In Reply.—The letter by Kozarsky and Keystone speaks to the heart of the matter regarding immunization recommendations for travelers. The reason for doing research on travelers is to be able to assess the risk of disease and the benefit of immunization for subgroups of travelers going to specific destinations, and not merely to rely on theoretical advice. Kozarsky and Keystone raise the issue of "lifestyle" among travelers, and imply that people on escorted tours may be at less risk of acquiring enteric fever than other travelers to Nepal. We do not have specific data on this issue, but we have observed the following:
Hygiene at expensive hotels may not be better than cheaper restaurants, based on our experience of treating "package" tourists for diarrheal illness. Where diarrhea can be acquired, enteric fever could also be acquired.
We are not in a position to detect enteric fever among most package