UNIQUE MANAGEMENT ISSUES PERTAINING TO IMMIGRANTS AND EXPATRIATES
IMMIGRANTS:
International migrants make up 2.3 % of the world's population and contribute significantly to population growth in the developing world (e.g. 88% of European growth from 1990-1995). When immigrants travel, they often travel back to their countries of origin which are often tropical countries in the developing world. The term VFR refers to this group who are "Visiting Friends and Relatives" in other parts of the world. There may be unique travel risks for travellers in this group for the following reasons:
(1) They may underestimate risks, or think they are "immune".
(2) Increased exposure to food and water borne diseases.
(3) Increased exposure to vector borne disease.
(4) Financial and cultural barriers to obtaining pre travel advice/ prophylaxis.
(5) Decreased compliance with prophylaxis.
(6) Trips are often at short notice, for special occasions (weddings, funerals).
Food and water borne disease - Immigrants may return home to countries where there is non-potable water and higher risk of diseases such as Hepatitis A, E, typhoid, dysentery, parasites.
Hepatitis A - older immigrants may be immune to Hepatitis A, but younger immigrants and their children will be non-immune.
Typhoid - up to 77% of typhoid cases are reported in VFR's (26% are under 10 years old). High risk areas include India (50 % of cases), Mexico (10%) and Philippines (5%). Previous infection does not convey immunity.
Strategies -Educate VFR's that they are not necessarily "immune" .
-Need to boil water, milk.
-Food and water handouts (consider different language versions).
-Ensure Hepatitis A immunity (check HAV antibody or vaccinate).
-Typhoid vaccine.
-Educate about Hepatitis E/ special risk for pregnant females.
-Discuss follow up for severe diarrheas/ avoids.
Other Infections -
Varicella - chickenpox is less common in some countries (e.g. Asia), therefore some immigrants may be non-immune.
Meningitis - meningococcal meningitis is higher risk for those visiting subSaharan Africa (West, East and Central) during the winter months, (December - June) particularly if they visit with indigenous people. Some risk may also exist for travellers to India, Nepal, and Mongolia.
Tuberculosis - Immigrants are usually screened for TB. Long trips home to their countries of origin may expose them to TB, particularly where there is co-existing HIV and TB.
Strategies -Check immunity to Varicella/ offer vaccine to non immune.
-Offer quadrivalent meningitis vaccine to those at risk.
-Discuss TB skin testing for those at risk.
Blood Borne Diseases (STI's) - Immigrants are not routinely screened for these. (e.g.,Canada screens immigrants for TB, Syphilis and, since Jan.02, for HIV). Hepatitis B is not routinely screened for, therefore many immigrants are not aware of their status.
Hepatitis B - 350 million are chronically infected worldwide. Countries with 8 -10% carrier rates include sub Saharan Africa, lots of Asia, the Pacific, Amazon, and southern parts of East and Central Europe. 5% carrier rates exist in the Middle East and India.
Hepatitis C - 170 million are infected worldwide. 11% of Egypt's population has antibodies. Hepatitis C is endemic in Africa, South America and Asia.
HIV - High risk in many parts of Africa, Asia, the Indian sub continent .
Strategies -Educate re: sexual transmission/ safe sex.
-Educate re: avoidance of blood borne diseases.
-Prescreen for Hepatitis B status (previous infection, carriers, immune), and offer vaccination for non immune. Ensure that kids who missed school immunization programs are offered Hepatitis B vaccine.
Parasitic Diseases - Schistosomiasis (parasite transmitted by wading in fresh water), Loiasis (parasite transmitted by flies), Echinococcosis (tapeworm transmitted by contact with dogs), Leishmaniasis (parasite transmitted by sandflies), and Trypanosomiasis (parasite transmitted by tsetse flies) are a few of the parasites transmitted in developing countries.
Strategies- remind travellers and their children to avoid fresh water swimming, contact with local flies, and with local animals.
4 Important Vector Borne Diseases -
Japanese B Encephalitis - transmitted during the rainy season in areas where there are rice fields and pig farms, in South East Asia. JBE may be a risk for immigrants returning home to rural farming areas of SEA.
Dengue - transmitted in urban, tropical settings. May be a particular risk for those previously infected with dengue (increased risk of dengue hemorrhagic fever, DHF).
