visiting friends and relatives tourism

Visiting friends and relatives (VFR) is BIG. Here’s why

Visiting friends and relatives, often referred to as VFR, is one of the most prominent types of tourism . Whether you are a tourism management student or a tourism industry entrepreneur, it is important that you understand this vital sector of the tourism industry .

In this article, I will tell you what is meant by the term ‘visiting friends and relatives’ (VFR) and where the term came from. I will also tell you a bit about the reasons why people might travel to visit friends and relatives and how this industry has grown in recent years. Lastly, I will give you some examples of where and how VFR might occur in a global context.

What is visiting friends and relatives (VFR)?

Is vfr tourism, where did the term vfr come from, changing patterns of visiting friends and relatives, globalisation, growing expat population, freedom of movement, desire to travel, degrowth in vfr, examples of vfr, to conclude: visiting friends and relatives (vfr).

Visiting friends and relatives is a term that we hear thrown around frequently within the tourism industry. And, to be frank- it’s actually not difficult to understand.

Essentially, VFR is the movement of a person away from the place in which they live to a place where a family member or friend lives. Within the context of tourism, it is a prerequisite that said visit is far enough away from the person’s home and lasts a long enough duration that it can be classified as ‘tourism’.

Does visiting my grandma for afternoon tea at her home in the next village count as tourism?

What about if I travel to Spain to stay with my dad for two weeks in the summer holidays?

Well, whilst it may seem pretty obvious (the first is not tourism and the second is), there is no hard and fast rule that says when VFR is and isn’t tourism.

If you have read some of my other posts, such as A Definition of Tourism , you will notice that this is a recurring theme in the tourism literature. It is all too common that the boundaries are blurred and that the grey areas leave the door open for subjectivity and ambiguity.

How do Governments measure VFR? How can we compare VFR industries across different parts of the world? The answer- who knows and, well- no.

Visiting friends and relatives (VFR) is a concept that was defined by tourism industry stakeholders in order to better understand this sector of the tourism industry.

Segmentation of this type enabled travel industry researchers and academics to study the relationship between VFR travellers and aspects such as economic and social impacts of tourism .

By having a better understanding of the VFR sector, tourism businesses could be better informed to plan their operations. So, for example, hotels could better understand what facilities guests might be seeking and tourist attractions can understand what provisions may be needed for these types of tourists .

The notion of visiting friends and family, or VFR, has changed significantly over the years.

Migration patterns have changed a lot- think back to the advent of the slave trade compared to todays economic migration- I am a prime example of this with out move from the UK to China .

Over the years travel has become easier, more affordable and more convenient. It is easy to hop on a budget airline flight to fly across Europe for a couple of days. Whilst it takes a bit longer, it is also perfectly reasonable to travel to the other side of the world to visit friends and family for a few weeks.

Other factors that have influenced the growth of VFR includes increased urbanisation of areas, the building of more airports and transport infrastructure and globalisation .

Reasons for the growth in visiting friends and relatives (VFR)

There are several different reasons for the growth in the visiting friends and relatives market around the world. This includes globalisation, a growing expat population , migration, freedom of movement, education and the desire to travel.

I will further explain each of these below.

Globalisation is the notion that we are all becoming more alike, or more ‘global’. Globalisation is increasingly present in almost every aspect of the world that we live in. From English schools in Taiwan, to smart phones in Ethiopia to fajitas in Australia , the world is becoming more and more connected and more and more alike.

Globalisation is bringing people together- we can communicate more easily and understand each other better than before. But globalisation is also increasing distance between us. People who would never have considered a move to, say Japan, are not relocating across the globe for better financial benefits, knowing that they can still get many of their home comforts.

Many business are opening up offices, headquarters and factories around the world and workforces are distributed all over the globe. This means that there is more business travel than ever before.

The corporate world has, in many regards, become a multinational industry. This has meant that there has been an increase in people moving to live overseas around the world. In the UAE, for example, less than 12% of people who live there are Emirates, meaning that the expat population makes up more than 88%! Wow!

Naturally, expats will want to travel to visit their friends and families from time to time, and their friends and families are likely to want to visit them too. This is a clear example of VFR.

People have chosen to migrate from place to place throughout the history of tourism .

Over the years migration patterns have changed. Sometimes people migrate for safety reasons, such as war and political instability. Other times people choose to migrate for economic reasons, usually because the country that they are travelling to offers a better financial situation. And some people choose to migrate for other reasons such as the culture , the weather or the social aspects of a destination.

Popular migration origins, whereby people have opted to migrate the UK throughout the past couple of decades include; India , Pakistan, Jamaica, Nigeria and Poland.

People who have migrated out of the UK in recent years have typically chosen to relocate to the USA, Australia, New Zealand, Spain, Singapore and Hong Kong.

People who migrate will often return to their country of origin to visit their friends and relatives. Likewise, their friends and relatives will often travel to visit them.

Having the freedom to travel to different places has inevitably impacted the VFR industry.

This is most evident in Europe, where the EU four freedoms has resulted in years of uninterrupted travel within the union. A decade or so ago there was a significant influx of people with passports from Eastern European countries moving to the UK. This was as a result of the economic opportunities available to in the UK compared to their home countries.

Education has also become increasingly globalised. Where I live, in Hangzhou, China , people pay a lot of money to send their children to international schools, where they are prepped to attend university in the UK or America. This is common practice in many parts of the world.

VFR amongst students and their families is a significant part of the visiting friends and relatives sector.

Lastly, the most dominant reason for an increase in VFR is the desire to travel.

People nowadays want to see more of the world than ever before. People want to experience new cultures and do things that may not be possible in their home areas (i.e. sunbathing on the beach or skiing on a mountain).

Increased desire to travel has resulted in more people moving overseas, embarking on expatriate lifestyles and travelling for VFR purposes.

Whilst there has been a clear upwards trend in visiting friends and relatives around the world for many years, this was thwarted by the COVID-19 pandemic. During this time irreversible societal changes occurred including a growth in the shut in economy and technological advancements in telecommunication.

