- Email: [email protected]
A multidisciplinary approach to engage VFR migrants in Madrid, Spain
Travel Medicine and Infectious Disease (2012) 10, 152e156
Available online at www.sciencedirect.com
journal homepage: www.elsevierhealth.com/journals/tmid
CASE REPORT
A multidisciplinary approach to engage VFR migrants in Madrid, Spain ´rbara Navaza, Anne Guionnet, Rogelio Lo ´pez-Ve ´lez Miriam Navarro*, Ba Tropical Medicine and Clinical Parasitology, Infectious Diseases Department, Ramo´n y Cajal Hospital, Ctra. de Colmenar, km 9.1, 28034 Madrid, Spain Received 17 December 2011; received in revised form 2 March 2012; accepted 5 March 2012 Available online 15 May 2012
KEYWORDS VFR; Visiting friends and relatives; Health education; Malaria
Summary VFRs are at a greater risk of contracting travel-related illnesses such as malaria, and their knowledge about travel health tends to be poor. Since 2009, community-based activities targeting potential and impending VFRs were performed by a multidisciplinary team in Madrid, Spain. The design and distribution of multilingual and culturally-sensitive material following a qualitative research, and intercultural mediators were key tools of the health education programme. ª 2012 Elsevier Ltd. All rights reserved.
Brief report The term VFRs refers to those travellers visiting friends and relatives, who tend to be migrants. This population is at a higher risk for contracting travel-related illnesses when compared to other groups of travellers.1e3 The lack of risk perception by VFRs when travelling to their countries of origin and the consequent poor seeking for pre-travel health advice play a main role on it. In addition, their level of knowledge about travel health tends to be poor.4 To devise novel and adapted methods targeting
* Corresponding author. Tel.: þ34 91 3368108. E-mail addresses: [email protected] (M. Navarro), [email protected] (B. Navaza), [email protected] (A. Guionnet), [email protected] (R. Lo ´pez-Ve ´lez).
impending and potential VFRs seems crucial in order to engage them, basically for two reasons: 1) most of the travel-related diseases they may acquire are preventable, and 2) VFRs have specific characteristics (such as language and culture) that have to be taken into account in preventive activities.5 It has been demonstrated that innovative and specific methods are required to increase awareness of the need for pre-travel health advice among VFR travellers.5,6 Nevertheless there are rare community-based campaigns. Recently, Leder et al.7 presented innovative activities to engage VFRs in Australia, and they should be commended. Spain received in the past ten years more migrants than any other country in the world, after the US.8 Currently, more than 5.7 million people in Spain (12.2% of the population) are foreigners, and in the region of Madrid this figure is even higher: 17%.9 Migrants who enter the country with no resident permit cannot get a round trip to their
1477-8939/$ - see front matter ª 2012 Elsevier Ltd. All rights reserved. doi:10.1016/j.tmaid.2012.03.001
An approach to engage VFR migrants in Madrid countries of origin to visit family and friends. Nonetheless, after living in Spain for some years, migrants have the opportunity to get this document. Thus, the number of VFRs is expected to increase in the following years. The Tropical Medicine Unit of the Ramo ´n y Cajal Hospital in Madrid, Spain, holds a pioneering health education programme adapted to migrants which also embraces activities aimed at VFRs. In this programme, called ‘New citizens, new patients’, activities are community-based and culturally-sensitive. It is aimed at migrants living in Spain and run by a multidisciplinary team of physicians, translators, intercultural mediators and a psychologist. The main activities of this health education programme targeting VFRs take place in Madrid and are resumed in Fig. 1. The programme was targeted at potential VFRs coming from Latin American and Sub Saharan African countries. We are specially focused on Sub Saharan African migrants. Although this population represents only 4.1% of documented migrants emigrants with residence permite,9 they are more at risk for severe malaria while visiting their countries of origin. Several cases of complicated malaria among African VFRs (adults and their children) have been reported in Spain, mainly in patients from the Spanish ex-colony of Equatorial Guinea and other West Sub Saharan African countries such as Nigeria or Cameroon.10,11 In an initial phase of the programme, we obtained