Sources and Appropriateness of Medical Advice for Trekkers

Sources and Appropriateness of Medical Advice for Trekkers Mike Townend Background: Little has previously been published on the sources of health advice used by trekkers. This paper investigates the sources of advice used by a group of British trekkers and the appropriateness of the advice which they were given. Methods:A questionnaire was issued to 17 clients of a U.K. trekking operator. Clients were asked which advice sources they had used and how useful they found them.they were also asked about advice which they had received on vaccination, antimalarial drugs, and other health precautions.the appropriateness of such advice was assessed by reference to standard advice sources used in the United Kingdom. Results: One hundred replies were received, a response rate of 93.5%. Responders had traveled to India (lo%), Nepal (45%) and Morocco (45%).The most frequently used advice sources were general medical practitioners or health centers (69%) and the tour operator (68%), many trekkers using more than one source. Specialist travel advice centers and general practitioners were rated most highly by 67% and 59% of users for usefulness and 6% and 52% of users for being informative. Other travelers were also rated highly as a source. Some appropriate vaccinations were under-recommended while others which were not appropriate were recommended. Antimalarial drugs were recommended when needed but they were sometimes recommended when not appropriate. Advice on other health risks was generally inadequate. Conc/usions:Trekkers need access to more relevant health advice.tour operators need to have better medical information to pass on to their clients, and health professionals need more education about health risks for and the avoidance of health risks by trekkers. Although much has been published about altitude little has been published on the other aspects of the health of those taking a trekking holiday. and, in particular, on the sources of advice which trekkers use prior to traveling abroad.trekking consists of walking from one place on one s itinerary to another carrying food and belongings, often in remote or mountainous areas and usually with the help of guides or porters.this study investigates the sources of health advice used by 1 trekkers traveling from the United Kingdom to India, Nepal and Morocco and the appropriateness of the advice which they were given. Methods Questionnaires were distributed by trek leaders at the time of travel to 17 consecutive clients of an established travel company in the United Kingdom who were leaving for trekking holidays during the period from February to April 1996. Clients were asked to return the questionnaires after the conclusion of their holiday.the questionnaire inquired about the sources of health advice Mike Townend, MB, ChB (Hons), Diploma in Travel Medicine: General Practitioner, Cockermouth, Cumbria, UK. Reprint requests: Dr. MikeTownend, 24 Fitz Road, Cockermouth, Cumbria CAI3 OAD, UK. JTravel Med 1998; 5:73-79. used prior to departure, the nature of the advice given, and the trekkers perception of its usefulness, comparing it with advice which would be considered suitable for the destination and the type of holiday. The sources of information used in deciding the appropriateness of advice given were the HMSO publication Immunisation against Infectious Disease, thetravax on-line computer database, and the U.K. Malaria Guidelines. Appropriateness was assessed according to the detailed itinerary of the trip in question and the levels of risk for the individual for the type of travel involved, and not simply with reference to the country.the areas of advice covered by the questionnaire included vaccination, malarial prophylaxis, and other lion-inimunizable health risks. The acceptance of advice on vaccination and malarial prophylaxis was also investigated. After an initial response rate of only 36%, a further identical questionnaire was sent out to nonresponders and a response rate of 93.5% was eventually btained.m questiomlaires returned were received within 3-4 months of the departure dates and within 2 to 3 months of the traveler s returning home. As the study was intended to be investigative and descriptive with no prior hypothesis, no statistical analysis of the results was carried out. Results One hundred questionnaires were returned, resulting in a response rate of 93.5%. Fifty percent of respondents were female, 49% male and 1% failed to identify 73 Downloaded from https://academic.oup.com/jtm/article-abstract/5/2/73/18939 on 26 December 217

