Travel Advice Given by Pharmacists
Neville Kodkani,]enn$er M.]enkins, and Christoph E Hatz
Background: In 1993 more than 1 million Swiss residents traveled to a tropical or subtropical country. Although most pretravel advice is given by general practitioners, a number of travelers also seek advice from pharmacists. Little is known
about the quantity and quality of travel advice given or the sources of information used by this group.
Methods: One-hundred and twenty randomly selected pharmacists from three Swiss cantons were first interviewed in a
cross-sectional study on the telephone. All study participants subsequently received a pretested questionnaire, in which
most of the questions asked on the phone were repeated, with additional questions regarding the sources of information used for travel advice and the cooperation of general practitioners. Included in both parts of the study were t w o
scenarios of fictive travelers seeking health advice for destinations frequently visited by Swiss tourists (Thailand and
Kenya).
Results: Of 136 pharmacists approached, all who said they sometimes gave travel advice, agreed to participate (88%).
Fifty-six percent of them give travel advice regularly (mean 2-3 times per month). General knowledge on the main health
hazards was good, but for treatment of travelers’ diarrhea, only 59% spontaneously mentioned the need for increased
fluid intake, whereas 100 % recommended antidiarrheal drugs. Protection from the sun was mentioned only by 10 % of
the respondents, and only 8 % said that the traveler should seek advice from a medical doctor. Over 95% could name the
three most important measures against mosquito bites, although up to 20% still recommend Vitamin B1 as well. On the
telephone, only 19% (forThailand) and 31% (for Kenya)gave accurate advice on malaria protection, and 13% (for Thailand)
and 3% (for Kenya) could make correct recommendations about vaccination. However, more than 50% said that in practice they would consult documentation before giving any advice, with the Bulletin o f the federal Ofice ofHealth (BFOH)
being the most commonly used source of information. In the questionnaire interview, where documentation was used,
the accuracy of advice increased, especially for malaria protection (74% correct for Thailand and 93% for Kenya).
Conclusions: The overall knowledge of Swiss pharmacists on travel medicine issues is satisfactory. Specific questions
need further attention, such as treatment of travelers’ diarrhea, sun protection and advice on malaria prophylaxis and
vaccinations. For the latter two, clients should also consult a medical doctor. Collaboration between doctors and pharmacists, and the consistency of the advice given, are important in improving compliance. Reliable information sources
are available in pharmacies and are used.
where they go for initial advice, 1.2% mentioned pharmacists,6and a more recent study in Spain suggested that
there the propotion is probably higher, and increasing.’
In practice,almost all Swiss travelers will visit a pharmacist’s
shop at some stage in their preparations for the journey.
Those who initially go to a medical doctor will usually
go to the pharmacy to buy the prescribed medicaments,
and also to equip themselves with nonprescription items.
Some may go to a pharmacy first, and ask for information and advice about whether they need to see a doctor. The quality of advice gwen by pharmacists is therefore
an important factor in travel health, but little is known
in Switzerland about either the frequency or the accuracy of the advice given by pharmacists to prospective
travelers who visit their shops.
In the present study, a sample of Swiss pharmacists
was asked how often they give travel advice. Their levels of general and specific knowledge of travel medicine
were assessed.We also looked at the sources of information
available to them to keep up to date with the latest
developments in the field. In addition, the study also investigated the cooperation between pharmacists and medical doctors, which is very important to achieve the best
possible compliance by the traveler with the advice
Tropical destinations are very popular with Swiss
travelers. In 1993,more than 1 million Swiss tourists visited tropical o r subtropical countries.’ A growing number of travelers seek advice about possible health hazards
before departure, sometimes from specialized clinics 01
specialists in tropical medicine, but very often from general practitioners (GPs) or pharmacists.? Previous studies3.4z5have examined the information given by
nonspecialist GPs, and have shown that there is a large
variation in the amount and accuracy of advice given.
Pharmacists provide professional advice to travelers.
When travelers in Germany were asked in an earlier study
Neville Kodkani, MD, Jennifer M. Jenkins, MSc, Christoph F:
Hatz, MD: Medical Department, Swiss Tropical Institute,
Basel, Switzerland.
This paper was presentedat the Fifth International
Conference on Travel Medicine, Geneva, Switzerland, March
24-27, 1997.
