CORRESPONDENCE * All letters must be typed with double spacing and signed by all authors. * No letter should be more than 400 words. * For letters on scientific subjects we normally reserve our correspondence columns for those relating to issues discussed recently (within six weeks) in the
BMJ.
* We do not routinely acknowledge letters. Please send a stamped addressed envelope ifyou would like an acknowledgment. * Because we receive many more letters than we can publish we may shorten those we do print, particularly when we receive several on the same subject.
Overprescription of cholera vaccine SIR,-Though Drs Alison Mott and Paul Kinnersley's article documents very usefully the overprescription of cholera vaccine to travellers by general practitioners, it fails to emphasise that the Department of Health itself is primarily responsible for the contradictory information that both travellers and general practitioners have received on this subject.' Its publication Before You Go,' which is widely distributed to the public, does not follow the World Health Organisation's guidelines but recommends cholera vaccination for all countries where cholera is endemic. An attempt to explain to a patient that one disagrees with the advice given in the booklet issued by the Department of Health is likely to fall on deaf ears. This situation is particularly unfortunate as the two booklets Before You Go and While You Are Away3 contain useful irnformation about drinking water, safe sexual practices, and infectious diseases and could be issued to all travellers by general practitioners in their surgeries. I would also like to disagree with the interpretation by Drs Mott and Kinnersley of the information given in Immunization Against Infectious Diseases, again published by the Department of Health.4 This is widely used by general practitioners as their immunisation handbook. Though it quotes the World Health Organisation's view and the limited use of cholera vaccine, it still persists in suggesting that vaccination may confer some personal protection, and still recommends that people travelling to countries where cholera is endemic should be vaccinated. Might I suggest that the only step necessary to reduce overprescription of cholera vaccine would be to place pressure on the Department of Health to bring its own recommendations in line with informed medical opinion concerning this subject. J SILVERMAN Health Centre, Linton, Cambridge CB I 6JS I Mott A, Kinnerslev P. Overprescription of cholera vaccine to travellers by general practitioners. Br Medj 1990;300:25-6.
(6 January.) 2 Department of Health. Before you go. London: HMSO, 1989.
(SA 40.) 3 Department of Health. While You are awaY. London: HMSO, 1989. (SA 41.) 4 Department of Health and Social Services. Immunization against infectious diseases. London: HMSO, 1988.
SIR,-Drs Alison Mott and Paul Kinnersley take upon themselves a grave responsibility when they talk about "educating general practitioners" before they are sure that their own house is in order. ' For those of us who have to deal with people who travel BMJ
VOLUME 300
27 JANUARY 1990
to tropical Africa and Asia and who have to cope with the problems when they return the position is not as simple as the reader might be led to believe by the article. My department has for years looked after OXFAM's fieldworkers and Oxford University's expeditions and many members who travel in the course of their work. The World Health Organisation's recommendation that cholera vaccine should no longer be given was based on the fact that vaccination did not prevent the spread of cholera throughout Africa. No one would claim that cholera vaccine is one of our best prophylactic preparations, but an alarming number of travellers are asked in many Third World countries if they have been vaccinated against cholera, and if they have not the immigration official has an arrangement with a local person who will vaccinate them. No doubt this is a good source of extra income, but the risk now of contracting not only hepatitis B but also HIV from non-sterile needles is great, and that alone is ample reason for giving cholera vaccine. Some countries demand a valid vaccination certificate as their official policy. In the floods of the Sudan in 1988 it became clear that people who had had two or more immunisations against cholera had a 50% lower chance of contracting cholera than those who had had one injection or none.2 When the vaccine is given intradermally in a dose of 0-2 ml side effects are very rare, even after multiple injections, and the cost negligible. BENT JUEL-JENSEN Radcliffe InfirmarN, Oxford OX2 6HE
the requirement in May 1989.) Additionally, though a certificate is not required for entry into India, "travellers proceeding to countries that impose restrictions for arrivals from India" are required to possess a certificate. Seasoned travellers will often ask for cholera certificates for travel to countries where they know from experience that they may have problems with immigration authorities if they do not possess one. This particularly applies to travellers to or between countries in Africa. For these I have heard a number of people suggest that a certificate should be supplied without the vaccine. I regard this as unethical and fraudulent. The certificate is valueless because vaccination does not prevent carriage of the vibrio across international borders. The protection is not totally valueless. General practitioners cannot be expected to be up to date with recommendations unless their sources give more uniform advice. "Special centres" have the benefit of a constantly reviewed database as well as considerable experience, making the recommendation of cholera vaccination and other procedures more rational. J M STEWART British Airways,
London WIR 5TA 1 Mott A, Kinnersley P. Overprescription of cholera vaccine to travellers by general practitioners. Br MedJ 1990;30:25-6. (6 January.) 2 World Health Organisation. International travel and health: vaccination requirements and health advice. Geneva: WHO, 1989.
