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The Middle East is one of the most rapidly growing destination for travelers. Objective. The aim of this study was to determine the medical conditions affecting travelers needing medical assistance in Bahrain International Airport (BIA). Logbook documenting medical conditions of travelers presenting to the BIA clinic from January 1 till the end of December 2004 was reviewed. A total of 3,350 travelers attended the clinic, constituting 0.12% of the disembarking and transit travelers. Most common conditions faced were respiratory problems (24.4%), followed by headaches (19.2%), trauma, musculoskeletal pains (12.9%), and gastrointestinal problems (11.0%). Only 2.1% of all complaints were referred to secondary care. The majority of cases were handled by the nurse. Majority of the patients examined had acute minor medical problems. Ninety-eight percent of conditions affecting travelers were handled in the airport clinic by the nurse and the family physician. Airport clinic could serve as an efficient emergency triage system for filtering serious illnesses needing urgent management.
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© 2007 International Society of Travel Medicine, 1195-1982
Journal of Travel Medicine, Volume 14, Issue 1, 2007, 37–41
37
Travel medicine has developed into a unique
medical specialty that transcends the manage-
ment, health education, behavioral changes, and
reduction in injuries.
1 One of the major reasons for
the rising rates in the international travel is expan-
sion of tourism, which has risen more than 7% per
year during the past four decades.
1
Between 20 and 70% of the 50 million people trav-
eling each year from the industrialized to the devel-
oping world report some illness associated with their
travel. Although most illnesses reported are mild, 1%
to 5% of travelers become ill enough to seek medical
attention either during or immediately after travel.
Of these, 0.01% to 0.1% of travelers require medical
Medical Problems Encountered Among Travelers in Bahrain
International Airport Clinic
Farouq Al-Zurba , MD , * Bassem Saab , MD ,
and Umaya Musharrafi eh , MD
* Family Medicine, Primary Health Care, Ministry of Health, Kingdom of Bahrain ;
Department of Family Medicine,
American University of Beirut, Beirut, Lebanon
DOI: 10.1111/j.1708-8305.2006.00089.x
Background . The Middle East is one of the most rapidly growing destination for travelers.
Objective . The aim of this study was to determine the medical conditions affecting travelers needing medical assistance
in Bahrain International Airport (BIA).
Method . Logbook documenting medical conditions of travelers presenting to the BIA clinic from January 1 till the end
of December 2004 was reviewed.
Results . A total of 3,350 travelers attended the clinic, constituting 0.12% of the disembarking and transit travelers.
Most common conditions faced were respiratory problems (24.4%), followed by headaches (19.2%), trauma, musculo-
skeletal pains (12.9%), and gastrointestinal problems (11.0%). Only 2.1% of all complaints were referred to secondary
care. The majority of cases were handled by the nurse.
Conclusions . Majority of the patients examined had acute minor medical problems. Ninety-eight percent of conditions
affecting travelers were handled in the airport clinic by the nurse and the family physician. Airport clinic could serve as an
effi cient emergency triage system for fi ltering serious illnesses needing urgent management.
F. A.-Z. was the airport physician who collected the data
and wrote the fi rst draft. B. S. was involved in the concept,
wrote the abstract, and contributed to the second and
third drafts. U. M. contributed to the literature review
and wrote the second draft. F. A.-Z. wrote the fi nal manu-
script. All authors approved this document.
Corresponding Author: Farouq Al-Zurba, MD, Fam-
ily Medicine, Primary Health Care, Ministry of Health,
PO Box 1113, Kingdom of Bahrain. E-mail: farouq@
zurba.com
evacuation, and 1 in 100,000 dies.
1,2 While Europe
remains the leading destination for tourists, East Af-
rica, the Pacifi c, the Middle East, and Africa are rap-
idly growing destinations (recent annual growth rates
ranging from 10% to 25%). Additionally, there is a
signifi cant increase in number of elderly travelers and
a rapid growth of tourism to developing regions of
the world, both carrying high risks for travelers.
1,3
Bahrain International Airport (BIA) experienced
its busiest year in 2004, with a 20% growth in pas-
sengers. During that year, there were 5 million pas-
sengers, with 2,836,649 arrivals and transit
passengers.
4 The airport serves the Kingdom of
Bahrain, covering an area of 711.9 km
2 in the
Arabian Gulf, with an estimated population of 689,418
in 2003, of which 62.1% are Bahraini.
5 A health
clinic specifi ed for travelers who are coming into or
departing from the airport is situated in BIA, with
easy access from arrival, departure, and transit areas.
The passengers clinic is staffed by experienced
registered nurses on a 24-hour basis, backed up by a
family physician with 31 years of practice experi-
ence. The physician is on-call around the clock.