Reprint requests: Dr. Christoph Harz, MD, Medical
Department, Swiss Tropical Institute, Socinstrasse 57, PO.
Box, 4002 Basel, Switzerland.
J Travel Med 1999; 6: 87-93.
87
88
J o u r n a l of T r a v e l M e d i c i n e , V o l u m e 6 , N u m b e r 2
given. Suggestions are made about possible ways of
improving the information provided by pharmacists.
as space for additional suggestions. Finally, personal comments and requests were invited.
Study Population and Methods
Data Analysis
Pharmacists with a Swiss Federal Diploma were
randomly chosen in alphabetical order &om the official
lists of pharmacies in the Canton of Berne and the
neighboring cantons of Fribourg and Solothurn,and asked
by telephone whether they were willing to participate
in the survey, unal the required sample size of 120 was
reached. One halfof the participants were located in rural
areas (at least 10 km away &om city centers with more
than 20,000 inhabitants) and half in urban areas. A preliminary study with six pharmacists in urban areas and
six in rural ones was carried out in the nearby canton
of Aargau to test the questionnaire. The study was carried out from March to July 1995.
There were two parts to the study, first a telephone
interview and then a questionnaire sent by mail. The telephone interview was intended to test the knowledge
immediately available, whereas in filling o u t the questionnaire the participants were encouraged to use any
sources of information available to them.
During rhe telephone interview, the study participants were first asked whether they gave travel advice,
and how ofien. If they did give such advice, they were
asked a series of questions to assess their general knowledge of travel health issues. They were also asked spec& questions about the advice they would give, especially
concerning malaria and necessary vaccinations, to two
individuals planning to travel independently: a man planning a trip to Th;uland, and a woman semng off for Kenya.
These countries are among the most popular destinations
for Swiss travelers.To round off the telephone interview,
the pharmacists were asked to name the five most important items which should be included in a traveler’s firstaid kit. The interview lasted 8-12 minutes, and the
answers were recorded on a prepared form.
The questionnaire was sent approximately 2 weeks
later. It included the same questions as the telephone interview, but this time the pharmacists were explicitly asked
to use the information they had available, before they
answered. They were also asked to state what sources of
information they had at their disposal, and to state how
ofien they would use them by grading them &om 1 to
5 (1 being the highest = always used, 5 being the lowest = never used). The questionnaire also included questions about cooperation between pharmacists and medical
doctors in the region, and asked for suggestions for
improving this cooperation. In the written questionnaire,
the questions on measures against malaria and diarrhea,
on vaccinations and on the contents of a first-aid kit
included 3 list of items for the participant to select,as well
The answers given to the questions on vaccination
and malana prevention were classified as “accurate”ifthey
were in agreement with the standardized recommendations of the Swiss Working Group for Travel Advice
(SWGTA),w h c h were in use at the time of the interview.8 For protection against malaria these recommendations were as follows. For Thailand: mefloquine
(stand-by treatment), mefloquine or doxycycline in border regions to Cambodia or Burma (prophylaxis). For
Kenya: mefloquine (prophylaxis) for the whole country.
Vaccination against diphtheria/tetanus, poliomyelitis and
hepatitis A was recommended for both countries, plus
yellow fever for Kenya. To assess the answers to the
questions on the contents of a traveler’s emergency kit,
the same questions were posed to Swiss speciahsts in tropical medicine. Advice was also recorded as “accurate” if
it included additional recommendations that were appropriate and not potentially harmful (e.g., recommendation of vaccination against typhoid fever).
Data were analyzed using version 6.02 of the program Epiinfo (Centers for Disease Control and Prevention, Atlanta GA, USA). Proportions were compared
using the chi-square-test with Yates’ correction. Differences with a significance level of 95% were considered
significant (p 5 .05).
In most cases, no statistically significant differences
between the urban and rural groups were found either
in the answers or in the return rate for the questionnaire.
Results given are therefore for the whole study population, unless a difTerence between urban and rural groups
is specifically mentioned.
Results
A total of 136 pharmacists were contacted on the
telephone, and 120 (88%) agreed to participate, 61 in
urban and 59 in rural areas. A total of 101 satisfactorily
completed questionnaires (83%) were returned. In the following section, results from the telephone interview are
marked (T) and those f?om the questionnaire (Q).