It is likely that many areas will never be the same again. The elderly, who were once averse to using smart devices with significant technological capabilities, have now mastered the use of FaceTime. Group get togethers on Zoom are now commonplace. Microsoft Teams is now the most used classroom around the world.

It is likely that some of these areas will remain popular and may even continue to grow in the future. While there will always be a place for visiting grandma in Scotland and attending a work conference in Budapest, these will likely be less popular now that the world has adapted to using modern technologies that overcome the barriers of distance.

Here are some examples of situations whereby a person might travel for VFR purposes:

• Visiting an aunty who moved to Canada ten years ago
• Going to stay with an old school friend who lives in Portugal
• Meeting your spouses family who live in Ghana
• Travelling to Thailand to attend a family wedding
• Going to visit your son at university in California
• Travelling to Dubai to visit your best friend who moved there for work last year
• Spending a month in Australia with your grandchildren who were born down under
• Taking a short trip to Romania to visit your sick relative
• Returning to your university town for a reunion event

Hopefully now you understand what is meant by the term VFR and you understand why it is such an important part of the tourism industry. As you can see, there are many different situations whereby a person may choose to travel for VFR, from attending a school reunion to visiting your grandma. If you found this interesting, why not follow me on social media? Links at the top of the page!

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Visiting Friends or Relatives

People who travel from their country of residence (a high-income country) and return to his or her home country (low- or middle-income country) to visit friends or relatives are called VFR travelers. VFR travelers may have different experiences from tourists because they usually stay for a longer period of time, eat local food, and interact with people in the local community. These activities can put VFR travelers at higher risk for certain diseases. If you are planning VFR travel, follow CDC’s steps below to stay safe and healthy.

Before Travel

Even if you traveled to another country to visit your friends or relatives in the past, there may be vaccines, medicines or other health precautions you need to take for your next trip. Take the following steps to prepare for your trip.

Check CDC’s destination pages for travel health information . Check CDC’s webpage for your destination to see what vaccines or medicines you may need and what diseases or health risks are a concern at your destination.

Make sure you are up to date on all of your routine vaccines . Routine vaccinations protect you from infectious diseases such as measles that can spread quickly in groups of unvaccinated people. Many diseases prevented by routine vaccination are not common in the United States but are still common in other countries.

Make an appointment with your healthcare provider or a travel health specialist  that takes place at least one month before you leave. They can help you get destination-specific vaccines, medicines, and information. Discussing your health concerns, itinerary, and planned activities with your provider allows them to give more specific advice and recommendations.

Common Diseases and Illness among VFR Travelers

Many VFR travelers assume they are immune to malaria if they were born or lived a long time in a country with malaria, but immunity can decrease after a person moves away. In some instances, VFR travelers have died of malaria after they returned to the United States.

If you are traveling to a country with malaria, talk with your health care provider about malaria prevention medication. Because you need to start taking malaria pills before you leave the United States, do not wait until you are in the country to purchase malaria medication. Visit CDC’s Malaria webpage for more information..

Take recommended medicines as directed. If your doctor prescribes medicine for you, take the medicine as directed before, during, and after travel. Counterfeit drugs are common in some countries, so only take medicine that you bring from home and make sure to pack enough for the duration of your trip, plus extra in case of travel delays. Learn more about traveling abroad with medicine .

Foodborne and diarrheal illness

Heading Home Healthy

VFR travelers may be more likely to get foodborne and diarrheal illnesses because of the places they visit and foods they eat. Generally, food that is cooked and served hot is safe to eat, and beverages from sealed containers are safe to drink. Avoid food served at room temperature, raw fruits, or raw vegetables (unless they can be peeled), tap water, and ice made from tap water. Wash your hands with soap and water. If soap and water are not available, use hand sanitizer containing at least 60% alcohol. See CDC’s webpage Choosing Safe Food and Drinks While Traveling for more information.

Hepatitis A and Typhoid fever

Some illnesses that often spread through contaminated food or drinks, such as hepatitis A and typhoid, can be prevented by vaccination. Ask your health care provider about getting vaccinated before traveling.

Waterborne Illnesses

VFR travelers may be exposed to contaminated or unclean water. When this water is used for drinking, cooking, washing food, preparing drinks, making ice, or brushing teeth, it can make you sick with diarrhea, vomiting, and stomach pain. When you swim or wade in this water, you can become ill. Learn how to avoid contaminated water during travel .

After Travel

If you traveled and feel sick, particularly if you have a fever, talk to a healthcare provider and tell them about any areas you recently traveled to. 

If you need medical care abroad, see Getting Health Care During Travel .

More Information

• Visiting Friends or Relatives in CDC Yellow Book
• Malaria in CDC Disease Directory
• Food and Water Precautions in CDC Yellow Book
• Water Disinfection in CDC Yellow Book

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Article Contents

Evolution of the term “vfr travel”, changing patterns of population mobility, redefining “vfr” travel, determinants of health and the vfr traveler, application of these concepts by travel medicine professionals, public health officials, and researchers, conclusions, acknowledgments, declaration of interests.

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The Visiting Friends or Relatives Traveler in the 21st Century: Time for a New Definition

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Elizabeth D. Barnett, Douglas W. MacPherson, William M. Stauffer, Louis Loutan, Christoph F. Hatz, Alberto Matteelli, Ron H. Behrens, The Visiting Friends or Relatives Traveler in the 21st Century: Time for a New Definition, Journal of Travel Medicine , Volume 17, Issue 3, 1 May 2010, Pages 163–170, https://doi.org/10.1111/j.1708-8305.2010.00411.x

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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.

A primary goal of pretravel consultation is assessment of risk of travel‐related illness or injury to provide individualized advice about reducing these risks. Purpose of travel has emerged as one key factor influencing health risk during travel. Over the past decade, a specific group of travelers, those intending to visit friends or relatives (VFR travelers), has been identified with increased risk of travel‐related morbidity.