~~~~ ~~ ~~ 74 Journal of Travel Medicine, Volume 5, Number 2 Table 1 Sources and Perceived Usefulness of Pretravel Medical Advice Used by Trekkers hi.. @) Finding Source No. PA) Findiq Source Advice Source No. (%) Using Soicrce* Most hfurfnatiw Mosr USCfi l Travel agent 9 (9%) 2 (22%) 2 (22%)) Tour operator 68 (68%) 19 (28%) 16 (24%) GP/Health center 69 (69%) 41 (59%) 36 (52%) Travel advice center 15 (15%) 1 (67%) 9 (6%1) Books/Library 34 (34%) 16 (47%) 13 (38%) Other 18 (18%) 1 (56%) 12 (67%) *n = 1 gender.ten percent traveled to India, 45% to Nepal and 45% to Morocco. The length of stay in all three countries was 2-3 weeks. Travelers to India had a period of sightseeing at lower altitudes as well as a mountain trek and were thus at risk of malaria. Some travelers to Nepal also visited lowland areas with a risk of malaria, but some did not. Malaria was not considered a risk in Morocco. Accommodation on trek in India and Morocco was in local hotels and lodges while in Nepal it was in tents. There was little close or prolonged physical contact with local people and therefgre a relatively low risk of personto-person irhection.there was a possibility of contact with animals in all trekking destinations.trekkers in Nepal were usually more than 24 hours from medical help and those in other countries were probably similarly remote for at least part of the time. Table 1 shows the sources of advice used prior to traveling and the trekkers perception of how useful the advice was. Many trekkers consulted more than one source, but the most frequently used sources were general practitioners, who were perceived to offer the most informative and most useful advice by 59.4% and 52.2% of users, respectively, and the tour operator organizing the holiday.the tour operators, however, were perceived as the most informative and useful sources by only 27.9% and 23.5% of users, respectively. Specialist travel advice centers were used by only 15% of trekkers, but were rated as most informative by 66.7% and most useful by 6% of users, making them the source perceived to be the best overall by a small margin. Other travelers were also perceived as a useful source of information, but travel books and travel agents were not rated very highly. Eighty-two percent of trekkers used more than one source of advice, with 54% using two sources and 23% using three sources. Only 6% used more than three sources. Vaccination Advice Vaccination advice given for travelers to the three countries and the appropriateness of that advice are summarized intables 2,3 and 4. It was considered appropriate for trekkers traveling to India to receive vaccinations against tetanus, poliomyelitis, hepatitis A, typhoid and rabies (seetable 2).All Table 2 Vaccination Advice for Trekkers Traveling to India No. (%) No. (%) liaaination Advised* Accepted Appropriatenessf Cholera 2 (2%) Diphtheria 2 (2%) Hepatitis A 7 (7%) HepA immunoglobulin 1 (1%) Hepatitis B 2 (2%1) Japanese B 2 (2%) Meningococcal 6 (6%) Polioniyelitis 1 (1%) Rabies Tetanus 1 (1%) Tuberculosis Typhoid 9 (9%) 7 (LOO%I) 2 (1%) 6 (1%) 1 (1%) 1 (1 %1) 9 (1%) *n = 1 =appropriate for this trip; = not appropriate for this trip but sometimes indicated for travel to this country; -- inappropriate - Table 3 Vaccination Advice for Trekkers Traveling to Nepal No. (76) Nu. (?A) Vaccinatrori Advised* Accepted Appropriateness Cholera 18 (4%) Diphtheria 9 (2%) Hepatitis A 37 (82%) HepA immunoglobulin 3 (7%) Hepatitis B 9 (2%) Japanese B Meningococcal 31 (69%) Poliomyelitis 37 (82%) Rabies 12 (27%) Tetanus 37 (82%) Tuberculosis 4 (9%) Typhoid 4 (89%).9 (5%) 7 (78%) 34 (92%) 3 (1%) 9 (1%) 27 (87%) 36 (97%) 11 (92%) 33 (89%) 4 (1%) 37 (93%) *n = 45 = appropriate for this trip; = not appropriate for this trip but sometimes indicated for travel to this country; - inappropriate - Downloaded from https://academic.oup.com/jtm/article-abstract/5/2/73/18939 on 26 December 217