Frequency of Giving Travel Advice
The participants all stated in the telephone interview
that they sometimes gave travel advice in their pharmacy.
and 56% stated that they gave such advice regularly, on
average 2-3 times per month. There was a large variation, with 8% giving advice frequently (>5 times per
week) and 10% less than 6 times per year. In the written questionnaire the results were similar, though fewer
(3%) said they gave advice fkequently.
K o d k a n i e t a l . , T r a v e l A d v i c e G i v e n by P h a r m a c i s t s
Table 1 Recommended Protective Measures against
Mosquito Bites (In %, n = 101. more than 1 answer allowed)
Telephone
Interview
Written
Questionnaire
Repellents
100
Protective clothing
Mosquito nets
Insecticides, mosquito coils
Vitamin B
87
100
98
97
Protective Measure
63
3
10
44
20
General Knowledge of Travel Medicine
When the pharmacists were asked what they considered to be the most common health problem among
travelers to the tropics, 86% (T)and 97% (Q) named “gastrointestinal problems.” Malaria was considered to be
the most dangerous disease for travelers to the tropics by
78% of all participants in the telephone interview and
84%of those who returned the questionnaire. AcquiredImmune Deficiency Syndrome (AIDS) was mentioned
by 5% and hepatitis A also by 5%.
Treatment of Travelers’ Diarrhea
With respect to treatment, in the telephone inter-
view 59% of the pharmacists recommended an increased
intake of fluid, should diarrhea occur during the trip,
though this proportion increased to 90% in the questionnaire. In contrast, 100 % (T) and 96 % (Q) recommended taking drugs against diarrhea. A majority (87%)
advised loperamid alone or in combination. Antibiotics
were recommended by 34% (T) and 39% (Q).However,
most pharmacists advised their clients to take them only
in case of complications and if possible under the supervision of a medical doctor. In the questionnaire, prophylaxis use as a regulator of the intestinal flora was
recommended by 30% of the participants.
Measures against Malaria
Advice given included recommendations about
protection against mosquito bites and about prophylactic and curative medication.
89
Recommended measures for protection against
mosquito bites are shown in Table 1. All the pharmacists
recommended insect repellents, and the ones mentioned
are a l l brands with an adequate content of di-ethyl-mtoluamide (DEET).Most of them (T 85%;Q 98%) recommended protective clothing and the use of mosquito
nets while sleeping (T 63%; Q 97%). In the telephone
interview, few recommended other alternatives, but in
the questionnaire (where h r t h e r possibilities were suggested), 44%recommended the use of insecticide sprays
on the clothing, and 37% the use of insecticides or mosquito COILS in the room. A number ofpharmacists ( T l P ? ;
Q 20%) recommended the use of Vitamin B1 preparations as a preventive against mosquito bites.
The results of the question on antimalarials in the
telephone interview and the questionnaire are summarized in Table 2 . Only those participants completing
both parts of the study are listed (n=l01). Data are not
available on how many pharmacists would give advice
without checking their documentation first. Only 27 of
the pharmacists were willing to give immediate advice
on the telephone on malaria prophylaxis for a traveler
to Thailand. O f these, 17 gave “standard” advice and 2
a satisfactory alternative (19% of all participants). For
Kenya, 35 were willing to give spontaneous advice, and
31 of them (31%of all respondents) gave acceptable
answers. In the written questionnaire the number giving accurate advice increased to 74% (for Thailand) and
to 93% (for Kenya). Seventy-four percent of all participants gave correct advice for both scenarios in the written questionnaire. When asked whether they would
recommend homoeopathic medications, 97% of the
pharmacists said they would not.
Advice on Vaccinations
The advice given by the pharmacists concerning necessary vaccinations for the two travelers is shown in
Table 3. Again, only the answers of those participants completing both sections ofthe study are listed (n=101). O n
the telephone, only a very small number of pharmacists
gave accurate advice (Thailand 13%, Kenya 3%), but
fable 2 Advice on Antimalarial Medication Given by Pharmacists (In %, n = 101; na = not applicable)
Thailand
(Telephone)
Accurate advice
19
Wrong advice
Send client to m e d d doctor
Consult their documentation
Doctor or documentation
8
12
50
12
na+
No answer
Thailand
Kenya
(Telephone)
Kenya
(Written Questionnaire)
74
19
4
31
93
2
na*
na *
44
14
4
na*
na*
3
n/at
1
(Written Questionnaire)
~~
*In the questionnam interview participants were expressly asked to use their documentation.