background information on migrants’ knowledge and beliefs about travel-related health. First, from September to November 2008, we carried out a qualitative research consisting of 15 in-depth interviews with migrants from Sub Saharan African and Latin American countries who were living in Madrid. The results of the qualitative research were very helpful for the creation of appropriate educational materials. It was observed that parents used to seek pre-travel advice for their children, so the importance of protecting children was highlighted in leaflets and posters and a mention to paediatricians was included. Other identified item was the VFR migrants’ perception of Spanish medical staff: They were seen as professionals with poor
153 capabilities to treat tropical diseases. Thus, materials also included information about specific and specialised healthcare resources for seeking medical advice before and after their journey. Once the qualitative research was concluded ein the first half of 2009e, we created multilingual, culturally tailored and fully illustrated leaflets and posters (Fig. 2). The materials were especially focused on Sub Saharan African population, but they were also used among Latin American migrants. These materials were translated into French and English, the most common vehicular languages of the target population. They contain information about health risks when travelling to the tropics, preventative measures (before, while and after travelling) and contact information for seeking pre-travel advice and post-travel assistance, emphasizing advises about malaria prevention and early diagnosis. The materials were designed and adapted by healthcare staff and intercultural mediators. Before printing they had been tested with migrants coming from Sub Saharan and Latin American countries. This measure was adopted in order to assure the materials were fully comprehensible and will not hurt sensibilities. The most remarkable contribution of the intercultural mediators at this stage was in relation to the colours that should be used to represent the risk in the maps (warm colours as red or yellow). Mediators were also very helpful in the design of drawings as they explained which images could be mostly understood, disregarding the educational level of readers. From the second half of 2009 up to now, two volunteer intercultural mediators from Sub Saharan Africa specifically trained for this purpose informed migrants individually and without giving any specific medical advice. In waiting room of the Tropical Medicine consultation mediators informed Sub Saharan African patients about travel-related health in and gave them the leaflets. Sixty-four impending and potential VFRs (43 men, 21 women) were informed in their own languages, in order to raise their awareness about the importance of seeking pre-travel medical advice. They
Distribution of multilingual and culturally tailored leaflets and delivering of information about travel health by trained intercultural mediators. Main scenarios: * Waiting room of the Tropical Medicine consultation. Information was given individually to raise awareness about risks while travelling and the importance of seeking pre-travel advice: 64 people from Sub Saharan Africa informed and 64 leaflets distributed (2009-2011). NGO devoted to African population: 120 people informed about travel health and malaria prevention; 120 leaflets distributed (2011). * Latin American migrants’ social event (National Day of Bolivia): 75 leaflets distributed (2009). * Embassies and consulates, businesses, healthcare centres with high percentage of migrant patients, NGOs and migrant’s associations in Madrid. Two annual community-based campaigns (before summer and Christmas holidays): 1,260 leaflets and 60 posters distributed (2010 and 2011). * Internet (www.saludentreculturas.es). Multilingual educational materials are freely available in this website. More than 245,000 visits (2010 and 2011).
Figure 1
VFR health education programme’s main activities.
154
M. Navarro et al.
Figure 2 Culturally adapted poster about health and travel, extracted from the leaflet. English version. It also contains information about where to go for seeking medical advice in Madrid before and after travelling.
were coming from 16 Sub Saharan African countries, mainly from Equatorial Guinea (16%), Republic of Guinea (14%) and Senegal (12%). The median of time living in Spain was 36 months (range 1e240) and their main vehicular languages were French (47%), Spanish (17%) and English (15%).
