

–

patient level (misperception of disease risk), and

–

provider level (inadequate knowledge of travel medicine).

RecommendationsRecommendations

•

Consideration to make malaria chemoprophylaxis more affordable to VFR family groups travelling to at-

risk areas, reducing financial barriers to protecting all family members.

•

Typhoid and hepatitis A vaccination should be offered free for travellers in most GP practices.

•

Advice such as bite prevention and food and water hygiene advice is available from the open-access NaTHNaC

or CDC website

ConclusionConclusion•

New strategies are needed to properly address the needs of VFR travellers.

•

Pre-travel services should be convenient, accessible, affordable, culturally sensitive, and if possible, located within existing services to immigrant populations.

•

Clinicians caring for VFRs

need to be knowledgeable about their travel-related risks and have access to regularly updated, detailed pre-

travel health information.

Documents

Visiting Friends And Relatives Istm Donegal 29.08.09