‘On the telephone. all parucipants were required to give an answer.
4
8
J o u r n a l o f T r a v e l M e d ic ine , Volume 6, Number 2
90
Table 3 Advice on Vaccination Given by Pharmacists (In %, n = 101; na = not applicable)
Accurate advice
Wrong advice
Send client to medical doctor
Consult their documentation
Doctor or documentation
No answer
Thailand
(Telephone)
nrailand
(Written Questionnaire}
13
44
3
43
5
44
47
11
7
na *
na*
6
8
11
62
17
7
na*
nat
4
54
18
.at
Kenya
(Telephone)
Kenya
(Written Questionnaire)
na*
*In the qunbonnairr internevi parncipana were expressly asked to use their documentanon.
‘On the telephone. all pamnpana were required to g w e an answer.
53% and 61% respectively stated that they would want
to consult their documentation before answering; 11%
that they would send the client to a doctor,and 17 % that
they would do both. The number of correct recommendations in the written questionnaire rose to 43% for
both destinations, but the number of actually wrong
answers, which was rather low in the phone interview
(5 and 8%). rose to about the same level (Thailand 44%,
Kenya 47%).There were seven pharmacists in both cases
who would also send the client to a doctor.
Additional Health Advice and Written Information
In the questionnaire,pharmacists were invited to offer
additionai health advice for the travelers to Kenya and
Thailand. Advice about food and hygiene was given by
one third of them, and information about the prevalence
ofHuman Immunodeficiency Virus (HIV) and other sexually transmitted diseases by 15%. Protection from the
sun was mentioned by just lo%, and only 8% said the
travelers should definitely ask a medical doctor for advice
before leaving.
Sources of Information Used by Pharmacists
The information sources the pharmacists used were
predominantly written ones. The Bulletin of the Federal Office of Health (BFOH),*is mentioned by 96% of
the study participants as a source of information. It was
also the source most often used, reaching a median score
of 1.65 in the range from 1 = always used to 5 = never
used. It w x followed by s p e d c information available h m
the pharmaceutical industry, mentioned by 86% of pharmacists (median score = 2.93) and the “Handbook for
Pharmacies (CH),”which was mentioned by 95% of pharmacists but was given a mehan score of 3.27.
Among other sources, the Swiss Tropical Institute
In Base1 w3s the only travel clinic ranlung among the 10
most commonly used sources of information. I t was
ranked 5th. and was mentioned by 93% with a me&an
score of 3.37. Only one of the computer programs available, Tropiined,” was among the first 10 sources. It was
i n the 10th place. mentioned by 72% and with a median
score of 4.48. Suggestions made for improvement are covered in the discussion.
First-Aid Kit for Travelers
T h e study participants were asked to give advice
about a first-aid kit for a customer planning to travel to
a tropical or subtropical country. O n the telephone they
were asked to spontaneously name the five most important items, and in the written questionnaire to select the
most important items from a list (medication against
malaria and antidiarrheal medication were excluded, as
those were covered by other questions). Swiss specialists
in tropical medicine were asked the same questions for
comparison. O u t of 65 approached, 14 offered advice.
Table 4 shows that the two groups were largely in agreement. Both spontaneously placed “antidiarrheal drug”
at the top of the list, and included an analgetic/antipyretic,
a disinfectant, dressing material, an antibiotic and sun
protection.
Cooperationwith Medical Doctors
In this part of the questionnaire, participants were
asked to choose one of several alternative statements
about collaboration between physicians and pharmacists. Just over half the study participants (54%), in both
rural and urban regions, stated that the main form of
cooperation between themselves and the local physicians
is that the pharmacist double-checks all the recommendations given to travelers. A hrther group (18%)saw
their main hnction as chechng the dosage and explainTable 4 First-Aid Kit for Travelers: Items Recommended
(Not including personal and antimalarial medication)
Rank
1
2
3
4
5
6
Phnrmacists
(n = tOl)
Stviss Speciulists in Tropical
Medicine (n = 14)
Antidiarrheal drug
Analgetic/antipyretic
Disinfectant
Dressing material
Sun protection
Antibiotic
Antidiarrheal drug
Disinfectant
Dressing material
Analgetic/antipyretic
Antibiotic
Sun protection
Kodkani e t al., Travel Advice Given by Pharmacists
ing the administration of the prescribed medication. A
further option was to offer other suggestions, and here
7% of the respondents suggested that the pharmacist
was important as a “filter,” to decide which travelers
needed to get speciahzed advice from a doctor or clinic.
