Travel case scenarios as a demonstration of risk assessment of VFR travelers: introduction to criteria and evidence-based definition and framework.

BACKGROUND: Travel-associated health risks need to be balanced against the positive opportunities associated with interregional travel. As the perceived and real spectrum of health risks related to international travel increase both quantitatively and qualitatively, the need for more discriminating tools in clinical assessment for the purpose of mitigation, public health management, and research are needed. One group of international travelers identified as having increased risk of poor travel-related health outcomes are those who travel with the specific intent of visiting friends or relatives (VFR travelers). Due to variations in defining VFR travel in the health context there are issues in applying this designation uniformly from multiple perspectives. This article supports the standardization of VFR traveler definitions based on objective criteria and provides illustrations of the application of this definition through an illustrated approach to risk assessment based on these criteria and the differentials in the determinants of health between source and destination regions. METHODS: A working group was established by the Migration Health Sub-committee, International Society for Travel Medicine to assess the literature on VFR travel and health, review an evidence-based approach to managing health risk related to travel, and to propose criteria-based definition for VFR travel. The new definition of a VFR is a traveler whose primary purpose of travel is to visit friends or relatives where there is a gradient of epidemiological risk between home and destination. RESULTS: A case scenario discussion of VFR travel defined by criteria and risk assessment based on differential determinants of health is presented in this article. DISCUSSION: The goal of this article is to encourage discussion on travel health evaluation for the most "at risk" populations and to standardize the application of clinical, public health, and research approaches to defining VFR travelers in a risk management context.

The visiting friends or relatives traveler in the 21st century: time for a new definition.

BACKGROUND: Travelers visiting friends or relatives (VFR travelers) are a group identified with an increased risk of travel-related illness. Changes in global mobility, travel patterns, and inter-regional travel led to reappraisal of the classic definition of the term VFR. METHODS: The peer-reviewed literature was accessed through electronic searchable sites (PubMed/Medline, ProMED, GeoSentinel, TropNetEurop, Eurosurveillance) using standard search strategies for the literature related to visiting friends/relatives, determinants of health, and travel. We reviewed the historic and current use of the definition of VFR traveler in the context of changes in population dynamics and mobility. RESULTS: The term "VFR" is used in different ways in the literature making it difficult to assess and compare clinical and research findings. The classic definition of VFR is no longer adequate in light of an increasingly dynamic and mobile world population. CONCLUSIONS: We propose broadening the definition of VFR travelers to include those whose primary purpose of travel is to visit friends or relatives and for whom there is a gradient of epidemiologic risk between home and destination, regardless of race, ethnicity, or administrative/legal status (eg, immigrant). The evolution and application of this proposed definition and an approach to risk assessment for VFR travelers are discussed.

Population mobility, globalization, and antimicrobial drug resistance.

Population mobility is a main factor in globalization of public health threats and risks, specifically distribution of antimicrobial drug-resistant organisms. Drug resistance is a major risk in healthcare settings and is emerging as a problem in community-acquired infections. Traditional health policy approaches have focused on diseases of global public health significance such as tuberculosis, yellow fever, and cholera; however, new diseases and resistant organisms challenge existing approaches. Clinical implications and health policy challenges associated with movement of persons across barriers permeable to products, pathogens, and toxins (e.g., geopolitical borders, patient care environments) are complex. Outcomes are complicated by high numbers of persons who move across disparate and diverse settings of disease threat and risk. Existing policies and processes lack design and capacity to prevent or mitigate adverse health outcomes. We propose an approach to global public health risk management that integrates population factors with effective and timely application of policies and processes.

Online communication as a potential travel medicine research tool: analysis of messages posted on the TravelMed listserv.