Several publications have focused on VFR travelers, addressing risk assessment, health disparities, barriers to care, and general travel medicine considerations. 1 , – 4 Subsequent studies have assessed specific travel‐related illnesses in VFR travelers. Fenner et al. 5 found VFR travelers to be at increased risk of malaria, viral hepatitis, human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) and sexually transmitted infections compared with tourists and business travelers to the same destination. 5 A review of travelers seen at GeoSentinel sites (a global surveillance network devoted to examining travel‐related health problems) 6 found a greater proportion of serious and potentially preventable travel‐related illness in travelers who were identified as “immigrants” and selected “visiting friends or relatives” as their main purpose of travel compared with “nonimmigrants” whose purpose of travel was to visit friends or relatives. The authors of this study commented on lack of a standard definition for VFR travelers. 7 Lack of a standard definition for VFR travel in the existing literature makes it difficult to compare data and to generalize advice about travel‐related health risks and recommendations from one group of VFR travelers to another.

The purpose of this article was to address the development and evolution of the concept of VFR travel by reviewing how the term “VFR traveler” has been used in the past, to discuss why existing definitions may no longer meet the needs of a changing population of travelers, and to propose a definition of VFR traveler that reflects the current state of population dynamics and global travel and incorporates modern concepts of risk assessment and management. How this framework can be used by clinicians in a pretravel encounter, by public health officials in developing policies and programs focused on reducing travel‐related health risks, and by researchers in developing a research agenda for VFR travel that would inform the clinical and public health practice of travel medicine will be discussed.

The peer‐reviewed literature was accessed through electronic searchable sites such as PubMed/Medline, ProMED, GeoSentinel, TropNetEurop, Eurosurveillance, using standard search strategies for the literature related to visiting friends/relatives, determinants of health, and travel. In addition, public access reports from international and national organizations and agencies were accessed for information on VFR migrants and health. Organizations and agencies included: The World Health Organization, Centers for Disease Control and Prevention (Atlanta, USA), European Centers for Disease Control and Prevention, the Health Protection Agency (UK), and others. An expert panel, convened with the support of the International Society for Travel Medicine, reviewed all results and participated in the preparation of this report. As this report involved no contact with patients or individuals or personal medical information, research ethics approval was not sought.

Travel for the purpose of visiting friends or relatives (VFR travel) is a concept first defined by the travel and tourism industry and included travelers whose main purpose of travel was family‐related, and were therefore distinct from tourist, business, or long‐term travelers such as missionaries or other volunteers. The term was used in reference to both domestic and international travel for the purpose of gathering economic data about different types of travelers and did not have specific health connotations. 8 , 9 Travel industry research focused on the relationship between VFR travelers and potential economic impact and opportunities in tourism markets. 10 Travel medicine experts noted that they were observing a traveler who appeared to be at higher risk for morbidity and mortality and was distinct from more traditional travelers such as tourists, students, backpackers, or business travelers. The travel medicine field adopted the term VFR and applied it to this population of travelers. A number of assumptions were made when using the term VFR traveler in the health context. 11 The “classic” VFR traveler criteria typically included: ethnicity of the traveler different from the host country population but similar to the destination population, intended purpose of travel to visit friends or relatives, and the destination representing a higher prevalence risk of specific tropical infectious diseases (eg, malaria).

A typical VFR traveler could be described as follows: A 30‐year‐old Nigerian man who immigrated to the United States at age 20 traveling to Nigeria to visit his parents in the village where he had been born and raised. This scenario captures the characteristics felt to be central to the “classic” definition of a VFR: an immigrant returning to his country of origin for a visit with friends or relatives who is racially or ethnically distinct from the majority population in his adopted country, moving from a higher income country with low tropical disease prevalence to a lower income country with higher risk of these diseases, and who is also experiencing living conditions more similar to the local population than that of a typical tourist or business traveler. The shortfall in the use of the classic definition of VFR traveler in an increasingly mobile world is that the underlying assumptions of what constitutes a VFR traveler no longer apply to a large number of travelers who may have risks of travel‐related illness which are similar to those experienced by the classic VFR traveler. What may have been a useful framework in the past may no longer apply to 21st century patterns of global travel and population mobility. An early indication of the inadequacy of this definition was the introduction of qualifiers to the term VFR. “Immigrant VFR” was introduced to distinguish the foreign‐born traveler from the child or non‐foreign‐born spouse of this immigrant traveler (“traveler VFR”), though both might travel to the same destination with the purpose of visiting friends or relatives. 7 Other authors chose terms such as immigrant traveler, migrant traveler, ethnic traveler, and semi‐immune traveler. It became apparent that the increased number of terms and the different ways in which they were applied was leading to increasing difficulty in drawing conclusions or developing recommendations that could be applied to the population of “VFR travelers.” 12

Changing global travel and migration patterns have provided additional impetus for reappraisal of the term VFR traveler. International tourist arrivals have increased from 150 million in 1970 to 900 million in 2007 and are expected to reach 1.6 billion by 2020. 13 More than half (an increase of 400 million arrivals) of this increase occurred in the 13 years since 1994, when the term VFR was used first by the travel industry (compared with the increase of 350 million arrivals in the previous 24 years between 1970 and 1994). Although travel arrivals to Europe remain highest in magnitude, travel to East Asia and the Pacific, South Asia, the Middle East, and Africa will experience the greatest rate of growth, with lower rates of growth being seen for arrivals to Europe and the Americas. Other changes in global mobility patterns include increased urbanization, leading to disparities in health risks between rural and urban areas of the same country or region, and increased intra‐regional migration, such as within Asia between countries with similar socioeconomic status but variation in other epidemiologic health risks. 14

Changes in global migration patterns and infectious disease epidemiology present challenges to the classic definition of VFR in the following ways: travel to some destinations may not be associated with the magnitude of increased risk of tropical diseases that has been present in the past (eg, decreased rates of malaria transmission in central urban areas of sub‐Saharan Africa 15 , 16 ); noninfectious risks of travel are being recognized and described in more detail (eg, trauma, road accidents, and air quality) 17–19 ; individuals with remote connections to their country/region of birth (second‐ or third‐generation immigrants) may be returning to explore their roots, staying with distant relatives; spouses, and children, not originally from the destination, may be accompanying a “classic” VFR traveler to his/her home; immigrants may travel for primary reasons other than visiting friends or relatives; and racial/ethnic distinction alone is not a sufficient factor on which to base increased health risk during travel (eg, leading to expressions of implicit bias and stereotyping by clinicians, researchers, and policy makers).