In the region of the study many GPs are legally
allowed to dispense medicine themselves, especially in
rural areas. When asked whether this was the case in the
areas where they worked, 71% of pharmacists workmg
in rural areas said that the doctors in their area did dispense medicines themselves, whereas in urban areas the
proportion was significantly less (44%, p = .012).
Discussion
The participation rate in this study was high compared to that in similar s t u d i e ~ . ~
Eighty-eight
~’
percent
of those contacted initially agreed to participate, and
83% of them returned the written questionnaire. The
interest aroused by the study is also reflected in comments
that were made by the participants,and in discussions held
with officials of the Swiss Association of Pharmacists.
The results show that the pharmacist’s shop is an
important source of advice for travelers to tropical areas,
with half the pharmacists stating that they would give
travel advice, on average 2-3 times per month. There was
remarkably little difference in the frequency of giving
advice between urban and rural areas. The amount of
travel advice given was only a little lower than the rate
found in a study of Swiss GPs, who said they gave travel
advice 4-5 times per month.3 Since the information
was based on recall, the results can only indicate an order
of magnitude for the numbers involved, but the results
indicate that around 10,000people per year visit the 120
pharmacists in the study. This was the first study in
Switzerland that concentrated on pharmacies.
It is unlikely in the Swiss setting that the pharmacist will be the only source of advice, since a doctor’s prescription is required for some of the necessary medicines
(e.g., antimalarials), and pharmacists are not entitled to
administer vaccinations A client is therefore likely to visit
a physician as well. However, few potential travelers will
be able to avoid visiting a pharmacy, since even in areas
where doctors are allowed to dispense their own medicines they are unlikely to have stocks of everything
needed for a tropical journey. In fact, in this study there
was no significant M e r e n c e in the frequency of giving
advice to travelers between the 58/120 pharmacists who
worked in areas where doctors can dispense their own
medicines and those who did not.
More than half of the pharmacists considered that
it was their responsibility to check the recommendations
of the doctor for a particular patient, and to give further
explanations.
91
Some of them suggested that the pharmacist also has
a role to play in advising clients whether or not they need
to get medical advice before traveling to a particular destination. In addition, the pharmacist may play an important role in giving advice on aspects of prevention and
treatment of diseases not necessarily covered by the
doctor.
Overall, the pharmacists who took part in our investigation showed satisfactory general knowledge on travel
health issues. A trend as to which group of pharmacists
was more prone to giving wrong advice was not detected,
not even in the group of study participants giving advice
rarely.
The majority knew that diarrheal disease is generally the most common healih problem likely to be
encountered by tourists from Western countries going
to the tropics. Their advice on a suitable “first-aid kit”
for travelers was largely in agreement with that of specialists in tropical medicine.
The advice the pharmacists would offer on vaccinations and malaria prophylaxis was frequently inaccurate when compared to the “standard” advice of the
SWGTA although the accuracy improved greatly when
they were in a position to consult their documentation.
Vaccination and the prescribing of antimalarials do not
lie within the area of responsibhty of the pharmacists;
nevertheless, it is important that they should give information consistent with that given by medical doctors and
travel clinics. In the first place, they may play an important role in helping the client to decide to go to a doctor or clinic for advice. Secondly, it is important for the
pharmacist’s advice to agree with that given elsewhere.
The traveler is likely to become confused if given conflicting advice, whereas if the same advice is reprated,
compliance is known to be improved.”
Other important aspects of travelers’ health are
within the area of competence of the pharmacist. Knowledge about how to prevent mosquito bites was very
good; almost all the study participants could name the
three most efficient measures. This may also reflect the
fact that most of the protective measures mentioned are
available for sale in the pharmacies. However, a smaller
number of pharmacists gave additional advice regarding
mosquito protection, for example using insecticides to
spray the clothes. In addition, 10-20% of all pharmacists
still recommended the use of Vitamin B1 preparations,
although in various studies no significant reduction of
bites from mosquitoes could be proven,”,” which indicates a need for more adequate information.