Malaria - Immigrants (especially elders) often believe they are immune to malaria. They may be partially immune, but this is usually lost 6 -12 months after leaving the malarial country. Return trips home to their countries of origin may involve prolonged travel to rural areas and villages, with their kids. High risk areas include West, East and Central Africa where falciparum malaria is common. Lack of protection from mosquitoes and noncompliance with malaria prophylaxis make fatal malaria more likely.
Yellow Fever - transmitted in tropical South America and West and East Africa. Can be a risk for both rural and urban travellers. Immigrants may not know vaccine status.
Strategies -Encourage compliance with personal protection measures against mosquitoes (e.g., DEET, screens, bed nets, skin protection).
-Assess need for initial vaccination or boosters for JBE.
-Educate re: risk of falciparum malaria and loss of immunity to malaria.
-Give handouts in other languages.
-Encourage compliance with antimalarials, for all family members.
Offer Yellow Fever vaccine for those at risk.
Miscellaneous Risks - include trauma and rabies.
Trauma - particularly motor vehicle accidents, remain high risk in countries where seat belts, lights and regulations may be missing.
Rabies - is high risk in places such as West Africa, South America and India. Children are vulnerable due to proximity to animals, and inability to report injury. Many developing countries do not have access to rabies immunoglobulin or adequate rabies vaccine.
Strategies - Use safe transport and avoid night travel on roads.
Monitor kids, and ensure that all suspicious animal bites are followed up with good quality rabies post exposure treatment (RIG and rabies vaccine).
High Risk Immigrant Groups:
(1) Kids
(2) Elderly
(3) Chronic Disease
(4) Pilgrims
(5) Pregnant
(1)Kids: -Encourage routine and travel specific immunizations.
-Update immunizations if going for a prolonged visit.
-Educate re: diarrhea treatment and follow up.
-Avoid unnecessary injections, exposure to blood borne diseases.
-Avoid contact with animals, especially dogs.
-Use personal protection measures against mosquitoes.
-Advise parents re: 1st.aid kit.
(2)Elderly: -Influenza and pneumonia shots in addition to travel shots.
-Compliance with antimalarial.
-Access to care if problems.
-Use translator or family member to explain travel risks .
(3)Chronic Disease:
-Encourage assessment with GP +/- specialist before departure.
-Take medications in hand luggage.
-Pros and cons of medications purchased locally.
-Ensure no drug interactions with antimalarials.
-Access to medical care, dialysis etc.
(4)Pilgrims: -Avoid heat exposure and trauma (risks for Hajji in Mecca)
-Update routine/encourage travel vaccines.
-Encourage influenza and pneumonia vaccination if at risk.
-They require specific vaccinations for visas (meningitis).
(5)Pregnancy: - Educate re:risk of malaria during pregnancy.
-Discuss optimal malaria prophylaxis.
-Lack of screening/ follow up for those travelling at short notice.
-Encourage initial ultrasound prior to travel.
-Access to care if complications (bleeding, early labour).
-Ensure vaccination where applicable.
-Risk of Hepatitis E in pregnancy (up to 25% mortality rate).
EXPATRIATES:
Expatriates are people who take up residence overseas . They then become an "expatriate" in their new country of residence. Those at highest risk are expat's such as CUSO, VSO, Peace Corps, and missionaries who work in remote areas,
(1) Pre departure issues.
(2) In country health issues.
(3) Return health assessment.
(1). Pre departure issues -
Psychosocial issues: -
-relocation of home and family to a new country.
-changes in work, climate, food, economics, politics.
-costs of relocation are large ($250 - 500,000 for a major family relocation).
-the ability to adjust to the new country may be more difficult for some individuals, and may require considerable flexibility.
-counselling re:culture shock should be made available to families
Health issues: -
-pre departure medical often required by companies.
-pre existing health problems should be identified.
-pre screening has medical/ legal implications. Repatriation is very expensive.
-regular screening should be maintained (e.g., paps, mammography, colonoscopy).
-mental health screening should check for psychiatric disorders, drug and alcohol use.
-dental care important.
-visual check, renew glasses.
-travel medicine assessment should determine vaccine status and specific health risks in new country. Very important for remote, tropical sites.
-ensure adequate supplies of medication , including medication needed for malaria prophylaxis and any antibiotics required. Drugs purchased overseas may be sub standard.
