travel clinic nursing an educational program for nurses that wish to provide pre-travel assessments...
TRANSCRIPT
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Travel Clinic Nursing An educational program for nurses that wish to provide
Pre-Travel Assessments and Consultations
Bonnie Sawyer-BandaUniversity of Central Florida
Fall 2012NGR 6776L
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Steps to a Healthy Journey
Part I – Define Travel Health Nursing Part II - Assessment Part III - Trip research and risk identification Part IV - Pharmacological Interventions Part IV – Non-Pharmacological Interventions
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Part I - What is Travel Medicine?
“The highly specialized area of medicine
devoted to the maintenance of the health of
international travelers through health
promotion and disease prevention.”
(Kozarsky and Keystone, 2008, p.1)
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Why study Travel Medicine?
According to the World Tourism Organization there were 980 million international travelers in 2011. This number is expected to reach 1.6 billion by the year 2012 (UNWTO, 2012).
One study showed that 76.5% of international travelers think that seeking medical advice before traveling is important. However, only 58.9% actually got information before traveling. This study demonstrated a lack of traveler’s knowledge about safety measures and health information regarding disease prevention (El Sherbiny and Wafik, 2011).
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What is travel health nursing?
Travel health nursing is an emerging specialty focusing on the health needs of the traveler. It is an interdisciplinary specialty that uses the knowledge of epidemiology, public health, curative medicine and health education (Rosselot, 2004).
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Why have a Travel Medicine Clinic?
Provide a needed service to our local population
Maintain a healthy Central Florida / Seminole County – prevent diseases from coming here to infect us and our families
Provide International Travelers with information that will enable them to have a healthy journey
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Part II-Steps to a Healthy Journey
Assess client’s health Analyze their itineraries Select appropriate
vaccines Provide education
about prevention and self treatment of travel related diseases (Shaw, 2006; Spira, 2003)
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Pre-travel visit
Focus on disease prevention and health promotion
Pre-trip preparation should be 4-6 weeks prior to departure and 3-6 months ahead for more complex travel such as extended stays or remote adventure trips.
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Assessment
Pre-travel Assessment: This form will be posted on the Travel Clinic internet site for clients to access, retrieve and complete prior to visit.
When the traveler calls to make an appointment, they should be directed to the web site to retrieve, print the form and fill out prior to visit.
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A focused health history is comprised of 6 areas
Demographics – age, gender, country of birth Medical History – acute and chronic health problems,
pregnancy, hospitalizations, and surgeries, psychological or psychiatric problems. State of current health.
Allergies – vaccines, foods, medications, environmental triggers, anaphylaxis history
Medications – all, including prescription drugs, OTC. Herbal remedies and drugs acquired abroad.
Immunizations- documentation, vaccination dates and any adverse reactions
Travel illness – history of trip illness or injury, experience with health care abroad, knowledge of first aid and use of travel medications (anti-diarrheal), travel insurance (Rosselot, 2004).
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Specific information about the trip
All destinations, in order of travel, including layovers. Duration of travel with dates of departure and length of stay in
each location Type of travel (urban vs. rural, business, backpacking, group,
solo, family vacation) Means of transportation and type of accommodation (luxury or
budget hotels, camping, homes, hostels, cruise ship) For example, travelers staying in budget hotels in malaria
endemic locations are more likely to contract malaria than those who stay in air conditioned luxury hotels (Spira, 2003).
Activities planned during the trip: purpose of trip, work and pleasure plans, water activities, contacts with locals and sexual activity (Rosselot, 2004).
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Part III
Trip research and risk identification
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Part III: Trip research and risk identification
Using professional knowledge, experience and updated resources the travel nurse identifies important health and safety risks for this particular traveler on this particular trip.
