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CORRESPONDENCE

Inadequacies in Health Recommendations

To the Editor: The article Inadequacies in Health Rec- ommendations Provided for International Travelers by North American Travel Health Advisors, (Journal of Travel Medicine, Vol 1, No. 2, June 1994) by Dr. J.S. Keystone and col- leagues is both interesting and informative.The authors stress the need for consistent, high-quality travel health advice.We agree and also believe that public health is gen- erally better equipped to offer comprehensive updated advice than are private practitioners.

As public health physicians in rural Manitoba, we deal with some issues specific to the provision of services to international travelers residing in rural regions of our province. Traditionally, these travelers have either been underserviced or have tended to access travel advice in urban centers.They now increasingly seek health advice and immunization “closer to home.” Our challenge is to provide high-quality service, while seeing only a relatively low volume of travelers.The availability of various recent new resources, including your journal, helps us meet this challenge.

With regard to Dr. Keystone’s article, we are not certain what type of travel clinics were surveyed. The questionnaires were stated to have been distributed only to World Health Organization - designated yellow fever centers; the number of Canadian centers so designated is stated to have been 128 in 1990. One of us (Anna Macdonald) carried out a survey in 1991, which deter- mined the existence of only 69 Canadian yellow fever centers. We, therefore, wonder whether the Canadian travel clinics surveyed in Dr. Keystone’s study included both yellow fever and nondesignated centers.

We also question whether it is realistic to recommend antimalarials to a couple on a first class Caribbean cruise that includes an overnight stay in Haiti. Although Haiti is a malarious area, it seems that the necessity of taking chloroquine for 1 week before the 1 night stay, as well as for 4 weeks following, is likely to be unacceptable to the majority of travelers. Insect precautions alone would seem a more reasonable recommendation, given the very short stay, and would likely achieve better compliance.

Comments &om the authors on these matters would be appreciated.

Anna MacDonald, MD, FRCPC Shelly Buchan, MD, CCFC FRCPC Manitoba Health Family Services, Selkirk, MB, Canada

In Reply: We appreciate the comments received by Drs. Macdonald and Buchan. Our list of travel clinics surveyed in Canada was obtained from the Laboratory Center for Disease Control in Ottawa. Our letter to each clinic included a statement about its identification as a site where travel health information and yellow fever vacci- nation were available. Sites that did not provide these were asked not to complete the questionnaire, but to simply return it to us with the appropriate designation.

We agree with the recommendations given by Drs. Macdonald and Buchan regarding antimalarial mea- sures for an overnight stay in Haiti. Certainly, personal protection measures are critical to the prevention of infection. In fact, when we give travel health advice, we always try to educate the traveler about the risk of infec- tion in a certain area and weigh this against the poten- tial problems which may be encountered from prophy- 1axis.This scenario is a good example where an educated traveler may appropriately choose to just use insect pre- cautions. However, the survey asked for the best answer, and the choices did not include “insect precautions.” In fact, in answer to some of the other questions, survey participants made additional suggestions, which were evaluated individually. For this question, no other sug- gestions were made. We were primarily looking to see if Haiti would be recognized as a malarious area and unfortunately in many cases it was not.

Though not the primary determinant of travel health recommendations given, medicolegal issues also need some consideration. At least in the United States, the Centers for Disease Control and Prevention guide- lines provide information which is used to define the “standard of care” in this field.Therefore, if one recom- mends “insect precautions only” for prevention of malaria for travelers to an endemic area (even for one night), it is important to document that the traveler has been told of the risk of infection and chose to use only personal protection measures.

Jay S. Keystone, M D Roberta Dismukes, RN Lisa Sawyer, RN Phyllis Kozarsky, M D The Emory Clinic Section of Internal Medicine Atlanta, Georgia

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