BACKGROUND: Access to the Internet and electronic mail has created opportunities for online discussion that can facilitate medical education and clinical problem solving. Research into the use of these information technologies is increasing and the analysis of these tools can support and guide the activities of professional organizations, including educational endeavors. OBJECTIVE: The initial objective was to analyze patterns of information exchange on the International Society of Travel Medicine's (ISTM) travel health electronic mailing list related to a specific area of society interest. Secondary objectives included the analysis of listserv use in relation to subscriber demographics and rates of participation to support travel health educational activities. METHODS: This study examined the use of the ISTM TravelMed listserv over an 8-month period from January 1, 2006, to July 31, 2006. Descriptive data analysis included TravelMed user demographics, the type of posting, the topic and frequency of postings, and the source of information provided. RESULTS: During the study period, 911 (47%) of the eligible ISTM members subscribed to the TravelMed listserv. About 369 of these subscribers posted 1,710 individual messages. About 1,506 (88%) postings were educational; 207 (12%) postings were administrative. A total of 389 (26%) of the educational postings were primary queries and 1,120 (74%) were responses, with a mean string length of 2.9 responses per query (range: 1-51). Twenty participants contributed 40% of the educational postings. The topics with the most frequent postings were vaccines and vaccine-preventable diseases (473/31%) and malaria (258/17%). Postings focused on special populations, including pregnant women or immigrants, comprised a total of 14 postings (<1%). CONCLUSIONS: During the study period, a limited number of ISTM members (19%) authored postings on the listserv. Regular discussion centered on a limited number of recurring topics. The analysis provides several opportunities for the support of educational initiatives, clinical problem solving, and program evaluation.

Syphilis in immigrants and the Canadian immigration medical examination.

BACKGROUND: Immigrants to Canada must undergo screening for syphilis. This study presents the results of syphilis screening from 2000 to 2004 and describes its impact on Canadian syphilis reporting and epidemiology. The study identifies migrant groups at risk of syphilis disease. METHODS: All permanent resident applicants 15 years of age or older; younger individuals who have syphilis risk factors, and long-term temporary resident applicants are required to have non-treponemal syphilis screening done. Reactive results were confirmed. Immigration-related syphilis screening results were analyzed for year, migrant origin, migrant age and classification. RESULTS: A total of 2,209 individuals were found with positive syphilis serology from the screening of 2,001,417 applicants. The sex ratio of positive cases was M:F = 1.4. Rates per 100,000 applicants were: refugees 286, refugee claimants 267, family class 187, temporary residents 85, and economic class 63. Age and geographic distribution reflected sexual transmission, known international prevalence, and the Canadian processes of immigration. CONCLUSIONS: Certain immigration class applicants from syphilis high-prevalence source countries are a significant source of syphilis notifications in Canada. Identifiable populations and the immigration application medical processes represent global public health policy and program opportunities at the national level.

Arrest and detention in international travellers.

Systematic published reviews of national arrests of travellers abroad are rare. The pattern of arrest during international travel has implications for travellers and those involved in providing traveller services. There are also consequences for travellers who are arrested and detained abroad. The Consular Affairs Bureau, Foreign Affairs Canada assists Canadian civilians who are abroad. Beginning in 1995 the Consular Management and Operations System was used to track notifications of Canadian arrests abroad. This database was designed for the demographics, destinations, and reported causes of Canadians arrested abroad for 1996-2004. In this period, there were 6514 notifications of arrested Canadians abroad; 1024 (16%) females and 5490 (84%) males with an average age of 33.3 and 36.4 years, respectively. Recorded reasons for arrest were for females: drugs: 420 (41% of females arrested), violence: 75 (7%), other criminal acts: 198 (19%), immigration: 169 (17%), other minor causes: 20 (2%); and for males: drugs: 1554 (28% of males arrested), violence: 581 (11%), other criminal acts: 1468 (27%), immigration: 1056 (20%), other minor causes: 105 (1.9%); or the cause was not recorded for 142 women and 747 men. The USA was the most common host country for arrested Canadians. Alleged drug offences, other criminal activities, and immigration reasons were the most common cited reasons for arrest. Country of arrest reflected the pattern of Canadian international travel for recreation, business, and ancestral linkages. There are a wide-range of potential physical and mental health outcomes to arrest and imprisonment abroad that may be different in foreign jurisdictions due to language, culture, judicial processes and penalties imposed. The prison environment may also pose significant health risks.

Health and foreign policy: influences of migration and population mobility.

International interest in the relationship between globalization and health is growing, and this relationship is increasingly figuring in foreign policy discussions. Although many globalizing processes are known to affect health, migration stands out as an integral part of globalization, and links between migration and health are well documented. Numerous historical interconnections exist between population mobility and global public health, but since the 1990s new attention to emerging and re-emerging infectious diseases has promoted discussion of this topic. The containment of global disease threats is a major concern, and significant international efforts have received funding to fight infectious diseases such as malaria, tuberculosis and HIV/AIDS (human immunodeficiency virus/acquired immune deficiency syndrome). Migration and population mobility play a role in each of these public health challenges. The growing interest in population mobility's health-related influences is giving rise to new foreign policy initiatives to address the international determinants of health within the context of migration. As a result, meeting health challenges through international cooperation and collaboration has now become an important foreign policy component in many countries. However, although some national and regional projects address health and migration, an integrated and globally focused approach is lacking. As migration and population mobility are increasingly important determinants of health, these issues will require greater policy attention at the multilateral level.