1 Mott A, Kinnerslex 1P. Overprescription of cholera vaccine to travellers by general practitioiners. BrAlcdj 1990;300:25-6. (6
Januarv.) 2 Immunisationi Practices Advisory Committcc. Cholera vraccinc. AIAIWR 1988;37:617-24.
SIR,-Our immunisation service recommends cholera vaccination much less frequently than in the past and often counsels travellers not to have the vaccine. I agree that among the cases described by Drs Alison Mott and Paul Kinnersley' the traveller to Sudan is the only one to whom vaccine should have been recommended, but the decision is not always clear cut. Healthy Europeans are unlikely to contract cholera, and if they do then adequate rehydration and treatment with tetracycline or co-trimoxazole are quickly effective. For cholera, as well as other diseases with faecal-oral spread, good food hygiene and water treatment are paramount, but 60% protection is not to be totally disregarded if there is moderate or serious risk of exposure. The World Health Organisation's booklet International Travel and Health2 cites four countries where a vaccination certificate is required by travellers arriving from endemic areas-Pakistan, Pitcairn, Somalia, and Sudan. (Lesotho dropped
SIR, -Drs Alison Mott and Paul Kinnersley have shown that cholera immunisation would be recommended to travellers by general practitioners more frequently than by the Liverpool School of Tropical Medicine, and that the general practitioners in their sample varied among themselves in the advice that they offered to a series of five hypothetical patients.' They conclude that either cholera vaccine should be available only through special centres, or general practitioners should be educated about its use. Last year we showed that the prophylactic immunisations recommended by a sample of 50 general practitioners for a hypothetical traveller to Turkey varied considerably among doctors.2 Many of the recommendations were not supported by expert opinion. Thus vaccines other than that for cholera may also be prescribed inappropriately. One reason may be that general practitioners receive conflicting guidance on prophylaxis for travellers. Both Drs Mott and Kinnersley and ourselves noted multiple inconsistencies among the various sources of information quoted by the general practitioners in our respective samples. Dr John Holden has also drawn attention to this, and 257
BMJ.
* We do not routinely acknowledge letters. Please send a stamped addressed envelope ifyou would like an acknowledgment. * Because we receive many more letters than we can publish we may shorten those we do print, particularly when we receive several on the same subject.
Overprescription of cholera vaccine SIR,-Though Drs Alison Mott and Paul Kinnersley's article documents very usefully the overprescription of cholera vaccine to travellers by general practitioners, it fails to emphasise that the Department of Health itself is primarily responsible for the contradictory information that both travellers and general practitioners have received on this subject.' Its publication Before You Go,' which is widely distributed to the public, does not follow the World Health Organisation's guidelines but recommends cholera vaccination for all countries where cholera is endemic. An attempt to explain to a patient that one disagrees with the advice given in the booklet issued by the Department of Health is likely to fall on deaf ears. This situation is particularly unfortunate as the two booklets Before You Go and While You Are Away3 contain useful irnformation about drinking water, safe sexual practices, and infectious diseases and could be issued to all travellers by general practitioners in their surgeries. I would also like to disagree with the interpretation by Drs Mott and Kinnersley of the information given in Immunization Against Infectious Diseases, again published by the Department of Health.4 This is widely used by general practitioners as their immunisation handbook. Though it quotes the World Health Organisation's view and the limited use of cholera vaccine, it still persists in suggesting that vaccination may confer some personal protection, and still recommends that people travelling to countries where cholera is endemic should be vaccinated. Might I suggest that the only step necessary to reduce overprescription of cholera vaccine would be to place pressure on the Department of Health to bring its own recommendations in line with informed medical opinion concerning this subject. J SILVERMAN Health Centre, Linton, Cambridge CB I 6JS I Mott A, Kinnerslev P. Overprescription of cholera vaccine to travellers by general practitioners. Br Medj 1990;300:25-6.
(6 January.) 2 Department of Health. Before you go. London: HMSO, 1989.
(SA 40.) 3 Department of Health. While You are awaY. London: HMSO, 1989. (SA 41.) 4 Department of Health and Social Services. Immunization against infectious diseases. London: HMSO, 1988.