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Factor contributing to risk include:
Unstable medical conditions (cardiovascular, pulmonary, musculoskeletal, neuropsychiatric issues)
Traveler age – young and older travelers are at increased risk Pregnancy, especially in the 1st and 3rd trimester Medication and drug use (diuretics, alcohol and illicit drug use
raises the risk for many health and safety problems) Destination – travel to remote, rural and underdeveloped
destinations. Travel to areas with inadequate health and safety services; and travel to areas of unrest add to risk.
Season of travel – risk of infectious disease and climate related illness can vary with season of travel (rainy season, dry season)
Overseas work assignment can pose special occupational risks Contact with local individuals, especially children, refugees and
ill individuals increases risk of infectious disease. (Rosselot, 2004).
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It is important to research all trip destinations for
Vaccine preventable diseases
Safety issues Food and water borne
illness Vector borne diseases
such as malaria and dengue.
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Updated risk information is available from
Center for Disease Control and prevention (CDC) http://www.cdc.gov/travel
U.S. State Department - http://travel.state.gov/travel World Health Organization (WHO) http://
www.who.int/ith Travel Health Online – http://www.tripprep.com
(Good source for clients, can not be used by health care providers) (Leggat, 2004).
(Put these links in your favorites for easy retrieval)
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Smart Traveler Enrollment Program (STEP)
A free program where US citizens can register with the US State Department for updates on the latest security and safety announcements. Enrollment also helps the embassy locate your family if there is an emergency. http://www.state.gov/
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Part IV
Pharmacological Interventions
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Part IV: Pharmacological Interventions
Offer vaccines and travel medications Travelers should be up to date on all routine
immunizations and offered additional vaccines depending on risks identified.
When making vaccine recommendations, the nurse must consider: Prior immunization history Client age Pregnancy Allergies and medical history Date of departure and Trip duration
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Individual assessment
The nurse must evaluate every individual for contraindications, precautions and determine a suitable schedule for vaccines with multiple dose requirements (Rosselot, 2004)..
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Vaccine administration – Critical Skill
Preserve vaccine potency – Cold chain Delivery of immunizations in accordance with
latest care standards Federal law – risk communication dialogues Specialized chart documentation Travelers must be monitored for adverse
reactions
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Vaccines are categorized as
RoutineRecommended Required
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Routine
These are vaccines that are included in the standard United States childhood and adult schedules. The pre-travel visit is a good opportunity to update these vaccines as needed.
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Routine
Hepatitis B – 3 dose primary series indicated for long stay travel and certain at risk groups. One study found that 45% of travelers reported either
domestic or travel related hepatitis B risk factors (Conner, Jacobs and Meyerhoff, 2006).
Accessing medical or dental interventions in developing countries is a risk factor for acquiring Hepatitis B (Lau, 2007). Also, tattooing.
Those at highest risk are single males traveling alone. An accelerated schedule for Twinrix can be
administered on days 0,7 and 21-30 days followed by a booster at one year (CDC, 2012b). The traveler must receive 2 doses of Twinrix before departure to be protected against Hepatitis A!
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Hepatitis B Prevalence
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Routine Inactivated Polio – One time adult booster; needed for certain
destinations only. Adult travelers to endemic countries (Parts of Africa and India) should
have a booster of IPV which will give life-time immunity if they were fully vaccinated in childhood (Lau, 2007).
Influenza: Is the commonest vaccine preventable disease encountered by travelers. Influenza virus circulates all year in tropical zones. Airports, lounges
and waiting areas are common sites of infection (Lau, 2007). Measles, mumps, rubella: For non-immune travelers, 2 dose series. Pneumoccocal – single dose indicated for adults 65 and older and
certain at risk groups Tetanus and Diphtheria - booster every 10 years –(tdap one time in
lifetime) 5 year booster is recommended for travelers going for prolonged or
remote travel (Lau, 2007) Varicella – 2 dose series indicated for travelers without prior immunity.
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Recommended
vaccines that protect the traveler against diseases not usually seen in the U.S.
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Recommended Hepatitis A – 2 dose series to prevent food and waterborne
illness. Hepatitis A is the most common vaccine preventable illness.