-pre screening tests may be required (TB,HIV)
In Country Health Issues:
Environment:
-water quality, exposure to toxins, pollutants.
-food hygiene (need to wash/use iodine/other)
-air quality (e.g.,Kathmandu high risk for asthma/airways).
-trauma is cause of 20-25% of travel-related deaths.
Kids:
-behavioural changes common during adjustment phase.
-need to maintain immunization schedules.
-safety issues, motor vehicles, local animals.
-need to decide if they attend local school or home school.
Diarrhea:
-average 2-3 episodes annually.
-immunity improves over a year.
-need to recognize severe diarrhea (dysentery,toxigenic bacteria)
-self treatment options (quinolones or other) and when to get help
-reassure that looser bowels may be the norm
-parasitic infections found in longer stays (20 mos.)
Malaria:
-risk of falciparum malaria must be clear.
-high risk for certain occupations (night work, rural areas)
-local laboratories may not have adequate diagnostic facilities.
-long term use of anti malarial medication often required but problematic re:compliance, safety and cost, in chloroquine resistant zones. Doxycycline commonly used (cost $194/year). Mefloquine has been used for up to 8 years (cost $330/year). Malarone tends to be used for shorter intervals (cost $178/month) -few studies to fully document safety of long term use of these medications.
-high risk malaria countries tend to use different combinations to deal with prophylaxis and treatment failures.
-medication compliance drops off with time.
-personal protection against mosquito bites should be emphasized. Malaria mosquitoes often active from 2200-0400 in places like Africa.
-self treatment for malaria available but reserved for specific situations where site very remote or malaria prophylaxis cannot be used.
Pregnancy:
-access to regular screening and testing may be limited.
-risk of Hepatitis E (25 % mortality rate)
-malaria risk must be weighed against risk of malaria medication (no teratogenicity to date with mefloquine in first trimester)
-need to plan optimal site for delivery.
-adequate insurance to cover medical evacuation
Rabies:
-need to be aware of high risk areas and which animals transmit rabies.
-counselling to avoid contact with rabid animal
-expatriates.especially kids, are higher risk
-need to know initial wound care/ wash well
-know how to access good post exposure treatment (rabies immunoglobulin and tissue culture rabies vaccine)
-pre exposure vaccination if remote from medical help
Psychological Issues:
-culture shock can last 6 -12 months and involves various phases.
-moving overseas may not "fix" problems
-alcohol and drug use can worsen situation (28% of Medevac's in USA foreign service)
-risk-taking behaviour may occur
-repatriation/reverse culture shock can be more severe
Insurance:
-adequate to cover repatriation, medical evacuation
-regular health coverage may not cover routine visits
-may need to maintain coverage at home
Availability of Care
-may need to research adequate health care providers
-chronic disease monitoring may be difficult (diabetes, anticoagulation, medication)
-use of Internet resources, IAMAT, other contacts with colleagues to link with appropriate. professionals
Tuberculosis:
-annual risk of infection estimated to be 1% in developing countries.
Parasitic Infections:
-expats should be familiar with the transmission of local parasites
-avoid direct fresh water contact (e.g., 48% seroprevalence of schistosomiasis in Malawi expats after 4 years)
-avoid bare feet/ contact with soil
-avoid contact with vectors such as flies, mosquitoes, bugs.
HIV and Blood Borne Diseases:
-HIV rates exceed 20% in many African countries and certain parts of Asia.
-HIV prophylaxis medications are available but costly.
-emphasize importance of avoiding unnecessary injections, transfusions and other contact with blood and intimate body fluids.
-emphasize safe sex or abstinence.
-Hepatitis B recommended for all expats taking up long term residence overseas.
Return Health Assessment:
Expatriates should have some screening on returning home, directed toward known risk exposures.
-TB skin test,
-serology for blood borne disease if at risk
-screening for sexually transmitted infections
-stools for O & P, C & S if symptomatic
-serology for schistosomiasis if exposed
-referral to ID specialist/fever, significant symptoms
-fever = malaria until proven otherwise.
Psychological adjustment can be difficult for some. Job changes may occur
Submitted by Dr. Caroline Penn,
Travel Medicine and Vaccination Centre, Vancouver, B.C.
604-681-5656.