SIR,-Drs Alison Mott and Paul Kinnersley take upon themselves a grave responsibility when they talk about "educating general practitioners" before they are sure that their own house is in order. ' For those of us who have to deal with people who travel BMJ
VOLUME 300
27 JANUARY 1990
to tropical Africa and Asia and who have to cope with the problems when they return the position is not as simple as the reader might be led to believe by the article. My department has for years looked after OXFAM's fieldworkers and Oxford University's expeditions and many members who travel in the course of their work. The World Health Organisation's recommendation that cholera vaccine should no longer be given was based on the fact that vaccination did not prevent the spread of cholera throughout Africa. No one would claim that cholera vaccine is one of our best prophylactic preparations, but an alarming number of travellers are asked in many Third World countries if they have been vaccinated against cholera, and if they have not the immigration official has an arrangement with a local person who will vaccinate them. No doubt this is a good source of extra income, but the risk now of contracting not only hepatitis B but also HIV from non-sterile needles is great, and that alone is ample reason for giving cholera vaccine. Some countries demand a valid vaccination certificate as their official policy. In the floods of the Sudan in 1988 it became clear that people who had had two or more immunisations against cholera had a 50% lower chance of contracting cholera than those who had had one injection or none.2 When the vaccine is given intradermally in a dose of 0-2 ml side effects are very rare, even after multiple injections, and the cost negligible. BENT JUEL-JENSEN Radcliffe InfirmarN, Oxford OX2 6HE
the requirement in May 1989.) Additionally, though a certificate is not required for entry into India, "travellers proceeding to countries that impose restrictions for arrivals from India" are required to possess a certificate. Seasoned travellers will often ask for cholera certificates for travel to countries where they know from experience that they may have problems with immigration authorities if they do not possess one. This particularly applies to travellers to or between countries in Africa. For these I have heard a number of people suggest that a certificate should be supplied without the vaccine. I regard this as unethical and fraudulent. The certificate is valueless because vaccination does not prevent carriage of the vibrio across international borders. The protection is not totally valueless. General practitioners cannot be expected to be up to date with recommendations unless their sources give more uniform advice. "Special centres" have the benefit of a constantly reviewed database as well as considerable experience, making the recommendation of cholera vaccination and other procedures more rational. J M STEWART British Airways,
London WIR 5TA 1 Mott A, Kinnersley P. Overprescription of cholera vaccine to travellers by general practitioners. Br MedJ 1990;30:25-6. (6 January.) 2 World Health Organisation. International travel and health: vaccination requirements and health advice. Geneva: WHO, 1989.
1 Mott A, Kinnerslex 1P. Overprescription of cholera vaccine to travellers by general practitioiners. BrAlcdj 1990;300:25-6. (6
Januarv.) 2 Immunisationi Practices Advisory Committcc. Cholera vraccinc. AIAIWR 1988;37:617-24.
SIR,-Our immunisation service recommends cholera vaccination much less frequently than in the past and often counsels travellers not to have the vaccine. I agree that among the cases described by Drs Alison Mott and Paul Kinnersley' the traveller to Sudan is the only one to whom vaccine should have been recommended, but the decision is not always clear cut. Healthy Europeans are unlikely to contract cholera, and if they do then adequate rehydration and treatment with tetracycline or co-trimoxazole are quickly effective. For cholera, as well as other diseases with faecal-oral spread, good food hygiene and water treatment are paramount, but 60% protection is not to be totally disregarded if there is moderate or serious risk of exposure. The World Health Organisation's booklet International Travel and Health2 cites four countries where a vaccination certificate is required by travellers arriving from endemic areas-Pakistan, Pitcairn, Somalia, and Sudan. (Lesotho dropped
SIR, -Drs Alison Mott and Paul Kinnersley have shown that cholera immunisation would be recommended to travellers by general practitioners more frequently than by the Liverpool School of Tropical Medicine, and that the general practitioners in their sample varied among themselves in the advice that they offered to a series of five hypothetical patients.' They conclude that either cholera vaccine should be available only through special centres, or general practitioners should be educated about its use. Last year we showed that the prophylactic immunisations recommended by a sample of 50 general practitioners for a hypothetical traveller to Turkey varied considerably among doctors.2 Many of the recommendations were not supported by expert opinion. Thus vaccines other than that for cholera may also be prescribed inappropriately. One reason may be that general practitioners receive conflicting guidance on prophylaxis for travellers. Both Drs Mott and Kinnersley and ourselves noted multiple inconsistencies among the various sources of information quoted by the general practitioners in our respective samples. Dr John Holden has also drawn attention to this, and 257