From August to December 2011, a trained intercultural mediator was based in a non-governmental organisation (NGO) targeted at Sub Saharan African population two days a week. During this period, he informed 120 people about important preventative measures to be taken before,
An approach to engage VFR migrants in Madrid during and after travelling to tropical countries without giving any specific medical advice. In August 2009, an informative stand with leaflets about Chagas disease and travel health was set up in a venue in Madrid during the celebration of the National Day of Bolivia.12 Members of the multidisciplinary team engaged with the crowd and distributed 75 leaflets about travel health while raising awareness of the importance of pretravel medical advice. In 2010, two community-based informative campaigns took place in Madrid (one before Christmas and one before summer holidays). Another campaign was carried out before the summer of 2011. A total of 1260 leaflets and 60 posters (in English, French and Spanish) were distributed by intercultural mediators in primary healthcare centres, embassies and consulates, hairdressers, restaurants, call centres, travel agencies, migrant’s associations and NGOs devoted to migrants. In January 2010, professionals from different fields (health sciences, computing, anthropology, psychology, intercultural mediation and translation) started to design a multilingual website (English, French and Spanish) in order to improve the accessibility of health promotion information to VFRs. Targeted at migrants and professionals in both health and social fields, this website gathers information about health and intercultural mediation, and health-related resources in Spain, being one of its sections about travel health. Through this website, VFRs and professionals are able to access simple travel health messages and to consult and download the educational materials. We consider important to inform not only the impending VFRs. Attitudes need time to be changed, therefore we also inform the potential VFRs even if they will not travel shortly. The more times the message reach them, the more choices we have to succeed conveying the information in an effective manner. That is why we chose the waiting room of Tropical Medicine consultation: there are many undocumented patients who attend and there is enough time to invest while conveying the information. This is an ideal scenario to identify the impending VFRs and to inform the potential ones before they intend to travel, something that may be crucial for prevention. In addition, by giving multilingual and culturally adapted materials we contribute to spread the message in their social circle. With the adapted material and the intercultural mediators we overcome many cultural and linguistic barriers. A formal evaluation of the impact of these interventions was not performed. Some future strategies to measure the outcomes could involve counting the number of appointments for pre-travel consultation in this region or counting the cases of imported malaria among VFRs. Yet it can take many years before measurable changes are detected, and it would be logistically difficult and costly. The aim of this report is to describe preventative activities and materials that have had a good acceptance and the methods employed to develop such tools. Regarding the community-based campaigns targeted at impending VFRs, the timing is very important. VFRs living in Spain use to travel during the summer and Christmas holidays,13 therefore, the campaign will be more efficient if launched before these dates.
155 In order to understand the risk perception of VFR migrants and their social, linguistic and cultural characteristics, it is essential to establish the best timing, location and communication strategies for the preventative actions. Qualitative research, multidisciplinarity, community-based activities and intercultural mediators are key tools to convey effective messages to VFRs. More initiatives are needed to engage VFRs and we encourage other teams working in the same field to develop similar strategies and to share their methods and materials.
Conflict of interest None declared.
Acknowledgements VFRs’ activities are framed in the health education programme aimed at migrants in Spain (‘New citizens, new patients’) and supported by sanofi-aventis. Website’s design (www.saludentreculturas.es) was supported by Vodafone Espan ˜a. Authors’ affiliation centre belongs to the Red de Investigacio ´n Cooperativa en Enfermedades Tropicales (RICET). RED: RD06/0021/0020. We thank Serigne Fall and Alban Kouakou, intercultural mediators, for their support. Both did convey the individual travel-health messages in the waiting room of the Tropical Medicine consultation. Serigne Fall performed the community-based activities and was based in the NGO Karibu for the individual counselling.