Townend, Medical Advice for Trekkers 75 Table 4 Vaccination Advice for Trekkers Traveling to Morocco No. ('9) Ko. (96) Vucn'nntion Arivi.ted* Arrepted Appropriaieness? Cholera 12 (27%) 6 (SO%]) - Diphtheria 4 (9%) 3 (75%) Hepatitis A 37 (82%) 37 (1%) HepA ininmunoglobulin 3 (7%) 3 (1%) Hepatitis B 4 (9%) 4 (1YI) Japanese B - Meningococcal - Poliomyelitis 34 (76%) 31 (92%) Rabies 1 (2%) 1 (1%) Tetanus 34 (76%) 31 (9%) Tuberculosis 3 (7%) 3 (1%) Typhoid 31 (69%) 27 (87%) *n = 45 = appropriate for this trip; = not appropriate for this trip but sometimes indicated for travel to this country; - inappropriate 1 trekkers (1%) were appropriately advised to have tetanus and poliomyelitis vaccination. Nine (9%) were advised to have typhoid vaccine and all nine accepted it. Eight (8%) were advised to have protection against hepatitis A by means of human immunoglobulin or vaccination and 7 (88%) accepted. One trekker (1%) remained unprotected against typhoid and 3 (3%) remained unprotected against hepatitis A. Two trekkers (2%) were inappropriately advised to have cholera vaccine, as this vaccine is neither advised nor indeed available in the United Ihngdom at present.a similar number were advised, again inappropriately and also unsuccessfully, to have Japanese B encephalitis and diphtheria vaccination, both of which were considered inappropriate for this journey because of the short duration of stay and the lack of close contact with local people. Six (6%) were advised to have meningococcal AC vaccine arid all accepted, while two (2%) were advised to have hepatitis B vaccine and accepted. Both of these vaccinations were considered inappropriate because of the lack ofclose contact with local people and the short duration of stay. For similar reasons, tuberculosis protection was not advised for any trekkers nor was it considered appropriate for this type of traveling. Although rabies vaccine was considered appropriate for this type of traveling, no trekkers were advised to have it and all went unprotected. It was considered appropriate for trekkers traveling to Nepal to receive vaccinations against tetanus, poliomyelitis, hepatitis A, typhoid and rabies (seetable 3). Meningococcal AC vaccine was considered appropri- ate in view of the high prevalence of meningococcal infection in Nepal. Thirty-seven trekkers (82%) were advised to have tetanus and poliomyelitis vaccination; all accepted poliomyelitis but only 33 (89%) accepted tetanus. Forty (89%) were advised to have typhoid vaccination and 37 (93%) accepted it, and a similar number was advised to have hepatitis A protection either by vaccination or human immunoglobulin, ofwhom 37 (93%) accepted it. Vaccination against meningococcal infection was advised for 31 (69%), of whom 27 (87%) accepted it, while rabies vaccination was advised for only 12 (27%), of whom 11 (92%) accepted it. Cholera vaccination was inappropriately advised for 18 (4%), ofwhom 9 (5%) were under the impression that they had been given it in spite of its unavailability at the time. Nine (2%) were advised to have hepatitis B and diphtheria vaccination, inappropriately in view of the length of stay and lack of close contact with local people, of whom 9 (1%) and 7 (78%), respectively, accepted it. For similar reasons tuberculosis protection was considered inappropriate, but four trekkers (9%) were advised to have BCG vaccination and all four accepted the advice. It was not possible from the data obtained to assess whether there were special reasons for this advice. None were advised to have Japanese B encephalitis vaccination. It was considered appropriate for trekkers traveling to Morocco to receive vaccinations against tetanus, poliomyelitis, hepatitis A, typhoid and possibly rabies (see Table 4).Thirty-four trekkers (76%) were advised to have tetanus and poliomyelitis vaccination and 31 (91%) accepted. Forty (89%) were advised to have hepatitis A protection either by human immunoglobulin or by vaccination and all accepted, while 31 (69%) were advised to have typhoid vaccination, of whom 27 (87%) accepted it. Twelve trekkers (27%) reported having been inappropriately advised to have cholera vaccine, of whom 6 (5%) were under the impression that they had been given it despite its current unavailability in the United Kingdom. Four (9%) were inappropriately advised to have hepatitis B vaccination and 3 (7%) protection against tuberculosis, ofwhom 4 (1%) and 3 (loo%)), respectively, accepted. None were advised to have either meningococcal AC or Japanese B encephahtis vaccination, and only one (2%) was advised to have rabies vaccination. Advice on Antimalarial Drugs Antimalarial drugs were considered appropriate for all the trekkers traveling to India (Table 5).'AU 1 were appropriately advised to take chloroquine and proguanil and all did so, 9 of them (9%) taking the full course as directed. Of those traveling to Nepal, 13 (29%) visited lowland areas where malarial prophylaxis was considered Downloaded from https://academic.oup.com/jtm/article-abstract/5/2/73/18939 on 26 December 217

