Notifications of enteric diseases in returning travellers who visit friends and relatives overseas: A call for action

This report examines the health risks of enteric diseases for travellers visiting friends and relatives in developing countries.

Page last updated: 30 September 2008

A print friendly PDF version is available from this Communicable Diseases Intelligence issue's table of contents.

Vicki G Slinko, Kari AJ Jarvinen, Frank H Beard, Bradley J McCall

The health risks of travelling to developing countries are generally well appreciated in the Australian community. With the increasing frequency of global travel, travel medicine is acknowledged as an essential aspect of health services and travellers medical clinics in large cities assist overseas travellers with their health requirements.

A common purpose for overseas travel by foreign-born Australian residents and their children is ‘visiting friends and relatives’ (VFR), usually in their country of origin. It has been noted in other developed countries1–5 that these travellers account for a disproportionate amount of illness from malaria, hepatitis A and typhoid on return to their country of residence. A study in New South Wales identified VFR travel as a risk factor for hepatitis A.6 Considerable clinical and public health resources are required to control these introduced communicable diseases. However, the prevention of these illnesses in VFR travellers receives limited attention.

We recently examined case reports for notifications of hepatitis A, hepatitis E, typhoid and paratyphoid infections reported to the Brisbane Southside Population Health Unit (BSPHU) between 1 January 2006 and 3 April 2008. Cases where there was a clear record of visiting friends and relatives overseas were categorised as ‘definite’ VFR travellers. In the absence of a clear record, cases with a history of at least one month’s stay in a country with plausible associations to the name of the case were categorised as ‘probable’ VFR travellers.

The number and proportion of cases notified to the BSPHU with a history of VFR travel are shown in the Table. At least one quarter of hepatitis A notifications and half of the enteric fever notifications were in VFR travellers.

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Table. Notifications of hepatitis A, hepatitis E, typhoid and paratyphoid infection associated with overseas travel and travellers visiting friends and relatives and reported to the Brisbane Southside Population Health Unit, 1 January 2006 to 3 April 2008

Number notified Overseas travel Overseas travellers visiting friends and relatives
n % of notifications n % of notifications
Hepatitis A
7 (+ 2 probable)
23 (29)
Hepatitis E
1 (+ 1 probable)
50 (100)
7 (+ 2 probable)
58 (75)
3 (+ 1 probable)
38 (50)

When staying with friends or relatives, VFR travellers may adopt the living conditions of the local community; their diet will be dictated by local circumstances, they are more likely to drink untreated water, spend time in crowded conditions and in markets, have sexual contact with local residents and use local medical and dental services.2

It is possible that VFR travellers may be less likely to seek out and adhere to travel recommendations. Their health care provider may incorrectly assume that VFR travellers are aware of travel related health issues. Australian-born children of VFR travellers may be particularly vulnerable to vaccine preventable diseases such as hepatitis A7,8 while visiting their parent’s country of origin if the family do not seek pre-travel advice.

Travel health care should be accessible and culturally appropriate and language barriers may need to be addressed. Travel medicine is an important component of primary care with the health care provider requiring access to appropriate and up-to-date resources. Then, the message for these primary care providers is that travel related health recommendations apply to all travellers regardless of their ethnic origins or presumed immunity. The new edition of The Australian Immunisation Handbook9 emphasises this message. Vaccination and health education must be combined to ensure adequate protection for VFR and other travellers.

Multicultural organisations and councils could also be engaged to enhance communication with VFR travellers about the need to protect their health when travelling overseas and how to access appropriate medical services before departure. Travel health messages of this nature could be incorporated into existing health services and programs for people from culturally and linguistically diverse backgrounds.

However, challenges for communicable disease control will remain while there is a disproportionate amount of communicable disease in developing countries and increased global population movement. In the meantime, efforts should be made to improve awareness of the health issues for VFR travellers amongst primary care providers and the multicultural community.

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Dr Christine Selvey, Communicable Diseases Branch, Queensland Health

Author details

Dr Vicki G Slinko, Public Health Registrar1

Dr Kari AJ Jarvinen, Public Health Medical Officer1

Dr Frank H Beard, Senior Medical Officer2

Dr Bradley J McCall, Public Health Medical Officer1

1. Brisbane Southside Population Health Unit, Queensland Health

2. Communicable Diseases Branch, Queensland Health

Corresponding author: Dr Vicki Slinko, Public Health Registrar, Brisbane Southside Population Health Unit, PO Box 333, ARCHERFIELD, QLD 4108. Telephone: +61 7 3000 9128. Facsimile: +617 3000 9130. Email: Vicki_Slinko AT

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1. Fulford M, Keystone JS. Health risks associated with visiting friends and relatives in developing countries. Curr Infect Dis Rep 2005;7:48–53.

2. Angell SY, Cetron MS. Health disparities among travelers visiting friends and relatives abroad. Ann Intern Med 2005;142:67–72.

3. Ackers ML, Puhr ND, Tauxe RV, Mintz ED. Laboratory-based surveillance of Salmonella serotype Typhi infections in the United States: antimicrobial resistance on the rise. JAMA 2000;283:6668–6673.

4. Behrens RH, Collins M, Botto B, Heptonstall J. Risk for British travellers of acquiring hepatitis A. BMJ 1995;311:193.

5. Basnyat B, Maskey AP, Zimmerman MD, Murdoch DR. Enteric (typhoid) fever in travelers. Clin Infect Dis 2005;41:1467–1472.

6. Ward K, McAnulty J. Hepatitis A: who in NSW is most at risk of infection? N S W Public Health Bull 2008;19:32–35.

7. Yung A, Ruff T, Torresi J, Ledger K, O’Brien D. Manual of Travel Medicine: A Pre-travel Guide for Health Care Practitioners 2nd edn. Melbourne: IP Communications, 2004.

8. Fenner L, Weber R, Steffen R, Schalagenhauf P. Imported infectious disease and purpose of travel, Switzerland. Emerg Infect Dis 2007;13:217–222.

9. Australian Technical Advisory Group on Immunisation, Australian Government Department of Health and Ageing. The Australian Immunisation Handbook 9th edn. Canberra: Australian Government Department of Health and Ageing and the National Health and Medical Research Council, 2008.

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This issue - Vol 32 No 3, September 2008