The risk to a standard tourist is 3 per 1000 per month. The risk increases with adventurous and non traditional itineraries. 94% of tourists develop protective antibodies with 2 weeks of injection. (Spira, 2003)
A single dose of Hepatitis A vaccine offers immediate protection and can be given up to the date of departure. One dose of Twinrix (Hep. A+B) is not adequate to provide Hepatitis A protection. 2 doses, 4 weeks apart must be given. In cases of time constraint, a single dose of Hepatitis A vaccine should be given instead of Twinrix (Lau, 2007).
An accelerated schedule for Twinrix can be administered on days 0,7 and 21-30 days followed by a booster at one year (CDC, 2012b).
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Hepatitis A Prevalence
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Recommended
Meningococcal – one dose for travelers with current outbreaks (also for travel to the Hajj)
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Typhoid
CDC recommends typhoid vaccine for travelers to areas where there is an increased risk of exposure to S.Typhi. The typhoid vaccines do not protect against S. Paratyphi infection. Both typhoid vaccines protect 50%–80% of recipients; travelers should be reminded that typhoid immunization is not 100% effective, and typhoid fever could still occur. Two typhoid vaccines are available in the United States:
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Typhoid vaccines Oral live, attenuated vaccine (Vivotif
vaccine, manufactured from the Ty21a strain of S. Typhi by Crucell/Berna)
Primary vaccination with oral Ty21a vaccine consists of 4 capsules, 1 taken every other day. The capsules should be kept refrigerated (not frozen), and all 4 doses must be taken to achieve maximum efficacy. Each capsule should be taken with cool liquid no warmer than 98.6°F (37°C), approximately 1 hour before a meal. This regimen should be completed 1 week before potential exposure. The vaccine manufacturer recommends that Ty21a not be administered to infants or children aged <6 years.
Vi capsular polysaccharide vaccine (ViCPS) (Typhim Vi, manufactured by Sanofi Pasteur) for intramuscular use
Primary vaccination with ViCPS consists of one 0.5-mL (25-mg) dose administered intramuscularly. One dose of this vaccine should be given ≥2 weeks before expected exposure. The manufacturer does not recommend the vaccine for infants and children aged <2 years.
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Oral Typhoid – Price check
Price check (as of 10/06/2012) for Vivotif
Wal-mart - $55.84 CVS - $66 Costco - $40.32 (do not
have to be a member, but must pay with cash, debit or Am Ex)
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Rabies
Found in many parts of Asia, Africa, Central and South America Bites or scratches from dogs or bats and also from cats,
monkeys, foxes, jackals, camels and other animals can cause rabies. The disease is fatal if not treated.
Animal avoidance is key to prevention. Do not pet, feed or approach wild or domestic animals. In the event of exposure – wash wound with soap and water
and seek medical care immediately for post exposure treatment (Rosselot, 2004). 8 human rabies cases associated with dog bites have been reported in the U.S since 2000. All cases were acquired abroad. In countries where canine rabies is endemic, all dog bites should be managed as rabies exposure until the dog’s disease free status can be confirmed (CDC, 2012a)
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Rabies 3 dose pre-vaccination series
indicated for long stay travelers Is transmitted through a bite or
a scratch of an infected animal. All travelers to endemic areas should be counseled about prevention. Vaccine should be considered for long term travelers and expatriates. Children are at high risk (Lau, 2007).
Even if travelers receive the vaccine and are subsequently bitten, they still need to thoroughly clean the wound and seek post exposure vaccination (Spira, 2003).
Rabies is invariably fatal.
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Japanese Encephalitis
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Japanese Encephalitis
Japanese Encephalitis – Culex mosquitoes
Risk to most travelers is low except for certain long stay travelers visiting rural, agricultural areas during the transmission season.
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Japanese Encephalitis
3 dose series indicated only for at risk travelers to certain destinations.