Several scenarios can be envisioned that highlight the challenges of VFR definition in the current era. These include:

A 23‐year‐old Canadian‐born white woman travels to India to be married to her Canadian‐born fiancé who is of Indian descent.

A 40‐year‐old man who works in the mines in South Africa returns to rural Botswana to spend the holidays with his family.

A 45‐year‐old businessman based in Singapore travels to Dubai to visit his family but will stay in a hotel as he will be conducting business while there.

An 18‐year‐old US‐born male of Vietnamese descent travels to Hanoi to visit distant relatives; he will get around the city on a motorbike.

An 8‐year‐old UK‐born Nigerian boy travels to Nigeria to go to boarding school in a town where he has no relatives or family friends.

In each of these scenarios, application of the “classic” VFR definition may not capture the complexity of travel‐related health risks for the individual traveler. A revised framework and definition of VFR travel that can embrace changes in global migration patterns, the increased variation in purpose of travel, and assessment of changing and variable epidemiologic travel health risks, is required. We therefore propose a revised definition of VFR travel with two components:

the intended purpose of travel is to visit friends or relatives; and

there is an epidemiologic gradient of health risk between the two locations supported by an assessment of health determinants.

The intent to visit friends or relatives at the travel destination is fundamental to the new framework. Connection with the local population is related to multiple aspects of the travel experience such as duration of travel, type of accommodation, mode of travel at the destination, exposure to food and water, intimate exposures, and access to social support systems including health care. These factors affect health of travelers to different magnitudes, and are listed in Table 1 . Focusing on the primary goal of travel (visiting friends or relatives) rather than on characteristics of the traveler (ethnicity or immigration status) provides a more useful foundation for travel consultation based on assessment of individual travel‐related health risks.

Factors that may influence the health of travelers (by strength of evidence)

Strong evidence = observational studies or stronger research design that includes comparative group of nontravelers or population data of comparative outcomes; weaker evidence = observational studies without comparative analysis.

The second part of the definition is the requirement for an epidemiological health risk gradient between home and destination. Classically, this has referred to increased risk for vector‐borne diseases (malaria, dengue, Japanese encephalitis, and chikungunya) or vaccine preventable diseases (hepatitis A, typhoid). The new framework encourages a broader view of health risks to include noninfectious risks such as accidents or injury, 20 air pollution, varying accommodations, extremes of climate, and high altitude. As travel patterns change, and there is more travel within regions and from known higher risk areas to lower risk ones, concepts must be broadened to include specific ways in which the risk gradient affects the traveler. For example, travelers from the Western parts of the United States to the Eastern United States may benefit from information about prevention of Lyme disease, travelers between the UK or Australia to the Americas and Europe might reduce their risk of road traffic accidents with some orientation to opposite side of the road driving, and residents of relatively crime free areas may benefit from counseling to avoid petty or violent crime when visiting large urban areas with increased crime. Conversely, the risk gradient may include travel from high‐ to low‐risk destinations for some health outcomes. For example, previous exposure to and therefore development of immunity to hepatitis A may decrease the risk of this disease to the VFR traveler. The link between the purpose of travel and risk gradients may work well in differentiating between travel‐related health risks of VFR travelers and those who travel for business, tourism, education, or employment, but it remains to be seen how well it will identify differences in outcomes for other purposes of travel, such as backpacking or humanitarian workers, and to what extent this is overlapping.

This proposed definition of a VFR traveler omits several of the characteristics that have been included in the previous definition. Specifically, it is not necessary to be an “immigrant” in the departure country to be a VFR traveler. The term “immigrant” has legal connotations as do other terms such as “refugee,”“alien,”“migrant,” and these administrative terms are used variably from country to country and even regionally within countries. An administrative or legal classification, when taken out of context, may have limited application to health determinants and risk of travel‐related health risks. Using administrative or legal class to predict health risk can lead to stereotyping and implicit assumptions about the patient/subjects/populations by the health care provider, researcher, or policy maker. These inaccurate assumptions about patients/subjects/populations may lead to provision of inappropriate clinical care and advice, introduce bias into study designs, and/or lead to inaccurately aimed public health interventions.

Children or spouses of foreign‐born individuals may face specific enhanced travel‐related health risks when they visit friends or relatives in a parent's or spouse's country of birth, and those who travel to visit friends or relatives may experience different health risks during travel than those risks which other types of travelers would experience in the same destination. The requirement to be an “immigrant,” or immigrant's child, has therefore been omitted from this framework. In addition, there is no ethnicity component; the traveler does not need to be ethnically distinct from the majority population of the departure country to be considered a VFR traveler. The movement away from this requirement refocuses the emphasis on assessment of travel‐related health risk rather than on characteristics of the traveler that may not be relevant to the specific risks he or she may face.

Removal of race or ethnicity from the definition of VFR is intended to bring scientific rigor to travel risk assessment. Race and ethnicity, when and where relevant to travel risk assessment, are more directly captured within the proposed VFR definition based on the intent of travel and the determinants of health. Both race and ethnicity are inter‐dependent variables within the broader concepts of socioeconomics, genetics and biology, behavior, and environmental assessment. Equally, immigrant status is an administrative classification that changes over time and varies by place and is not a direct or stable factor in assessing risk. There is a tendency in the literature for clinicians, researchers, and policy makers to assume “we all know who we are talking about” when using the term “immigrant.” This leads to poor scientific assumptions and conclusions that, in the end, limit generalization or comparison of populations (eg, is the “immigrant” population seen by my clinic the same as the one described in this article?). The change in the VFR definition is to address the limitations posed by confining the term VFR traveler only to travelers who are immigrants or who are ethnically distinct from the local population. We hope the new, more general definition, will encourage clinicians, researchers, and policy makers to define the population they are addressing in their methods, increasing the understanding of risk in specific populations and refining the literature. Furthermore, we hope the more general definition will encourage focusing on the determinants of health of individuals and populations and will decrease stereotyping and implicit bias currently evident in clinical practice and the literature.