76 Journal of Travel Medicine, Volume 5, Number 2 Table 5 Antimalarial Advice and Uptake No. (?A) No. ( %I No. (%) Advised Takiilg Taking Full No.$r Whom Country Drugs Drugs Course Appropriate India* 1 (1%) 1 (1%) 9 (9%) 1 (1%)) Nepal? 38 (84%) 27 (71%) 22 (81%) 13 (29%) Morocco 2 (4%) 1 (5%) 1 (5%) Total 5 (5%) 38 (76%) 32 (82%) 23 (23%) *n = 1O;tn = 45 appropriate. All 13 were appropriately advised to take chloroquine and proguanil and all did so, 12 (92%) taking the full course as directed.twenty-eight trekkers in Nepal (62%) &d not visit lowland areas, therefore for them antimalarial drugs were considered inappropriate.twentyone (75%) of them were inappropriately advised to take prophylaxis but only 13 (62%) did so, of whom only 9 (69%) took the full course.the remaining four trekkers in Nepal gave insuacient information on their itinerary to assess the appropriateness of antimalarial advice; all four of them were advised to take medication and all took it for the full course. Malaria was not considered to be a risk in Morocco, yet 2 trekkers (4%) were advised to take medication. Both did so, but only one completed a full course. In total, 5 trekkers were advised to take antimalarial drugs and 38 did so, ofwhom 8 (21%) suffered side effects, all being minor gastrointestinal upsets. All were appropriately advised about the length of treatment required and 32 (82%) completed the full course. Other Health Advice The non-immunizable disease risks for trekkers traveling to all three countries were considered to arise chiefly from travelers diarrhea, insect bites and diseases transmitted by them, contact with animals, and walking barefoot.advice on food and water hygiene and specific advice on preventing and treating diarrhea, and advice on avoiding insect bites, contact with animals and going barefoot would therefore be of importance. Risks from prolonged and close physical contact with local people were considered minimal, as was the possibility of bathing or swimming on these particular trips or of sexually transmitted diseases. Advice on these risks was therefore not considered essential. Table 6 summarizes the advice given on nonimmunizable risks. Eighty percent of trekkers to India, 78% of those to Nepal and 73% of those to Morocco were advised about food and water hygiene (76% overall). Fifty percent, 69% and 38% respectively (53% overall) were given more specific advice about travelers diarrhea. Only 3% of trekkers to India, 16% of those to Nepal and 2% of those to Morocco (I 1% overall) were given advice about avoiding insect bites, and only 296, 47% and 9% respectively (27% overall) were warned about contact with animals. Discussion The most fi-equently used sources of advice were GPs or health centers and the tour operator organizing the holiday, both being used by over two-thirds of all trekkers. Over one-third used books or public libraries as a source of advice, while about one in six used a specialist travel advice center. Less than one in ten consulted a travel agent for advice. About two-thirds of those using a travel advice center rated it as providing the most informative and useful advice, the highest rating of any of the sources used. This is perhaps to be expected bearing in mind the Table 6 Advice Given to Trekkers on Other Non-lrnrnunizable Health Risks Advised Travelers Advised Trawe/ers Advised Travelers Risk to India* to Nepal t to Morocco Total Advised Appropriatenesd Diarrhea 5 (5%) 31 (69%) 17 (38%) 53 (53%) Food/water Insects Animals 2 (2%) 21 (47%) 4 (9%) 27 (27%) Swimming 4 (4%) 31 (69%) 1 (22%) 45 (45%) Walking barefoot 3 (3%) 1 (22%) 21 (47%) 34 (34%) f Physical contact 2 (2%) 7 (16%) 1 (2%) 1 (1%) STDs 3 (3%) 1 (22%) 2 (4%) 15 (15%) 8 (8%) 35 (78%) 33 (73%) 76 (76%) 3 (3%) 7 (16%) 1 (2%) 11 (11%) *n = 1;tn = 45 = appropriate for this trip; = not appropriate for this trip but sometimes indicated for travel to this country Downloaded from https://academic.oup.com/jtm/article-abstract/5/2/73/18939 on 26 December 217

