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

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

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)

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).

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).

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

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)

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.

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.

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).

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).

Part III

Trip research and risk identification

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.

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).

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.

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)

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/

Part IV

Pharmacological Interventions

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

Individual assessment

The nurse must evaluate every individual for contraindications, precautions and determine a suitable schedule for vaccines with multiple dose requirements (Rosselot, 2004)..

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

Vaccines are categorized as

RoutineRecommended Required

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.

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!

Hepatitis B Prevalence

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.

Recommended

vaccines that protect the traveler against diseases not usually seen in the U.S.

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).

Hepatitis A Prevalence

Recommended

Meningococcal – one dose for travelers with current outbreaks (also for travel to the Hajj)

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:

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.

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)

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)

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.

Japanese Encephalitis

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.

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).

Required- Yellow fever

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)

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).

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.

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).

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.

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).

Choice of agent depends on:

Destination Trip duration Drug resistance Adverse effects Cost (Rosselot, 2004).

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.

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

Chloroquine phosphate

Is seldom used because it is no longer useful for protecting most travelers (Spira, 2003).

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).

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

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

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

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

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).

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).

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).

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).

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.

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.

Mosquitoes

“the most lethal animals on the planet”

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.

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.

Dengue has been diagnosed in FL

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).

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)

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).

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).

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)

TD - Continued

Pre-travel visit, the nurse needs to teach prevention measures and stress the importance of hand washing. Hand washing. Hand washing!!

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”

Water

Boiled or bottled (be sure the seal is intact)

NO ICE

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

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).

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

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.

Swimming in pools not properly chlorinated

Giardia Cryptosporidium Hepatitis A Norwalk virus

Walking barefoot

Cutaneous larva Migrans

Hookworm

Scuba Diving

The bends (decompression sickness)

Air embolism (pulmonary barotrauma)

Marine hazards (venomous injuries, infected cuts and abrasions)

Activities in rural or remote areas (biking, mountain climbing, trekking, camping)

Increased risk for inadequate or delayed medial treatment

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.

Problems of Climate and Altitude

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.

Hypothermia

Very young and elderly are at increased risk

Limit exposure, wear layers, adequate hydration

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).

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.

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,

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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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

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