JE is relatively rare and is indicated for people living in endemic areas or travelers spending more than one month in rural areas. The vaccine is has a high rate of adverse reactions (Lau, 2007).
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Required- Yellow fever
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Required – Yellow Fever
Yellow fever – one dose given at least 10 days before crossing borders. Yellow fever is the only vaccine mandated by WHO’s International Health Regulations (Spira, 2003)
Vaccine is contraindicated or problematic in the following individuals: Elderly patients over the age of 65 Infants less than 1 year old Individuals with impaired immune status Individual with anaphylactic hypersensitivity to eggs or
previous yellow fever vaccination Those with past history of thymus gland problems
(Lau, 2007)
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Yellow fever - caution in older adults
Older adults are six times more likely than younger adults to experience serious adverse side effects (Spain and Edlund, 2010).
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Yellow Fever
found only in Sub Saharan Africa and tropical South America (Yellow fever belt) – Aedes mosquito - a daytime biter
Is rare but potentially fatal Vaccine Personal protection
measures Filling out the yellow
certificate correctly – effective date is 10 days after the injection. Dates should be written day-month-year i.e. 02 Jan 2012.
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Required
Meningitis vaccination is mandatory only in Saudi Arabia for pilgrims undertaking the Hajj pilgrimage. Good for 3 years. Must be given 10 days prior to arrival (Spira, 2003). Must be documented in the yellow certificate.
Risk of infection is low, but fatality rate is 50% despite treatment. Risk is greatest in winter and dry season. (Spira, 2003).
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Malaria
Malaria – a life threatening illness. There is no vaccine!. Must take anti-malarial chemoprophylaxis
– female anopheles mosquito – bites dusk to dawn A hazard in more than 100 countries Responsible for 300-500 million infections yearly Can be fatal if not treated early Risk can vary greatly depending on destination,
season of travel and altitude.
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All travelers to areas endemic for malaria need to take the risk seriously!
They need to use anti-malarial medications and personal protective measures
No anti-malarial medication is 100% effective Malaria deaths in travelers are usually due to inappropriate
chemoprophylaxis or non-compliance. Medications suppress malaria by killing the asexual blood stages of the parasite before they cause disease. Protective levels of the medication must be in the blood before the parasite emerges from the liver. Therefore, the prophylaxis should be started before the first possible exposure and continue for a set period after the last possible bite (Spira, 2003).
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Choice of agent depends on:
Destination Trip duration Drug resistance Adverse effects Cost (Rosselot, 2004).
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Atovaquone/proguanil (Malarone)
Reasonably effective and has fewer side effects than mefloquine. Has the benefit of activity against liver stage parasite which means it can be stopped after one week which increases compliance.
Side effects: headache, vomiting, abdominal pain and dyspepsia with a frequency similar to placebo (Spira, 2003).
Instructions: Take one table daily. Begin 1-2 days pre-travel, daily during stay and 1 week post travel.
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Doxycycline
Side effects: May cause phototoxicity, vaginal candidiasis, bone and dental damage in fetuses and children younger than 8 years old (Spira, 2003)
Inexpensive Instructions: Take one tablet daily. Start 1-2
days pre-travel, daily during stay and 4 weeks post travel.
Chloroquine phosphate
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Chloroquine phosphate
Is seldom used because it is no longer useful for protecting most travelers (Spira, 2003).
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Malaria
Teach the traveler the symptoms of malaria so they may seek prompt medical treatment for flu like symptoms. Be sure and tell their health care provider where they have traveled (Rosselot, 2004).