Townend. Medical Advice for Trekkers 77 specialized nature of the service offered.the other sources used were almost as highly rated, particularly previous personal experience and the experience of other travelers or the trek leader. A similar rating was given to advice from a GP or health center, an encouraging finding for GPs in that their advice is seen as being almost as useful as that from a specialized advice center. Books were rated less highly as information sources, a finding which is in accordance with the author s findings in an unpublished survey of travel books. Many otherwise excellent travel guides give little useful information on health problems or precautions.the tour operator was rated as most useful or informative by only about a quarter of those using this source of information. Several trekkers mentioned, for example, that the tour literature for some treks advised them to have cholera vaccination whde other sources advised against it, or that health information from the tour operator was inadequate. There is clearly a need for tour operators to update and improve the information which they give to trekkers. For all three trekking destinations, vaccination against hepatitis A, poliomyelitis, tetanus and typhoid would usually be considered appropriate. Approximately 4 out of 5 of all trekkers were advised to have these vaccines, over 9% of whom accepted this advice. Trekkers to Morocco were less likely to be advised to have them, perhaps because Morocco is perceived to be a less threatening environment and a more established holiday destination than is India or Nepal. Rabies vaccination may be appropriate for many trekkers, particularly if their itineraries take them more than 24 hours away from reliable medical help, yet only 13% were advised to have the vaccine. No trekkers to India were advised to have rabies vaccine, and only one traveling to Morocco, but the need for rabies vaccine was perceived to be greater in Nepal, where 27% of trekkers were advised to have it. Hepatitis B, diphtheria, tuberculosis and meningococcal vaccination are, for the most part, not a great priority for the treks under consideration in view of the short length of stay and the relative lack ofciose contact with local people.the exception to this is that trekkers ip Nepal are now usually advised to have meningococcal vaccine. Over two-thirds of trekkers to Nepal were advised to have meningococcal vaccine, but almost as many traveling to India were similarly advised. More than one in five of all trekkers were also advised to have hepatitis B and diphtheria vaccination, and about half that number were advised to have BCG vaccination. Cholera vaccination is currently considered to be relatively ineffective and not appropriate for any destination, yet about one-third of all trekkers were advised to have it. Much of this advice appears to have originated from the tour operator and it was oi ten ignored. Although a majority of trekkers were protected against the most important immunizable diseases relevant to their particular journeys, there is still room for improvement in the numbers offered protection against them. Insufficient numbers were offered protection against rabies, and a substantial minority were given advice and vaccinations which they did not need. The reasons for inappropriate advice probably include lack of up-to-date information avdable from tour operators, travel books and GPs surgeries or health centers. In the primary care setting, travel advice is often given by a doctor or nurse who simply consults a wall chart for information on the country of destination when what is needed is a risk assessment which also takes into account the individual, the journey, the nature of the accommodation, and the activities to be undertaken. There is clearly a need for more education of GPs and practice nurses in risk assessment for the trekker. In adchtion, tour operators and trekking companies must recognize the need for up-to-date medical advice to enable them to give a better service to their clients. The itinerary of the trekkers to India exposed them to a risk of malaria which was recognized in the advice which they were given, all of them being correctly advised to take antimalarial drugs and 9% of them doing so.there appears to have been rather more confusion among advisors of trekkers to Nepal about whether antimalarial drugs were needed. Al those exposed to a risk of malaria were correctly advised to take prophylaxis, but 75% of those not exposed to the risk were also advised to take drugs. As most of those taking prophylaxis had asked their GPs for advice, this indicates a need for GPs and practice nurses to look more closely at the criteria for advising antimalarial drugs, taking into account not only the country of destination but also the time of year, the part of the country to be visited and the altitude ceiling