References 1. Bacaner N, Stauffer B, Boulware DR, Walker PF, Keystone JS. Travel medicine considerations for North American immigrants visiting friends and relatives. J Am Med Assoc 2004;291: 2856e64. 2. Angell SY, Cetron MS. Health disparities among travelers visiting friends and relatives abroad. Ann Intern Med 2005;142: 67e72. 3. Leder K, Tong S, Weld L, Kain KC, Wilder-Smith A, von Sonnenburg F, et al. Illness in travelers visiting friends and relatives: a review of the GeoSentinel surveillance network. Clin Infect Dis 2006;43:1185e93. 4. Pistone T, Guibert P, Gay F, Malvy D, Ezzedine K, Receveur MC, et al. Malaria risk perception, knowledge and prophylaxis practices among travellers of African ethnicity living in Paris and visiting their country of origin in sub-Saharan Africa. Trans R Soc Trop Med Hyg 2007;101:990e5. 5. Fenner L, Weber R, Steffen R, Schlagenhauf P. Imported infectious disease and purpose of travel, Switzerland. Emerg Infect Dis 2007;13:217e22. 6. Schlagenhauf P, Steffen R, Loutan L. Migrants as a major risk group for imported malaria in European countries. J Travel Med 2003;10:106e7. 7. Leder K, Lau S, Leggat P. Innovative community-based initiatives to engage VFR travelers. Travel Med Infect Dis 2011;9: 258e61. 8. Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat, World population prospects: the 2010 revision. [cited 2011 29th October];
156 Available from: http://esa.un.org/unpd/wpp/unpp/panel_ indicators.htm. 9. Instituto Nacional de Estadı´stica. Spain census data: foreigner population. Latest update 31 January 2011. [cited 2011 29th October]; Available from: http://www.ine.es. 10. Rey S, Zuza I, Martı´nez-Monde ´jar B, Rubio JM, Merino FJ. Imported malaria in an area in southern Madrid, 2005e2008. Malar J 2010;9:290. 11. Arna ´ez J, Roa MA, Albert L, Cogollos R, Rubio JM, Villares R, et al. Imported malaria in children: a comparative study
M. Navarro et al. between recent immigrants and immigrant travelers (VFRs). J Travel Med 2010;17:221e7. 12. Navarro M, Perez-Ayala A, Guionnet A, Perez-Molina JA, Navaza B, Este ´vez L, et al. Targeted screening and health education for Chagas disease tailored to at-risk migrants in Spain, 2007 to 2010. Euro Surveill 2011;16. pii Z 19973. 13. Van Herck K, Van Damme P, Castelli F, Zuckerman J, Nothdurft H, Dahlgren AL, et al. Knowledge, attitudes and practices in travel-related infectious diseases: the European airport survey. J Travel Med 2004;11:3e8.
Available online at www.sciencedirect.com
journal homepage: www.elsevierhealth.com/journals/tmid
CASE REPORT
A multidisciplinary approach to engage VFR migrants in Madrid, Spain ´rbara Navaza, Anne Guionnet, Rogelio Lo ´pez-Ve ´lez Miriam Navarro*, Ba Tropical Medicine and Clinical Parasitology, Infectious Diseases Department, Ramo´n y Cajal Hospital, Ctra. de Colmenar, km 9.1, 28034 Madrid, Spain Received 17 December 2011; received in revised form 2 March 2012; accepted 5 March 2012 Available online 15 May 2012
KEYWORDS VFR; Visiting friends and relatives; Health education; Malaria
Summary VFRs are at a greater risk of contracting travel-related illnesses such as malaria, and their knowledge about travel health tends to be poor. Since 2009, community-based activities targeting potential and impending VFRs were performed by a multidisciplinary team in Madrid, Spain. The design and distribution of multilingual and culturally-sensitive material following a qualitative research, and intercultural mediators were key tools of the health education programme. ª 2012 Elsevier Ltd. All rights reserved.
Brief report The term VFRs refers to those travellers visiting friends and relatives, who tend to be migrants. This population is at a higher risk for contracting travel-related illnesses when compared to other groups of travellers.1e3 The lack of risk perception by VFRs when travelling to their countries of origin and the consequent poor seeking for pre-travel health advice play a main role on it. In addition, their level of knowledge about travel health tends to be poor.4 To devise novel and adapted methods targeting
* Corresponding author. Tel.: þ34 91 3368108. E-mail addresses: [email protected] (M. Navarro), [email protected] (B. Navaza), [email protected] (A. Guionnet), [email protected] (R. Lo ´pez-Ve ´lez).