Death and international travel--the Canadian experience: 1996 to 2004.

BACKGROUND: Death during international travel concerns several levels of the travel industry. In addition to the immediate effects for the traveler, their family and friends, the nature of travel-related mortality has important implications for pretravel health advisors and providers of medical care services. METHODS: The Consular Affairs Bureau, Foreign Affairs Canada provides information and assistance to Canadian civilians abroad. Beginning in 1995, the Consular Management and Operations System tracked Canadian deaths abroad notifications. The annual data for 1996 to 2004 was extracted for sex, age, and cause of death by location for all reports received. RESULTS: There were 2,410 reported deaths in Canadians abroad; reported sex was 32% female and 68% male, average age of 61.7 and 60.4 years, respectively. Recorded causes of death: natural (1,762), accidental (450), suicide (92), and murder (106). Country of death reflected the pattern of Canadian international travel for recreation, business, and ancestral linkages. Average age of natural death (66 years) distinguished it from all other causes of death: accidental (45), suicide (41), and murder (43). CONCLUSION: Natural causes and suicide deaths may be anticipated or planned to occur abroad. The risk of death may be mitigated through personal knowledge and medical assessment and prevention strategies. Deaths due to vaccine-preventable diseases, exotic and infectious diseases were rare in this population. Consular services may be able to provide various types of support. Local laws and customs, as well as international regulations in health and quarantine govern other responsibilities such as funeral services and repatriation of the deceased to Canada.

The basic principles of migration health: population mobility and gaps in disease prevalence.

Currently, migrants and other mobile individuals, such as migrant workers and asylum seekers, are an expanding global population of growing social, demographic and political importance. Disparities often exist between a migrant population's place of origin and its destination, particularly with relation to health determinants. The effects of those disparities can be observed at both individual and population levels. Migration across health and disease disparities influences the epidemiology of certain diseases globally and in nations receiving migrants. While specific disease-based outcomes may vary between migrant group and location, general epidemiological principles may be applied to any situation where numbers of individuals move between differences in disease prevalence. Traditionally, migration health activities have been designed for national application and lack an integrated international perspective. Present and future health challenges related to migration may be more effectively addressed through collaborative global undertakings. This paper reviews the epidemiological relationships resulting from health disparities bridged by migration and describes the growing role of migration and population mobility in global disease epidemiology. The implications for national and international health policy and program planning are presented.

Emerging pediatric HIV epidemic related to migration.

In 2002, Canada introduced routine, mandatory HIV antibody screening for all residency applicants, including selected children. We report screening results from January 2002 to February 2005. Thirty-six pediatric HIV cases were detected (14/100,000 applicants); 94% of infected children were eligible to arrive in Canada. Thirty-two of the affected children were from Africa, and maternal infection was the main risk factor. Only 4 (11%) of the children had received antiretroviral therapy. In countries of low HIV incidence, migration-related imported infection in children may be an emerging epidemic. The early identification of HIV-infected immigrant women permits intervention to prevent mother-to-child HIV transmission. Routine HIV testing as a component of the medical examination of immigrants has national and international health policy and programmatic implications.

Evaluation of yellow fever vaccination centers in Canada.