The therapy of travelers’diarrhea is one field where
the pharmacist’s advice may be critical. Increased fluid
intake is the first ~ t e p , ’ ~but
, ’ ~on the telephone only 59%
of the pharmacists spontaneously named this as the
most important (and cheapest) way of treating diarrhea.
J o u r n a l of T r a v e l M e d i c i n e , V o l u m e 6, N u m b e r 2
92
Knowledge of this important measure is generally poor;
in another study only 5% of travelers mentioned it.‘5 In
contrast, 100 % of the pharmacists said they would recommend taking a drug at the onset of diarrhea. Almost
all recommended loperamid, which should not be given
without a careful explanation about indications and
possible side effects. Rather, more pharmacists &d mention increased fluid intake in the written questionnaire
(where it was one of the alternatives offered), but the
telephone interview probably reflects more closely the
real life situation in the pharmacy, where recommendations would u s u d y be given spontaneously. A number made inadequate recommendations, for example
using regulators of the gut flora, which have no proven
beneficial effect. Many pharmacists recommended that
their clients take a supply of antibiotics, but they generally said they would advise their clients to ingest them
only in case of additional symptoms and if possible,
under medical supervision.
I t is clear that although the pharmacists in the study
were quite well informed about travel medicine, there
is considerable room for improvement, especially in recommendations about the treatment of travelers’diarrhea
and protection from the sun. It.is also important that pharmacists should be well informed about the standard recommendations for antimalarials and vaccinations.
Although the client is likely to visit a doctor or clinic for
advice on these matters as well as the pharmacist, if conflicting messages are given, compliance is likely to be low.
Compared to an earlier study among Swiss pharmacist~~
there has been a significant improvement regarding travel advice. In 1982-although assessed with a
different study design-only 9% of the interviewed
pharmacists gave accurate advice about vaccinations and
malaria drugs.In comparison to a study among Swiss and
German CP’s with an h o s t identical study design,’ general knowledge about travelers’ health issues is similar.
There are important differences of specdic issues such as
vaccinations, which are better handled by physicians,
whereas pharmacists give less advice on basic issues such
a$ sun protection or mosquito protection. This illustrates the importance of good cooperation between the
two groups of specialists.
There is also a need for reliable and consistent written information that can be supplied to the general public. In this survey, around 70?hof the pharmacists said they
gave written information to their customers. About one
third of them supply the “Medizinische Ratgeber” (a
booklet with medical advice for travelers produced by
a group of experts on travel medicine); another third offer
a variety of pamphlets &om different sources, including
the pharmaceutical industry, and 13% give customers a
computer printout with information.
Table 5 Ten Sources of Information Most Often Used by
Pharmacists (n = 101)
Rank Source
1
2
3
4
5
6
7
8
9
10
Mean Frequency
4 U s e ( I = always,
5 = new)
BFOH (Bulletin of the Federal
Office of Health)
Information h o r n the pharmaceutical
industry
Swiss Handbook for Pharmacists
Vademecum Berna
Travel Clinic, STI Basel
Medical Journals
Textbooks on travel/tropical medicine
Seminars
WHO information
Tropimed computer programme
1.65
2.93
3.27
3.29
3.37
3.72
3.92
4.19
4.34
4.45
A standardized procedure regarding travel advice
could result in a better compliance by the tourist. Many
pharmacists said that they would welcome further sources
of information. The BFOH is cited as the most important source of information. This document has been
updated in the meantime and now contains information
on a larger spectrum of health risks. Most of the sources
(Table 5) provide consistent and appropriate information
as they are harmonized by the SWGTA.
O n e of the most important requests of the pharmacists was that there should be one up-to-date publication with all necessary information. However, not all
the available sources of information appear to be used.
For example, very few pharmacists are using specialized
computer programs yet or information from the Internet, though this proportion is likely to increase when more
pharmacies have the necessary computer hardware.
T h e situation could be further improved by the
inclusion of more teaching on travel medicine during the
training of pharmacists. Many pharmacists would also welcome seminars and short courses on travel health so
that they can keep their information up-to-date. Finally,
the most important thing is to ensure good cooperation
between doctors, clinics and pharmacists. Only then will
the traveler get reliable and consistent travel advice.
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