impending and potential VFRs seems crucial in order to engage them, basically for two reasons: 1) most of the travel-related diseases they may acquire are preventable, and 2) VFRs have specific characteristics (such as language and culture) that have to be taken into account in preventive activities.5 It has been demonstrated that innovative and specific methods are required to increase awareness of the need for pre-travel health advice among VFR travellers.5,6 Nevertheless there are rare community-based campaigns. Recently, Leder et al.7 presented innovative activities to engage VFRs in Australia, and they should be commended. Spain received in the past ten years more migrants than any other country in the world, after the US.8 Currently, more than 5.7 million people in Spain (12.2% of the population) are foreigners, and in the region of Madrid this figure is even higher: 17%.9 Migrants who enter the country with no resident permit cannot get a round trip to their
1477-8939/$ - see front matter ª 2012 Elsevier Ltd. All rights reserved. doi:10.1016/j.tmaid.2012.03.001
An approach to engage VFR migrants in Madrid countries of origin to visit family and friends. Nonetheless, after living in Spain for some years, migrants have the opportunity to get this document. Thus, the number of VFRs is expected to increase in the following years. The Tropical Medicine Unit of the Ramo ´n y Cajal Hospital in Madrid, Spain, holds a pioneering health education programme adapted to migrants which also embraces activities aimed at VFRs. In this programme, called ‘New citizens, new patients’, activities are community-based and culturally-sensitive. It is aimed at migrants living in Spain and run by a multidisciplinary team of physicians, translators, intercultural mediators and a psychologist. The main activities of this health education programme targeting VFRs take place in Madrid and are resumed in Fig. 1. The programme was targeted at potential VFRs coming from Latin American and Sub Saharan African countries. We are specially focused on Sub Saharan African migrants. Although this population represents only 4.1% of documented migrants emigrants with residence permite,9 they are more at risk for severe malaria while visiting their countries of origin. Several cases of complicated malaria among African VFRs (adults and their children) have been reported in Spain, mainly in patients from the Spanish ex-colony of Equatorial Guinea and other West Sub Saharan African countries such as Nigeria or Cameroon.10,11 In an initial phase of the programme, we obtained background information on migrants’ knowledge and beliefs about travel-related health. First, from September to November 2008, we carried out a qualitative research consisting of 15 in-depth interviews with migrants from Sub Saharan African and Latin American countries who were living in Madrid. The results of the qualitative research were very helpful for the creation of appropriate educational materials. It was observed that parents used to seek pre-travel advice for their children, so the importance of protecting children was highlighted in leaflets and posters and a mention to paediatricians was included. Other identified item was the VFR migrants’ perception of Spanish medical staff: They were seen as professionals with poor
153 capabilities to treat tropical diseases. Thus, materials also included information about specific and specialised healthcare resources for seeking medical advice before and after their journey. Once the qualitative research was concluded ein the first half of 2009e, we created multilingual, culturally tailored and fully illustrated leaflets and posters (Fig. 2). The materials were especially focused on Sub Saharan African population, but they were also used among Latin American migrants. These materials were translated into French and English, the most common vehicular languages of the target population. They contain information about health risks when travelling to the tropics, preventative measures (before, while and after travelling) and contact information for seeking pre-travel advice and post-travel assistance, emphasizing advises about malaria prevention and early diagnosis. The materials were designed and adapted by healthcare staff and intercultural mediators. Before printing they had been tested with migrants coming from Sub Saharan and Latin American countries. This measure was adopted in order to assure the materials were fully comprehensible and will not hurt sensibilities. The most remarkable contribution of the intercultural mediators at this stage was in relation to the colours that should be used to represent the risk in the maps (warm colours as red or yellow). Mediators were also very helpful in the design of drawings as they explained which images could be mostly understood, disregarding the educational level of readers. From the second half of 2009 up to now, two volunteer intercultural mediators from Sub Saharan Africa specifically trained for this purpose informed migrants individually and without giving any specific medical advice. In waiting room of the Tropical Medicine consultation mediators informed Sub Saharan African patients about travel-related health in and gave them the leaflets. Sixty-four impending and potential VFRs (43 men, 21 women) were informed in their own languages, in order to raise their awareness about the importance of seeking pre-travel medical advice. They
Distribution of multilingual and culturally tailored leaflets and delivering of information about travel health by trained intercultural mediators. Main scenarios: * Waiting room of the Tropical Medicine consultation. Information was given individually to raise awareness about risks while travelling and the importance of seeking pre-travel advice: 64 people from Sub Saharan Africa informed and 64 leaflets distributed (2009-2011). NGO devoted to African population: 120 people informed about travel health and malaria prevention; 120 leaflets distributed (2011). * Latin American migrants’ social event (National Day of Bolivia): 75 leaflets distributed (2009). * Embassies and consulates, businesses, healthcare centres with high percentage of migrant patients, NGOs and migrant’s associations in Madrid. Two annual community-based campaigns (before summer and Christmas holidays): 1,260 leaflets and 60 posters distributed (2010 and 2011). * Internet (www.saludentreculturas.es). Multilingual educational materials are freely available in this website. More than 245,000 visits (2010 and 2011).