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Part V: Non-pharmacological interventions - Customized health
counseling
Most health and safety risks are not vaccine preventable
Top 2 causes of death in international
travelers: Cardiovascular disease Motor vehicle accidents
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Vehicular Safety:
Foreign country roads are poorly maintained
Traffic is complex with vehicles, pedestrians and animals
Signs are poor and in a foreign language
Traffic laws are not enforced
Travelers need to wear seat belts
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Air travel hazards
Jet lag The travel nurse can
recommend: adequate sleep before
departure maximum sleep during
flight adjust activities and
mealtimes to destination time zone
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Travel thrombosis
Travel thrombosis can lead to fatal pulmonary embolism:
Travelers at risk include older age pregnancy cancer obesity flights > 5 or 6 hours History of blood clots, stroke or recent surgery
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Travel Thrombosis
Prevention measures for travel thrombosis: Periodic walks Isometric exercises Drinking water Wearing support hose
Warning signs include: DVT -Pain, redness
and swelling behind the knee or swelling of one leg
PE – SOB, CP, coughing or fainting
SEEK IMMEDIATE MEDICAL ATTENTION! (Rosselot, 2004).
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Aerotitis
Caused by a change in cabin pressure. Results in ear pain, dizziness, decreased hearing or perforation of the ear drum
Can prevent by performing Valsalva’s maneuver during take-off and landing and/or decongestants. (Rosselot, 2004).
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Disinsection
Some countries require that airlines spray insecticides inside the cabin prior to landing. (to prevent transmission of vector borne illnesses – yellow fever, dengue, malaria) This can cause allergic reactions, hay fever or asthma attacks. Traveler needs to question the airline about this practice and take carry on medication as a precaution. They might opt to take a mask for use in the cabin (Murawski, 2002).
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Airborne illness
Tuberculosis, influenza, upper respiratory illness. Any disease spread with infectious droplets
Actions – avoidance measures: Ask to be moved away
from coughing passengers
Frequent hand washing Flu and pneumonia
immunizations Masks (Rosselot, 2004).
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Catering policies of airlines
Travelers may find themselves hungry on long flights. Recommend that carry nutritious foods with them. Children, older adults and travelers with chronic health problems are at greater risk.
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Insects and other animal vectors
Avoiding vectors is the key to preventing serious diseases
The travel nurse needs to educate the traveler about specific insects or animal hazards for the trip as well as ways to avoid them.
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Mosquitoes
“the most lethal animals on the planet”
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Mosquitoes
Responsible for the spread of Yellow fever, Dengue fever, Japanese Encephalitis, malaria and many other diseases!
Insect are attracted to people by carbon dioxide, lactic acid and body odor. Travelers should wear protective clothing (light colored) that are loose fitting and cover the arms and legs.
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Dengue Fever
Dengue Fever – The geographical continues to increase – Aedes mosquito – a daytime biter found in urban areas (Cases have been recognized in Florida!) Bite avoidance is important! Dengue hemorrhagic fever is more serious and sometimes fatal.
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Dengue has been diagnosed in FL
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Mosquito repellant
DEET – 20-50% should be applied to exposed skin.
Permethrin can be sprayed on mosquito nets or clothing and will protect against mosquitoes and ticks for weeks or months (Spira, 2003).
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Other insect vectors are:
Chagas disease is caused by Trypanosoma cruzi, a parasite related to the African trypanosome that causes sleeping sickness. It is spread by reduvid bugs and is one of the major health problems in South America (PubMed, 2010).
Sleeping sickness (tsetse fly) Leishmaniasis (female sand fly)
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Food and Waterborne Illness
Traveler’s Diarrhea – (TD) La turista, Dehli belly, Montezuma’s revenge, funny tummy, tourist trot.
Is the MOST COMMON TRAVEL ILLNESS!! 30-60% of travelers to developing countries are affected. It is the #1 health problem in international travel! (Cohen, 2007).
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Traveler’s Diarrhea (TD)
What is Traveler’s Diarrhea?
4-5 watery stools per day that may be accompanied by cramps, nausea, vomiting, bloating and fatigue.
Concerns about drug resistance prevent consensus guidelines recommending the prophylactic use of antibiotics (Cohen, 2007).