above which malaria is unlikely. In a11 cases except one, appropriate drugs were advised, namely chloroquine and proguanil, and an appropriate length of course was advised.approximate1y 4 out of 5 trekkers took the drugs for the full course, but as most imported malaria in the United Kingdom is seen in those who have not taken or completed a course of antimalarial drugs, the need to complete the course still needs to be stressed. It would appear from this study that those who needed prophylaxis were more likely to complete the course than were those who were inappropriately advised to take it. This may be a fortunate coincidence but may also reflect the fact that some trekkers became aware that they did not need drugs and simply stopped taking them. Seventy-six percent of all trekkers were given advice about food and water hygiene, and 53% were given additional specific advice about travelers diarrhea and how Downloaded from https://academic.oup.com/jtm/article-abstract/5/2/73/18939 on 26 December 217

78 Journal of Travel Medicine, Volume 5, Number 2 to prevent it. Travelers diarrhea is the health problem which a traveler to a developing country is most likely to develop, and food and water hygiene is the most iniportant aspect of preventing it. It is therefore at least as important for advisors to draw the attention of the traveler to such matters as it is to offer vaccinations.this study shows that although many advisors do so, they std do so a little less frequently than they offer vaccinations against typhoid, a disease which is a great deal less likely to occur. The next most frequent advice given to 45% of trekkers was about the hazards of bathing or swimming in unpurified water.while this may be of importance to some travelers to the countries under consideration, personal experience of trekking shows that opportunities to swim or bathe while on trek seldom occur and that when they do, the ambient or water temperatures and/or the speed of flow of the water make such activities seem less desirable. About a third of trekkers were warned about the dangers of going barefoot. This is of more relevance as trekkers may remove their boots to rest or cool their feet or may go about barefoot or wearing flip-flops around camping areas, exposing them to the risk of soil-borne infections or infestations. It is interesting and somewhat inconsistent that only 13% of trekkers were advised to have rabies vaccine, whde 27% of them were warned of the dangers of contact with animals. Close physical contact and sexually transmitted diseases were the subject of warnings to only 1% and 15% of trekkers respectively. They are of little relevance to this type of trip. Trekkers do not usually come into close physical contact with local people to an extent or for a length of time sufiicient to put them at risk from diseases of close contact such as tuberculosis or diphtheria, though they may be at a slightly greater risk from the outbreaks of meningococcal disease which tend to occur in Nepal in the pre-monsoon period. Advice on sexually transmitted diseases may be appropriate for travelers to virtually all countries, but the circumstances of a trekking holiday do not easily lend themselves to sexual encounters. Fifteen percent of all trekkers were nevertheless advised about the risks of sexual contact. Conclusions The sources of health advice used most frequently prior to traveling, by over two-thirds of trekkers, were the primary health care team and the tour operator organizing the holiday. Books were the next most frequent source, used by about a third of trekkers. The most informative and useful sources of advice as perceived by those who used them were specialist travel advice centers and the primary health care team, but the smaller numbers who used alternative sources such as the experience of other travelers also found those to be as useful. Books were not found to be as useful, and travel agents and the tour operator were perceived as the most informative and useful by only about a quarter of those using them. It could be argued that the perception of trekkers of the usefulness of the advice given is not necessarily a true reflection of its usefulness as it depends on the recall of those receiving the advice and on the knowledge base from which they judge its usefulness. The trekkers perception of usefulness is, however, likely to influence the credence which they attach to the advice and their likelihood of using the advice source again. Much