Figure 1
VFR health education programme’s main activities.
154
M. Navarro et al.
Figure 2 Culturally adapted poster about health and travel, extracted from the leaflet. English version. It also contains information about where to go for seeking medical advice in Madrid before and after travelling.
were coming from 16 Sub Saharan African countries, mainly from Equatorial Guinea (16%), Republic of Guinea (14%) and Senegal (12%). The median of time living in Spain was 36 months (range 1e240) and their main vehicular languages were French (47%), Spanish (17%) and English (15%).
From August to December 2011, a trained intercultural mediator was based in a non-governmental organisation (NGO) targeted at Sub Saharan African population two days a week. During this period, he informed 120 people about important preventative measures to be taken before,
An approach to engage VFR migrants in Madrid during and after travelling to tropical countries without giving any specific medical advice. In August 2009, an informative stand with leaflets about Chagas disease and travel health was set up in a venue in Madrid during the celebration of the National Day of Bolivia.12 Members of the multidisciplinary team engaged with the crowd and distributed 75 leaflets about travel health while raising awareness of the importance of pretravel medical advice. In 2010, two community-based informative campaigns took place in Madrid (one before Christmas and one before summer holidays). Another campaign was carried out before the summer of 2011. A total of 1260 leaflets and 60 posters (in English, French and Spanish) were distributed by intercultural mediators in primary healthcare centres, embassies and consulates, hairdressers, restaurants, call centres, travel agencies, migrant’s associations and NGOs devoted to migrants. In January 2010, professionals from different fields (health sciences, computing, anthropology, psychology, intercultural mediation and translation) started to design a multilingual website (English, French and Spanish) in order to improve the accessibility of health promotion information to VFRs. Targeted at migrants and professionals in both health and social fields, this website gathers information about health and intercultural mediation, and health-related resources in Spain, being one of its sections about travel health. Through this website, VFRs and professionals are able to access simple travel health messages and to consult and download the educational materials. We consider important to inform not only the impending VFRs. Attitudes need time to be changed, therefore we also inform the potential VFRs even if they will not travel shortly. The more times the message reach them, the more choices we have to succeed conveying the information in an effective manner. That is why we chose the waiting room of Tropical Medicine consultation: there are many undocumented patients who attend and there is enough time to invest while conveying the information. This is an ideal scenario to identify the impending VFRs and to inform the potential ones before they intend to travel, something that may be crucial for prevention. In addition, by giving multilingual and culturally adapted materials we contribute to spread the message in their social circle. With the adapted material and the intercultural mediators we overcome many cultural and linguistic barriers. A formal evaluation of the impact of these interventions was not performed. Some future strategies to measure the outcomes could involve counting the number of appointments for pre-travel consultation in this region or counting the cases of imported malaria among VFRs. Yet it can take many years before measurable changes are detected, and it would be logistically difficult and costly. The aim of this report is to describe preventative activities and materials that have had a good acceptance and the methods employed to develop such tools. Regarding the community-based campaigns targeted at impending VFRs, the timing is very important. VFRs living in Spain use to travel during the summer and Christmas holidays,13 therefore, the campaign will be more efficient if launched before these dates.