BACKGROUND: Health Canada regulates the designation of yellow fever vaccination centers (YFVCs) in Canada to ensure a national standard in the safe, effective, and appropriate use of yellow fever vaccine for Canadian travelers. The process for the designation of YFVC has evolved over the years, particularly with the development and implementation of specific criteria for designation. Standardized site visits in 1999 to 2001 demonstrated that noncompliance with the criteria jeopardized the objectives of the federal program. METHODS: A pilot evaluation questionnaire was developed and tested in seven YFVCs. The results provided the data necessary to appropriately adapt the questionnaire for on-site evaluations. The final questionnaire captured graded data on professional training, reference sources, services provided, and physical facilities and supplies. A minimum of 60% was needed to pass the evaluation. The YFVCs were given individual feedback on their results and the opportunity to comply with standards. RESULTS: During the period of 2000 to 2001, 183 YFVCs were in operation in Canada. A random sample of 69 YFVCs were visited and evaluated for compliance to the circulated criteria. Fifty-two (75%) of the YFVCs received satisfactory results (range 70% and higher), and specific remedial recommendations were made to 8 (12%) clinics with a borderline result (range 60-69%). Nine (13%) of the YFVCs failed (range 0-59%) the evaluation, with consequences ranging from notification of the infractions in writing to decertification. CONCLUSIONS: Although a majority of YFVCs met the evaluation criteria, a significant percentage (25%) of unsatisfactory and borderline compliance with Health Canada's criteria for designation of YFVCs means that there is a need for greater clarity and communication of the criteria and inspections for designated centers. To ensure that previously designated YFVCs and centers seeking designation consistently fulfill all the requirements, Health Canada is developing new methodologies of evaluation. The authors anticipate that all new and existing YFVCs will fully comply with the objective and specific criteria for designation.

Globalization of infectious diseases: the impact of migration.

With up to 2% of the world's population living outside of their country of birth, the potential impact of population mobility on health and on use of health services of migrant host nations is increasing in its importance. The drivers of mobility, the process of the international movement, and the back-and-forth transitioning between differential risk environments has significance for the management of infectious diseases in migrant receiving areas. The management issues are broad, high-level, and cross-cutting, including policy decisions on managing the migration process for skilled-labor requirements, population demographic and biometric characteristics, and family reunification; to program issues encompassing health care professional education, training, and maintenance of competence; communication of global events of public health significance; development of management guidelines, particularly for nonendemic diseases; access to diagnostic and therapeutic interventions for exotic or rare clinical presentations; and monitoring of health service use and health outcomes in both the migrant and local populations.

Bioterrorism - Health emergency preparedness and response.

Health emergency planning for preparedness and response against acts of terrorism, including the malfeasant threat or actual release of biological agents designed to harm others, has assumed a higher level of concern for most western nations, including Canada, following the explosive attacks in the United States on September 11, 2001. These terrorist attacks were followed by an outbreak of anthrax infections. The Bacillus anthracis spores in these attacks were dispersed by using regular postal services in the United States. In addition to the unsettling sense of social vulnerability that resulted from these attacks, a greater appreciation that the integration of public health, emergency health and social services with security activities was required to fully address the need to protect the health and other interests of the citizens. Collaborative work among regional, provincial, territorial, federal and international authorities within these domains is emerging as an effective response to the risk management of bioterrorism. The following is a brief description of the health framework for preparedness and response, and the biological agents of major concern in terrorism.

Health of displaced Albanian Kosovars in the former Yugoslav Republic of Macedonia: fitness to travel and health outcomes assessment.

INTRODUCTION: During the 1999 conflict in Kosovo, an estimated 850,000 people were displaced from Kosovo. Many thousands of these people arrived in the Former Yugoslav Republic of Macedonia (FYROM), for whom a humanitarian evacuation programme (HEP) was conducted by the United Nations High Commissioner for Refugees (UNHCR) and the International Organization for Migration (IOM). More than 91,000 people were moved to third countries under this programme. METHODS: A health assessment tool was designed, validated, and implemented to document the health status of the refugees prior to departure. The IOM evaluated 41,652 pre-travel "fitness to travel" medical assessments for refugees transported by the Organization. A colour coding system for fitness-to-travel was used to clearly identify refugees to the receiving health authorities according to their health condition at the time of departure. RESULTS: A total of 41,652 fitness-to-travel assessments were performed between 05 April and 25 June 1999, and were entered into a database. There were 21,923 females and 19,566 males. The average age was 25.3 years (women, 26 years; men, 24.3 years). Of these assessments, 4,647 (11.2%) individuals who were deemed fit-to-travel required medical assessment at the host destination, and of those 1,204 required urgent care. The majority of health complaints were acute respiratory tract infections and hypertension. CONCLUSIONS: A rapid and efficient system for fitness-to-travel was created to assist in the management of health issues related to the urgent and mass movement of refugees. The collected health information was of use to health-care planners during the crisis and for those responsible for the health-care of newly arrived refugees. The lessons learned have implications for future similar operations and for the development of research and education programs for both the refugees and the host recipient nations.