Independent of the reason for travel, the epidemiological risk is another important determinant of health that contributes to travel‐related morbidity. These risks should be taken into account during every travel consultation and are not unique to VFR travelers ( Table 2 ). The determinants of health that are also relevant to the travel health assessment include: socioeconomic factors (of the individual as well as the destination country); genetics/biology (variable susceptibility to disease such as preexisting malaria immunity; presence of glucose‐6‐phosphatase deficiency [G6PD]); behavioral characteristics of the traveler and the destination population (perception of control over one's destiny, risk‐accepting/taking behaviors, health beliefs); and environmental factors (public safety and security, housing, exposure to extremes of climate). Some of these factors have been validated as clearly associated with increased risk, whereas others are less well defined, and may carry various weights for different travelers.

Health determinants affecting risk of morbidity in travelers

Assessment of epidemiologic risk gradients and integration of the determinants of health into the pretravel consultation involve obtaining detailed information from the traveler and as such are integral to the work of the travel medicine provider. The new definition for VFR traveler represents an accommodation to increasing diversity in the types of travelers and to changing patterns of global travel. In fact, this approach represents a shift to a more clinically relevant paradigm where risk assessment for travel‐related morbidity is accomplished for all travelers based solely on assessment of epidemiologic risk and evaluation of these risks based on the determinants of health described, rather than by using types of traveler as proxies for differing types of risk to be experienced. One might argue that the definition is so broad as to eliminate the ability to distinguish subgroups that are at significantly increased risk and therefore warrant specific interventions. The elimination of the requirement to be an immigrant or to be ethnically distinct from the local population may blur the distinction between groups of VFR travelers, such as identified by the GeoSentinel network in defining “immigrant” and “traveler” VFRs. At this time, the identification of the purpose of travel continues to provide useful information for the travel medicine professional. Individual clinicians, researchers, and policy makers may still be addressing subpopulations but rather than assuming all “immigrants” or ethnically based populations are the same, we hope the broader definition will encourage more precise language in defining these subpopulations, creating more equitable, comparable, and scientifically sound data and recommendations. The following sections outline ways in which the new definition for VFR travel can be used today by clinicians, public health officials, and researchers.

This approach to travel risk assessment will place greater onus on the practitioner, public health official, and researcher. Standardizing an approach to clinical risk assessment based on incomplete or inexact knowledge of risk will highlight areas of uncertainty that are inherent in travel. Critical decision‐making in the face of uncertainty will also mean greater engagement of the traveler in deciding how to manage his or her own risks (and may decrease expression of implicit bias by providers). Similarly, public health officials will be pressed to apply more rigorous science in policy deliberations and program design related to travel health risk management. The highest expectations in applying a stable and robust VFR definition may be on the travel health researcher in creating quality study design and evaluations that can be generalized and applied in the real world setting of clinical and public health practice. But having recognized these challenges for practitioners, public health, and researchers, the greatest challenge in the new definition may well be the empowerment for the VFR traveler and their acceptance of a role in managing the uncertainty related to future events occurring during travel.

Pretravel assessment of VFR travelers can be enhanced by addressing specific topics within the domains of the determinants of health listed in Table 2 . Clinicians can use this approach to identify specific gradients of risk for VFR travelers in multiple areas in addition to infectious diseases. A more nuanced approach is also possible for travelers who may appear very different but in fact have quite similar risk profiles, or who appear similar but in fact may have quite different risks.

Risk assessment within these additional domains also encourages increased attention to factors and outcomes other than infectious diseases, such as road traffic accidents, air pollution, personal safety, psychological and psychosocial issues, and exposures to extremes of climate or severe weather events. This framework for risk assessment can also be applied to urban‐rural migration within a country (such as moving from an urban area of Brazil into a yellow fever endemic area, or moving, in many countries, from a relatively safe rural area into a large urban area with risks of urban violence, poorer sanitation, and air pollution). As inter‐regional travel increases and classic travel risks move away from infectious disease risks to a broader concept of travel‐related health problems, 21 it will be necessary to explore in more depth the risk gradient for VFR travelers in these different domains.

Application of this framework for VFR travelers will be new to many clinicians, though most travel medicine practitioners are already familiar with the process of risk assessment that is used in the routine practice of travel medicine. To facilitate use of the new definition specific to VFR travelers, case scenarios have been developed that illustrate application of the definition. 22 These cases will assist clinicians in understanding the difficulties incurred when using legal status or ethnicity to determine risk. Over time, this framework should facilitate design of studies involving VFR travelers.

Public Health Officials

Global security and migration‐related illness are topics of increasing international importance. 23 , 24 Acknowledging the increased role of VFR travel and potential for transmission of infectious diseases has been seen with respect to influenza, HIV infection, tuberculosis, hepatitis A, dengue, chikungunya, malaria, and other infectious diseases. 25 , 26 Noninfectious causes of morbidity may include exposure to counterfeit or adulterated medications, 27 , 28 contaminated or poisonous foods (melamine‐contaminated dairy products), accidents, physical or sexual violence, and exposure to air pollution or high altitude. Examples of public health initiatives to address potentially travel‐related noninfectious disease issues include “Look Right” signs in the UK and education and efforts to improve air quality around the time of the Beijing 2008 Olympics. Other public health interventions at local levels that attempt to address VFR travel risks include thermo‐screening upon departure at airports, 29 , 30 and health screening of returned domestic servants in Singapore. 31

Researchers

It is particularly important to define terms and frames of reference that will allow formulation of research questions and robust study design. The revised definition can be used consistently with the study designer determining whether they wish to use even more specific inclusion and exclusion criteria that ultimately will determine the comparability and generalizability of the study populations. This will also allow testing of previous assumptions about VFR travelers and exploring relative importance of specific aspects of risk (length of time out of country, local versus hotel accommodation/food, health beliefs, risk of blood or body fluid exposure, access to care). This will be invaluable in providing quality data to guide the clinical encounter and to inform public health policy and program design and implementation that ensures that an evidence‐based approach to clinical and public services is available to practitioners and travelers.

