Response to Letter:

We thank Drs Arya and Agarwal for their comments highlighting that among VFR travelers, risk for travel-related infections may differ by country of birth and that persons born in endemic countries may be more likely than, for example, US-born travelers to have prior immunity. While this might be true in some circumstances, for hepatitis A, recent studies suggest that a substantial proportion of adults from endemic areas lack protective antibodies.1 Typhoid fever and malaria also pose risks, even for travelers who have had illness previously, because infection does not confer lasting immunity.

Identifying at-risk travelers for pretravel health counseling, especially VFRs who may not be able to plan their travel far in advance, is challenging. Primary care clinicians could help meet this challenge through anticipatory counseling of patients likely to travel to high-risk areas, as part of routine health maintenance. Our findings suggest that US travelers to India of South Asian ethnicity are unlikely to seek pretravel health advice and represent a group that could be targeted for counseling. We agree that additional work is needed to identify novel ways to target these at-risk groups that can benefit from pretravel counseling.

Henry C. Baggett * , Paul M. Arguin , Phyllis E. Kozarsky , Christie Reed