Sick passengers are fi rst assessed by the nurse,
who decides whether to consult the physician or
38
J Travel Med 2007; 14: 37–41
Al-Zurba et al.
manage the problem alone. Guidelines for manag-
ing more than 40 common problems are available to
the nurse, who after assessing the sick passenger de-
cides if management is within the nurse s compe-
tence and scope of practice or if consultation with
the physician is required. The doctor may manage
the patient over the phone or attend to the patient
in person. Sick passengers access the clinic by them-
selves or are taken there by the civil aviation person-
nel or aircrew team. After preliminary evaluation,
the patient is either managed in the airport clinic or
after stabilization is referred to the hospital. Each
sick passenger is encountered by one visit to the
clinic during his/her embarking/disembarking. No
follow-ups or repeated consults were encountered.
Methods
Logbook for patients presenting to the BIA clinic
from January 1 till the end of December 2004
was reviewed. Items noted included presenting
problem(s), nationality of the patient, time of atten-
dance, and disposition of the patient. Chi-square
test was used to examine the signifi cance of differ-
ences using Statistical Package for Social Sciences
Program, version 11.0 (SPSS Inc., Chicago, IL, USA).
Results
A total of 3,350 travelers attended the clinic seek -
ing medical advice over the study period. This
constituted 0.12% of the disembarking and transit
Table 1 Distribution of travelers according to age and nationality
Nationality 0 10 10 20 20 30 30 40 40 50 50 60 60 70 70 80 >80 Total
Indian 26 10 113 120 69 25 7 7 1 378
Filipino 13 3 91 151 80 16 1 0 0 355
British 34 16 55 56 59 55 37 6 0 318
Pakistani 17 20 82 70 42 13 11 4 0 259
Bahraini 33 11 34 57 50 23 8 5 1 222
Saudi Arabian 19 10 43 55 37 12 3 0 0 179
Australian 42 18 27 20 26 13 5 7 1 159
Kuwaiti 20 15 35 28 16 5 3 0 0 122
Egyptian 5 2 29 28 42 4 2 0 1 113
Bengali 2 0 40 40 14 1 1 0 0 98
Persian 4 7 11 22 17 14 4 3 0 82
Jordanian 6 3 17 20 8 6 4 0 1 65
American 9 3 16 12 9 9 5 1 0 64
Lebanese 16 1 16 17 5 1 2 0 0 58
Qatari 6 5 13 11 11 3 1 0 0 50
Others 58 43 176 177 97 35 26 6 3 621
Total 310 167 798 884 582 235 120 39 8 3,143
Unknown
nationality
and/or age
407
travelers. The nationality and age distribution of
the travelers are shown in Table 1. The average age
of the patients was 34.4 years (range 2 mo to 90 y).
Men accounted for 64% of the patients. The distri-
bution of patients over the three nursing shifts was
almost equal, with minimal insignifi cant increase in
the evening hours.
A medical diagnosis was available for 77.8% of
the 3,350 travelers who required medical assistance
in BIA. Table 2 shows the problems for which trav-
elers required medical assistance. Most common
health problems diagnosed were upper respiratory
tract infections (24.4%), headache (19.2%), simple
injuries, musculoskeletal pains (12.9%), and gastro-
enteritis (11.0%). The vast majority of patients were
managed at the clinic and fi nalized by the nurse
alone.
Only 2.1% of the patients observed needed ur-
gent referral to secondary care. Of these, 19 (26.8%)
were attended by the family physician, 25 (35.2%)
referred after consulting with the physician over
the phone, and 27 (38%) referred immediately by
the nurse due to the critical condition of the patient.
The leading causes for referrals were chest pain
(69%), followed by trauma. Of these injured, only
15 of 205 (7.3%) patients needed referral for addi-
tional investigations and intervention. Of the 71
patients referred, 43.7, 39.4, and 16.9% were re-
ferred during the night, afternoon, and morning
shifts, respectively. Referrals to hospital were more
signifi cant in the afternoon and night shifts (
2 =
9.011, p = 0.011).
39
J Travel Med 2007; 14: 37–41
Medical Problems Encountered Among Travelers in BIA Clinic
Death was reported in two individuals: the fi rst
patient was a 54-year-old woman who suffered from
chest pain on board and arrived dead by a diverted
plane and the second patient arrived in a very criti-
cal situation and died within few minutes without a
diagnosis.
Discussion
This study is the fi rst that explores medical condi-
tions encountered at the BIA. While diffi cult to in-
vestigate due to the ubiquitous nature of the illness,
6
respiratory problems and common colds headed
the list of medical conditions in this study (24.4%).
The severe acute respiratory syndrome (SARS) out-
break of 2002 showed how air travel can have an im-
portant role in the rapid spread of newly emerging
infections and could potentially even start pandemics.
7
Transmission of upper respiratory infections to
other symptom-free passengers within aircraft
cabin is associated with sitting within two rows of a
contagious passenger for a fl ight time of more than
8 hours and is not a consequence of recirculating
50% of cabin air as previously believed.