A strong recommendation is made for the adoption, implementation, and evaluation of the proposed definition by the travel medicine community, including clinicians, researchers, and public health officials. The requirements for surveillance and research that addresses the risk of travel‐related illness in different groups of travelers, such the studies done by the GeoSentinel Network and TropNetEurop, will be aided by a more standard definition of VFR traveler. Within the framework of the definition, addressing the health risks in subgroups of VFR travelers, such as children of immigrants who are visiting their parents' country for the first time, business travelers who are also visiting friends or relatives, and individuals spending time staying with local families can then be examined.

Changes in global migration patterns and population demographics have prompted reappraisal of the concept of the VFR traveler. Some components of the classic definition no longer serve the purpose of defining a distinct group of travelers with enhanced risks of adverse health outcomes directly related to their travel. An approach to VFR travel focusing on intent of travel being to visit friends or relatives, and a gradient of epidemiological health risks between the home and travel destination is proposed. Evaluation of health risk based on individual and population determinants of health characteristic provides both a current and dynamic view of risk management.

Clinicians are encouraged to identify those who travel for the expressed intent of visiting friends or relatives as being a group for which a defined framework for risk assessment can be applied. This requires an evaluation of the health determinants as an indicator of risk related to travel. Public health officials will find this construct helpful in informing policies and designing and implementing programs to reduce travel‐related health problems on a population basis. Researchers in travel health will benefit from use of a standardized population‐based framework for research design and implementation. Using defined and comparable population‐based health determinants, researchers can study specific disease risks and outcomes relevant to the health of VFR travelers.

There is certainly a requirement to validate this framework. An integrated approach between clinicians, public health officials, and researchers to test these hypotheses and provide data‐driven recommendations for prevention of travel‐related illness in well‐defined groups of VFR travelers will be instrumental in advancing the field of travel medicine.

The authors acknowledge with great appreciation Ms Brenda Bagwell (Administrative Director, ISTM) and the International Society of Travel Medicine who provided generous logistical, financial, and organizational support for working group meetings resulting in this article. Brian Gushulak and Rogelio Lopez‐Velez provided valuable input.

The opinions expressed here are solely those of the authors and do not necessarily reflect the position of any government, agency, university, society, or other body to which they may be currently or in the past affiliated.

R. H. B. received support from the UCLH/UCL Department of Health's NIHR Biomedical Research Centers funding scheme. The other authors state they have no conflicts of interest to declare.

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Visiting Friends and Relatives, Tourism

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• Natan Uriely 3  

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The visiting friends and relatives (VFR) tourism is defined as “a form of travel that is about being co-present with significant ‘faces’, being their guests, receiving their hospitality and perhaps enjoying their knowledge of local culture” (Larsen et al. 2007 : 247). VFR tourists were largely ignored in research until the mid-1990s, mainly due to the common perception that they made little contribution to the commercial tourism and hospitality industry. Nevertheless, the economic importance of this segment has been clearly demonstrated in the past two decades by numerous studies that focus on consumer motivations, activities, and expenditures (Shani 2013 ). These contributions suggest that VFR is a legitimate segment with significant relevance to destinations as well as to the hospitality sector.

The growth and proliferation of VFR tourism has also received the attention of geographers and sociologists who are tuned to the decreasing distinctiveness of contemporary tourism from other...

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King, B. 1994 What is Ethnic Tourism? An Australian Perspective. Tourism Management 15:173-176.

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Larsen, J., J. Urry, and K. Axhausen 2007 Networks and Tourism: Mobile Social Life. Annals of Tourism Research 34:244-262.

Shani, A. 2013 The VFR Experience: “Home” away from Home? Current Issues in Tourism 16:1-15.

Uriely, N. 2010 “Home” and “away” in VFR Tourism. Annals of Tourism Research 37:857-860.

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Uriely, N. (2014). Visiting Friends and Relatives, Tourism. In: Jafari, J., Xiao, H. (eds) Encyclopedia of Tourism. Springer, Cham. https://doi.org/10.1007/978-3-319-01669-6_398-1

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Visiting friends and relatives tourism and implications for community capital

2013, Journal of Policy Research in Tourism, Leisure and Events

Visiting friends and relatives (VFR) tourism accounts for a substantial amount of worldwide travel, yet has received comparatively little attention regarding its impacts on sustainability. This paper provides an initial discussion that situates VFR tourism within a discussion on sustainable tourism development. The community capitals framework is used as a basis for the discussion. A review of academic literature on VFR and sustainable tourism provides the foundations for this paper. Due to the personal relationships inherent in VFR there are significant consequences regarding the social impacts of VFR tourism. Additionally, the economic implications of VFR tourism include a more stable demand, greater dispersal of spending, and engagement of residents as consumers. The ability of communities to absorb VFR tourism relative to other forms of tourism has positive indications for the cultural and environmental aspects of community development. As debates within the more recent literature consider the opportunities and possibilities for mass tourism to become more sustainable, this paper suggests that VFR could reasonably be considered a sustainable form of tourism and offers destinations a viable strategy for sustainable tourism development.

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This contribution suggests that community-based tourism (CBT) can create commercial and social value to destinations, local businesses as well as to residents. At the same time, it clarifies that CBT offers rich, immersive cultural experiences that can enhance the tourists' experiences when visiting different communities. It posits that sustainable CBT approaches can improve the local economic development (LED) of communities by reducing economic leakages from the tourism industry. It explains that there is scope for destination managers and tourism businesses to engage in sustainable tourism practices and to utilize local resources, in a strategic manner, in order to maximize linkages in their economy. In conclusion, this paper puts forward a theoretical model that clearly illustrates the business case to implement sustainable CBT strategies. It also implies that these strategies can ultimately result in opportunities for economic growth of tourism businesses and may increase the competitiveness of destinations, while safeguarding the environment and addressing their carrying capacities.