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TD – Continued…
Most common source of infection is contaminated food or water
Possible infectious agents: Escherichia coli Salmonella Campylobacter jejuni Shigella Norwalk virus Rotavirus Hepatitis A Parasites (giardia)
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TD - Continued
Pre-travel visit, the nurse needs to teach prevention measures and stress the importance of hand washing. Hand washing. Hand washing!!
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Safe Food Identification
How to identify safe food and water sources at their destinations
“Hot food served hot” “boil it, cook it, peel it or forget it”
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Water
Boiled or bottled (be sure the seal is intact)
NO ICE
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FOOD
Well cooked – nothing rare! Hot food – avoid buffets and salads Avoid thin skinned fruits such as raspberries or
strawberries Fresh fruits and vegetables that can be peeled by the
traveler are safe AVOID SALADS - SHELLFISH –UNPASTEURIZED
DAIRY-UNPASTEURIZED FRUIT JUICE Recommend Hepatitis A and Typhoid vaccines
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Self treatment of diarrhea consists of:
Fluid replacement Oral rehydration salts OTC drugs Bismuth subsalicylate (Pepto bismol) 2 tablets at meals at
bedtime (8 pills per day) Loperamide (Imodium) Fiber – Metamucil Probiotics are safe and effective for the prevention of traveler’s
diarrhea. A meta-analysis found that 85% of traveler’s diarrhea cases were prevented by probiotics (McFarland, 2007).
Antibiotics if symptoms are severe. Fluoroquinolones (ciprofloxacin [Cipro] norflaxacin[Noroxin], levofloxacin [Levaquin]), Azithromycin [Zithromax]or Furazolidone [Furoxone] (Spira, 2003).
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Respiratory Illness
Air pollution is a problem in many developing countries – remind high risk travelers with asthma, allergies and underlying respiratory problems to need bring medication for self treatment (Bronchodilators, decongestants, antibiotics, etc)
If traveler is going for extended stay, a baseline TB skin test might be a recommendation
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Occupational and Recreational Hazards
What the traveler will be doing is as important is where they will be doing it.
Leisure activities: Swimming or water sports Drowning - Swimming in fresh water ponds. rivers and lakes Schistosomiasis – (bilharzia or snail fever) parasitic
worms enter through the skin. Leptopirosis – infective spirochete that causes renal,
hepatic and pulmonary damage. Amoebae – can cause amoebic meningitis or
Traveler’s Diarrhea.
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Swimming in pools not properly chlorinated
Giardia Cryptosporidium Hepatitis A Norwalk virus
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Walking barefoot
Cutaneous larva Migrans
Hookworm
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Scuba Diving
The bends (decompression sickness)
Air embolism (pulmonary barotrauma)
Marine hazards (venomous injuries, infected cuts and abrasions)
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Activities in rural or remote areas (biking, mountain climbing, trekking, camping)
Increased risk for inadequate or delayed medial treatment
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New activities or Extreme Sports
parasailing, bungee jumping, rock climbing, rollerblading, snow skiing/boarding
The travel nurse needs to alert travelers to activity hazards and encourage the use of safety equipment to reduce risk.
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Problems of Climate and Altitude
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Heat related illness:
Heat stroke and heat exhaustion can occur in tropical locations with high temperatures and high humidity
Dehydration can occur in hot or dry destinations
Travelers need to know how to recognize, prevent and self treat. The best gauge of hydration is not thirst (a late gauge) but urination. Urination should occur every 4 hours and the urine should look clear.
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Hypothermia
Very young and elderly are at increased risk
Limit exposure, wear layers, adequate hydration
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Ultraviolet sun hazards Sunscreen – take with and
use correctly (SPF >15) Wear clothing that covers
arms and legs Wear wide brimmed hat and
sun glasses Avoid mid day sun Check medications do not
increase sensitivity Sunscreen effectiveness is
reduced by wind, heat, humidity, sweat and altitude.
When applying sunscreen and insect repellant...apply the sunscreen first to allow skin absorption, then repellant (Spira, 2003).