of the advice given on vaccinations was appropriate, with a majority of trekkers being advised to have the most appropriate vaccines for their particular trip. Rabies vaccine tended to be under-advised, given the nature of trekking holidays, and a substantial minority of trekkers were advised to have vaccinations which were not needed. More careful assessment of individual risk profiles for travelers is needed before advising on vaccinations. A majority of trekkers needing antimalarial drugs were correctly advised to take them, but many who did not need to take them were also advised to do so.the use of more specialized advice such as a computer database or a malaria help line and more careful inquiry into the circumstances of the trekking holiday would avoid this unnecessary advice. Advice on other health risks not amenable to vaccination or drug prophylaxis was less than satisfactory.the number of trekkers advised about food and water hygiene was slightly lower than those advised to have typhoid vaccination, and a minority of trekkers received appropriate advice about other potential risks.there is clearly a need for trekkers to have access to more relevant advice about non-imrnunizable health risks which form the majority of the risks to which they are exposed. Recommendations I. Tour operators need to give more comprehensive and accurate advice on health risks and precautions to their clients who book trekking holidays. This could best be achieved by their obtaining appropriate advice from appointed and suitably qualified medical advisors or from commercially operated advice centers and including it in their brochures and tour information. They should also advise clients to consult a travel advice center or a suitably qualified health care professional, as advice may need to be updated. 2. Health care professionals giving travel advice must be aware of the need to carry out a risk assessment when consulted by trekkers. They need to be more aware Downloaded from https://academic.oup.com/jtm/article-abstract/5/2/73/18939 on 26 December 217

Townend, Medical Advice for Trekkers 79 of the indications for vaccination and the circumstances under which malarial prophylaxis is appropriate.they also need to be aware of non-inmunizable health risks and to be able to give appropriate advice on avoiding them.this may be achieved by undertaking training such as is offered, for example, by the MSc, Diploma in Travel Medicine and Certificate courses offered by the University of Glasgow, by the availability of less intensive courses as part of their continuing education, and by the study of suitable material in professional journals and periodicals. There is also an argument for recognizing members of the primary health care team who have undergone training in Travel Medicine as being qualified to give advice to travelers. A precedent for this is the recognition given in the United Kingdom to GPs and practice nurses or midwives for their ability to reach certain standards in obstetric, minor surgery, asthma or diabetes care or for health promotion activities. Such recognition should be linked to the attainment of an agreed standard of knowledge and skill in Travel Medicine. References 1. Kayser B.Acute mountain sickness in western tourists around the Thorong Pass (54 m) in Nepal. J Wilderness Med 1YY1; 2:llO-117. 2. Murdoch DR. Symptoms of infection and altitude illness among hikers in the Mount Everest region of Nepal. Aviat Space and Environ Med 1995; 66:148-151. 3. Hackett PH, Rennie D. The incidence, importance and prophylaxis of acute mountain sickness. Lancet 1976; 2:1149-1154. 4. Howarth JW. Hazards of trekking in Nepal.Trave1 Med Int 1997; 15(3):1-4. 5. Shlim DK. Health and safety. In: Trekking in the Nepal Himalaya.Victoria, Australia: Lonely Planet, 1985. 6. Salisbury DM, Begg NT. Immunisation against infectious disease 1996. HMSO, London, 1996. 7. Lea G, Leese J. Health information for overseas travellers 1995. HMSO, London, 1995. 8. Travax on-line computer database. Scottish Centre for Infection and Environmental Health, Ruchill Hospital, Glasgow. 9. Bradley DJ,Warhurst DC. Malaria prophylaxis: guidelines for travellers from Britain. BMJ 1995: 31:79-714. 1. Farthing MJG.Travellers diarrhoea. Gut 1994; 35:l-4. Burgtheater, arguably the most celebrated German-language theater in the world. Vienna, Austria. Submitted by Charles D. Ericsson, MD. Downloaded from https://academic.oup.com/jtm/article-abstract/5/2/73/18939 on 26 December 217