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Visiting family and friends (VFF) tourism, also called visiting friends and relatives tourism, is the practice of traveling to familiar or unfamiliar places for the purpose of meeting people who are personally esteemed or valued. VFF is considered to be among the oldest manifestations of travel. VFF tourism involves notions of movement, dispersion, and distancing. By implication, therefore, such travels are undertaken with the explicit intent of maintaining and/or strengthening far-flung relationships. Even in a world where communications and technologies permeate almost all settings of contemporary life, journeys to places where family, friends, and relatives have relocated can serve to reforge these important social connections. Past tourism literature has long undervalued the social and economic contributions of VFF tourism. As a result, investigations of such contributions have been largely neglected. More recently, however, this concept has gained some academic interest as well as industry importance. The emerging discourse on VFF tourism, although formative in the way marketers promote their destinations, justifies the need for extensive and in-depth engagement.

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Family of missing American in Bahamas calls for U.S. to intervene

The family and friends of a Chicago woman who went missing in the Bahamas last month are calling on the United States to intervene in the investigation into her disappearance. 

Taylor Casey was last seen on June 19, about two weeks into a monthlong yoga retreat on Paradise Island in Nassau. Her family and friends held a news conference in Chicago on Thursday, Casey’s 42nd birthday, demanding action from the federal government.

“Please help us find Taylor,” Casey’s mother, Colette Seymore, said through tears. “I just want the senators to light a fire under the people in the Bahamas feet so they can correctly search for my child and help to bring my child home.”

Casey’s friends and relatives have been urging Illinois’ senators to pressure the State Department and FBI for help. They said they want U.S. officials to intervene with Bahamian authorities in Casey’s disappearance. 

“If we don’t have answers, we’re going to keep pushing,” Emily Williams, a close friend of Casey’s, said. “That’s why we’re calling on the senators, Dick Durbin, Tammy Duckworth, to put pressure on the State Department, to tell the Royal Bahamian Police Force to get the FBI down there right now and find Taylor.”

A spokesperson for Durbin’s office called Casey’s disappearance “deeply distressing” 

“It’s critical that the U.S. continues to work with the Government of the Bahamas to support all efforts to locate her,” the spokesperson said in an email. “The Senator and his staff are doing their best to provide support and regularly communicate with our State Department and the Government of the Bahamas to expedite this critical process.”

A representative for Duckworth’s office did not immediately return a request for comment. 

In an interview with NBC News on Wednesday, Casey’s mother revealed that her daughter is transgender. She said that she did not want to initially disclose that publicly because she feared it would negatively affect the search for her daughter. 

At Thursday’s news conference, Casey’s friends and family repeated some of their previous criticisms of the Bahamian authorities over their handling of the investigation. 

They accused Bahamian National Security Minister Wayne Munroe of telling reporters information that contradicts what U.S. Embassy officials told Casey’s family and friends.

Munroe told reporters in June that he believed the FBI was advising the RBPF’s investigation into Casey’s disappearance. But Casey’s family and friends told NBC News on Wednesday that the embassy told them the FBI was not involved in the case.

The embassy referred NBC News to the State Department.

"We have no higher priority than the safety and security of U.S. citizens abroad," a spokesperson for the State Department said in an email. "We stand ready to provide consular assistance to U.S. citizens in need and to their families."

The spokesperson added that the State Department does not share information with the media about private U.S. citizens without their written consent and referred NBC News to the FBI.

A spokesperson for the FBI referred NBC News to the Royal Bahamas Police Force and declined to comment further. The RBPF did not immediately return a request for comment regarding the involvement of the U.S. government in Casey’s disappearance.

Scott Duffey, a former criminal investigator at the FBI who is a co-director of the Wilmington University Criminal Justice Institute in Delaware, said that the FBI would surely be assisting the investigation by now if the Bahamian authorities found any signs of foul play in Casey’s disappearance. 

“I just don’t see the FBI not being in lock step with the authorities there if there was the slightest, and I mean slightest, bit of information to indicate that she did not disappear on her own,” Duffey said.

Police have not indicated there is any evidence of foul play. They have recovered Casey’s phone and a journal, but her passport remains missing. Seymore and Williams cleared out the tent Casey was staying in at the retreat, which they said still contained most of her personal belongings.

If the FBI were assisting in the case, Duffey said, the family most likely would have heard from the agency by now.

“The FBI typically doesn’t typically wait for the family to be sounding the alarm for them to say, ‘Oh, OK. Now we’ll get involved,’” he said. “That’s not how the FBI works.”

More coverage of Taylor Casey’s disappearance

• Mother of American missing in Bahamas shielded daughter's trans identity
• Bahamas authorities find phone of Chicago woman who disappeared during yoga retreat
• Chicago woman on Bahamas yoga retreat goes missing; family 'deeply concerned'

In an interview with NBC News on Wednesday, Seymore said she was under the impression that the RBPF was “unconcerned” with her daughter’s disappearance. 

During Thursday’s news conference, Seymore pointed to the RBPF’s announcement last week that it had put its chief superintendent, Michael Johnson — who leads the department’s criminal investigations — on leave and under investigation. She suggested this strengthened her argument that her daughter’s case was being handled with a “lack of care.”

The family said they were expecting to get an update from the RBPF by the end of the week. The update did not come in time for Casey’s birthday.

“Taylor, today is your birthday, and we all just want to say happy birthday, although it’s not so happy because you are not here with us,” Seymore tearfully said. “The pain I felt 42 years ago while birthing you doesn’t compare to the pain I feel on today with you missing out of our lives.”

She added, “I wonder: Where you are? Are you OK? Are you in danger? Are you sick? Are you hurt? My nights are sleepless with worry about you. I am lost without you. We all are.”

For more from NBC Out, sign up for our weekly newsletter.

Matt Lavietes is a reporter for NBC Out.

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We Went on a Great Trip With Our New Couple Friends. What Happened After Has Thrown Me.

I have no idea what went wrong.

Care and Feeding is Slate’s parenting advice column.  Have a question for Care and Feeding?  Submit it here .

Dear Care and Feeding,

My husband and I moved to an East Coast suburb about six years ago from a large city. About two years ago, my husband and I became close to another family—let’s call them Amy and Gary. They are outgoing and popular in the community, and our children loved playing with their kids, who are similar ages. We celebrated our birthdays and other big events and even went on a family vacation together. They would introduce us to other friends in their circle as their “best friends.”