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Altitude sickness
Travelers at risk who travel higher than 6,000 to 9,000 feet.
Acute Mountain Sickness (AMS) usually occurs with ascents > 9,000 ft. Headache, fatigue, insomnia,, anorexia, nausea or
vomiting If ascent continues, cerebral edema and pulmonary
edema can occur confusion, ataxia, LOC
Avoid direct travel to high altitudes; avoid alcohol and overexertion, “Never take a headache to a higher level” Descend if symptoms persist.
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Motion Sickness
Prevention begins with sitting in the most stable part of the vehicle
Plane – forward section of the wings
Boat – center of the boat at the waterline looking at he horizon
Car or bus – next to the window and open the window for fresh air,
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Sexually Transmitted Diseases (STDs) and Bloodborne Pathogens
5-67% of travelers have sex with people that are not their usual partners
Travelers are at risk for HIV or other STDs if they have unprotected sex
Travel nurse needs to counsel about the risks of casual sex
Abstinence condoms effect that alcohol and drugs can have on
judgment
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References: CDC (2010) 10 Essental public health services. Retrieved 03/25/2012 from http://www.cdc.gov/nphpsp/essentialservices.html CDC. (2012a). Imported human rabies – New Jersey, MMWR 2012. 60 (51&52). 1734-1736. CDC. (2012b). Recommended adult immunization schedule-United States, 2012. MMWR. 61(4). 1-5. Cohen, M. (2007). Traveller’s ‘funny tummy’: Reviewing the evidence for complementary medicine. Australian Family Physician.
36(5).335-336. El Sherbiny, N., and Wafik, G. (2011). A study of travel medicine among national and international travelers in Egypt. Journal of
Public Health and Epidemiology. 3(7). 324-328. Hill, D., Ericsson, C., Pearson, R., Keystone, J., Freedman, D., Kozarsky, P., DuPont, H., Bia, F., Fischer, P., and Ryan, E.
(2006) The practice of travel medicine: Guidelines by the infectious disease society of America. Clinical Infectious Diseases. 43. 1499-1539.
Kozarsky, P. (2006). The body of knowledge for the practice of travel medicine – 2006. Journal of Travel Medicine. 13(5). 251-254.
Kozarsky, P. & Keystone, J. (2008). Introduction to travel medicine. Travel Medicine, second edition. Mosby Elsevier Lau, S. (2007). Travel vaccination. Australian Family Physician. 35(5). 304-310. Leggat, P. (2004). Travel medicine online: International sources of travel information on the internet for travellers. Travel Medicine
and Infectious Diseases. 2. 93-98. McFarland, L. (2007). Meta-analysis of probiotics for the prevention of traveler’s diarrhea. Travel Medicine and Infectious
Disease. 5. 97-105. Murawski, J. (2002). “Ladies and gentlemen, you are about to be sprayed” aircraft disinsection-what has been, what is, and
where to go from here. Presented at AFL-CIO 19th Annual SCSI International Aircraft Cabin Safety Symposium. Retrieved 01/26/2012 from http://ashsd.afacwa.org/docs/scsi2_papermar02.doc
PubMed Health (2010) Chagas Disease. retrieved 02/26/2012 from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002348/ Rosselot, G. (2004). Travel health nursing: Expanding horizons for occupational health nurses. American Association of
Occupational Health Nurses Journal. 52(1). 28-41. Shaw, M. (2006) Running a travel clinic. Travel Medicine and Infectious Disease. 4. 109-126. Spain, M and Edlund, B. (2010). Travel immunization update for older adults. Journal of Gerontological Nursing. 36(4). 9-12. (UNWTO) World Tourism Barometer (2012). First Printing - Vol. 10 – January 2012Retrieved 02/23/2012 from
http://dtxtq4w60xqpw.cloudfront.net/sites/all/files/pdf/unwto_barom12_01_january_en_excerpt.pdf
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The End