155 In order to understand the risk perception of VFR migrants and their social, linguistic and cultural characteristics, it is essential to establish the best timing, location and communication strategies for the preventative actions. Qualitative research, multidisciplinarity, community-based activities and intercultural mediators are key tools to convey effective messages to VFRs. More initiatives are needed to engage VFRs and we encourage other teams working in the same field to develop similar strategies and to share their methods and materials.
Conflict of interest None declared.
Acknowledgements VFRs’ activities are framed in the health education programme aimed at migrants in Spain (‘New citizens, new patients’) and supported by sanofi-aventis. Website’s design (www.saludentreculturas.es) was supported by Vodafone Espan ˜a. Authors’ affiliation centre belongs to the Red de Investigacio ´n Cooperativa en Enfermedades Tropicales (RICET). RED: RD06/0021/0020. We thank Serigne Fall and Alban Kouakou, intercultural mediators, for their support. Both did convey the individual travel-health messages in the waiting room of the Tropical Medicine consultation. Serigne Fall performed the community-based activities and was based in the NGO Karibu for the individual counselling.
References 1. Bacaner N, Stauffer B, Boulware DR, Walker PF, Keystone JS. Travel medicine considerations for North American immigrants visiting friends and relatives. J Am Med Assoc 2004;291: 2856e64. 2. Angell SY, Cetron MS. Health disparities among travelers visiting friends and relatives abroad. Ann Intern Med 2005;142: 67e72. 3. Leder K, Tong S, Weld L, Kain KC, Wilder-Smith A, von Sonnenburg F, et al. Illness in travelers visiting friends and relatives: a review of the GeoSentinel surveillance network. Clin Infect Dis 2006;43:1185e93. 4. Pistone T, Guibert P, Gay F, Malvy D, Ezzedine K, Receveur MC, et al. Malaria risk perception, knowledge and prophylaxis practices among travellers of African ethnicity living in Paris and visiting their country of origin in sub-Saharan Africa. Trans R Soc Trop Med Hyg 2007;101:990e5. 5. Fenner L, Weber R, Steffen R, Schlagenhauf P. Imported infectious disease and purpose of travel, Switzerland. Emerg Infect Dis 2007;13:217e22. 6. Schlagenhauf P, Steffen R, Loutan L. Migrants as a major risk group for imported malaria in European countries. J Travel Med 2003;10:106e7. 7. Leder K, Lau S, Leggat P. Innovative community-based initiatives to engage VFR travelers. Travel Med Infect Dis 2011;9: 258e61. 8. Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat, World population prospects: the 2010 revision. [cited 2011 29th October];
156 Available from: http://esa.un.org/unpd/wpp/unpp/panel_ indicators.htm. 9. Instituto Nacional de Estadı´stica. Spain census data: foreigner population. Latest update 31 January 2011. [cited 2011 29th October]; Available from: http://www.ine.es. 10. Rey S, Zuza I, Martı´nez-Monde ´jar B, Rubio JM, Merino FJ. Imported malaria in an area in southern Madrid, 2005e2008. Malar J 2010;9:290. 11. Arna ´ez J, Roa MA, Albert L, Cogollos R, Rubio JM, Villares R, et al. Imported malaria in children: a comparative study
M. Navarro et al. between recent immigrants and immigrant travelers (VFRs). J Travel Med 2010;17:221e7. 12. Navarro M, Perez-Ayala A, Guionnet A, Perez-Molina JA, Navaza B, Este ´vez L, et al. Targeted screening and health education for Chagas disease tailored to at-risk migrants in Spain, 2007 to 2010. Euro Surveill 2011;16. pii Z 19973. 13. Van Herck K, Van Damme P, Castelli F, Zuckerman J, Nothdurft H, Dahlgren AL, et al. Knowledge, attitudes and practices in travel-related infectious diseases: the European airport survey. J Travel Med 2004;11:3e8.