After the vacation, I started to notice that it was always us initiating our get-togethers with Amy and Gary. My husband would reach out to Gary and get one-word responses, or none at all. Over time, they stopped inviting us to join events and declined our invitations as well …

Whenever we see them around town, they are super friendly and talkative as if we’re still close. In fact, people assume we are still great friends because in public they act as if nothing has changed.

My husband has said that things just fizzled out, and he’s fine not knowing what happened. I’ve been suffering a lot of anxiety, worrying that there’s something we did to make them pull away. I keep thinking about that joint family vacation—it really seemed as if we all had a good time, and there were no arguments or conflicts that I saw. I also miss being close with Amy, plus the community that came from being part of their circle.

I see Amy at school drop-off almost every day, and I feel that this will continue to weigh on me. Our children still call each other “best friends” and will be going to school together through high school, which means we’re going to continue to see them around all the time. Should I follow my husband’s lead and just assume that this wasn’t meant to be? Or should I try to have a conversation with Amy to see what happened? I don’t want to come across as desperate, asking why she’s not my friend anymore. It feels juvenile, but I’m just trying to get clarity.

—Unexpectedly Unfriended

Dear Unfriended,

Oh, man, I feel you. Making friends as an adult in a new community is such a torment. You think you’re a grown-ass person, then all of a sudden you’re subject to all the anxiety and heartache of a middle schooler. When we moved from our big city to our East Coast suburb, it took us years to find our actual friends—and those years included getting ghosted a lot by people we thought were hot prospects, including, yes, one family who accompanied us for what we thought was a delightful, fun joint vacation but which turned out to be the last thing we ever did together. I’m getting hives just remembering it!

No good can come of asking Amy what happened to your friendship. You’re not going to change her mind about being your friend by asking what you did wrong. You’ll absolutely feel like you’re acting desperate. The only result of this conversation that would make you feel better—Amy apologizing for how she’s made you feel, then renewing your friendship—is not going to happen. And you’ll come out of the conversation as frustrated and hurt as you are now—if not more so.

So swallow your annoyance and accept that, at least right now, you two are not going to be best friends with Amy and Gary and you are not going to know why it’s turning out that way. Continue being friendly at drop-off. When you communicate about playdates or birthdays, play it cool. Maybe in a year or three or five, you’ll find that you’ve been drawn back together, and that will be fine.

In the meantime, try to connect with some people who are not part of the greater Amy-Gary friendplex. Broaden your circle. Your friends do not have to be the parents of your children’s friends! Indeed, often it’s easier if they’re not. Sign up for a social sports league, or seek out parents on your block, or invite the new family in town over for a drink. Cast a wide net. Are you condemning yourself, by doing so, to many false starts and disappointments and hurt feelings and people whom you had a great time with never, ever reciprocating your invitation? Yes. It sucks. But that’s what you have to do.

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Ossipee Valley Fair, Moxie Festival and more happening this weekend

The Maine International Film Festival starts Friday in Waterville.

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Now that we’re all comfortably settled into the rhythm of summer, let’s do a classic summer thing and go to a fair!

Jeremy Schoff of York leads his oxen, Pete and Red, during the ox pull on Thursday at the Ossippe Valley Fair in 2021. Ben McCanna/Staff Photographer

The Ossipee Valley Fair starts today and runs through Sunday. We especially love the Farmer Olympics because the hay bale toss and blind wheelbarrow obstacle course competition is fierce. Ray Routhier has details about Ossipee Valley and several others fairs happening this summer in Bangor, Waterville and Acton, among other locales.

Go a little farther afield and find a Maine summer fair for you

Aretha Aoki & Ryan MacDonald (right, in bear suit) performing IzumonookunI (stet capital letter at the end). Aretha Aoki & Ryan MacDonald will be bringing this dance program to the Bates Dance Festival July 12 and 14, 2024 at the Schaeffer Theatre on the Bates College campus in Lewiston, Maine. Photo by Colin Kelly

Another summer tradition is the Bates Dates Festival in Lewiston . Performances are underway, and arts writer Megan Gray has the scoop on “IzumonookunI” by Aretha Aoki and Ryan MacDonald. See it tonight and Saturday.

Topsham couple’s Bates Dance Festival performance is inspired by kabuki, punk rock and their 7-year-old

Big Yellow Taxi. Photo by Julian Parker Burns

I’m headed to One Longfellow Square on Friday night to see the Massachusetts-based Joni Mitchell tribute band Big Yellow Taxi. They’ll be playing Mitchell’s 1974 album “Court and Spark,” along with other tunes.

Tribute to Joni Mitchell celebrates 50 years of ‘Court and Spark’

“3 Vendors of Ipanema” is directed by Lewiston native Jonathan S. Lee. Courtesy of JSL Films

We weren’t kidding when we said there’s a lot going on right now. The 27th annual Maine International Film Festival starts on Friday and runs through July 21 in Waterville. Our film writer, Dennis Perkins, offers up his picks for 12 screenings worth your while.

12 hidden gems of this year’s Maine International Film Festival

Spectators watching a previous year’s Moxie Festival Parade in Lisbon Falls. Carl D. Walsh/Staff Photographer

Our weekly events roundup includes the East Bayside block party in Portland and the Moxie Festival in Lisbon Falls. Should you make it to the festival on Saturday, don’t miss “American Idol” alum Julia Gagnon singing at 1:30 p.m.

Kennebunks garden tour, Moxie Festival, East Bayside block party

One with Everything from Gunnar’s Icelandic Hot Dogs. Photo by Ray Routhier

Need a break from standard-issue hot dogs? We love them too, but sometimes a new twist is just what your taste buds need. Ray Routhier stopped by Gunnar’s Icelandic Hot Dogs cart . If you like what you read, you can find it parked from 4-9 p.m. Thursday at Apres in Portland, then on the roof of Bayside Bowl on Friday and Saturday evenings.

Sick of red snappers? Try an Icelandic hot dog instead

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