8 Until the
emergence of the SARS epidemic, respiratory in-
fections were not commonly considered an impor-
tant cause of travel-related morbidity and mortality.
Therefore, upper respiratory tract infection was
our concern in 2004. When comparing to previous
reports, respiratory symptoms are seemingly be-
coming more prevalent than alimentary com-
plaints.
9 This could be due to more awareness and
fear among travelers of the impending new respira-
tory infections, which necessitate them to seek early
evaluation and treatment.
Neurological symptoms included giddiness,
faintness, and headaches, with the latter being the
most common. Neurological symptoms are the sin-
gle largest category of medical incidents, prompt-
ing 31% of all air-to-ground medical calls and
causing 34% of all diversions (second reason for di-
version after cardiovascular problems). Seizures,
dizziness/vertigo, and loss of consciousness/syncope
were the most common reasons for diversion.
10
Despite the fact that the problem of jet lag could not
be studied specifi cally in relation to the neurologi-
cal symptoms, jet lag can still overlap with many of
the neurological complaints encountered.
A common health problem associated with travel
in developing countries is travelers diarrhea.
Diarrhea affects 30% to 80% of international tra-
velers. In this series, 11% of travelers suffered
from gastrointestinal problems. Though mortality
caused by travelers diarrhea is extremely uncom-
mon, the morbidity of untreated disease is substan-
tial.
11 Because no stool analysis was done, one cannot
be sure if the diarrhea is due to infection. Diarrhea
is also a symptom of irritable bowel disease, which
may occur with the stress accompanying traveling.
Psychiatric complaints accounted for 1% of total
medical cases encountered. Despite the fact that the
percentage of psychiatric problems was low, the ac-
tual risk may be much higher. Travel often involves
stresses such as family separation, distance from
usual support systems, cultural and linguistic ad-
justment, jet lag, fatigue, and illness. These stresses
can provoke either new or relatively dormant psy-
chiatric illness. In this context, the dyschronism of
circadian rhythms and jet lag probably play a role in
the exacerbation of major psychiatric disorders.
12
Physicians should also be aware that illicit drug use
and malarial medication can be the cause of some
psychiatric ailments in travelers; addressing these
issues are important in the returning travelers.
13
An Australian report showed that musculoskele-
tal problems made up one fi fth of claims fi led by
travelers.
14 In this study, musculoskeletal problems
and injuries accounted for 12.9% of all complaints.
This is lower than that reported in the literature due
to the fact that most injuries may have been encoun-
tered only during the travel trip and not throughout
the period of travel. Twenty-one percent of the falls
were related to escalators; these accidents are
amenable to intervention strategies and can be
prevented. Furthermore, lacerations and fractures
seem to occur more in travelers than in local people,
and there is evidence that such injuries tend to be
more serious among travelers.
15
The most common complaint necessitating re-
ferrals in our series was chest pain. This is signifi -
cant because most common causes of serious
morbidity and mortality associated with chest pain
in travelers relate to cardiovascular diseases
16,17 and
venous thromboembolism, the latter representing a
signifi cant public health problem in some countries
like New Zealand.
18
Table 2 Reasons for medical assistance in Bahrain
International Airport
Problem Encounters, n (%)
Upper respiratory tract problems 816 (24.4)
Headache 642 (19.2)
Musculoskeletal problems 434 (12.9)
Gastroenteritis 368 (11.0)
Medication and assist 230 (6.9)
Short breath 82 (2.4)
Psychiatric problems 35 (1.1)
Problems not documented 743 (22.2)
40
J Travel Med 2007; 14: 37–41
Al-Zurba et al.
Thirty-eight percent of the referrals were made
by the nurse and agreed upon later by the physician.
The percentage of sick passengers who needed evac-
uation to hospital was less than that in other pub-
lished reports. This may be due to missing serious
medical conditions or the inclusion of more sick pa-
tients on board to begin with and who needed medi-
cal attention during and immediately after travel.
1
The airport clinic could resemble for some an emer-
gency unit, where seeking medical care would
shorten waiting times and avoid appointments, thus
offering quick answers about the urgency of their
condition in timely and effi cient manner.
The majority of sick travelers were handled by a
well-trained nurse. A considerable number of pas-
sengers needed only assurance, who presented
with minor complaints like common cold, gastro-
enteritis, muscle pains, and minor traumas, and
others requested refi ll of medications. The nurses
involved have long experience of more than 25
years and good training. The availability of clinical
guidelines besides the latter two issues may explain
why the physician involvement was not frequent.
The increase in referral to secondary care during
the night and afternoon was correlated with in-
crease of passengers traffi c during this period.
Our work suggests a good and an effi cient role
model illustrating good team spirit, skilled and
competent personnel in delivering medical care,
and an effi cient triage system.
The provision of health advice and the adminis-
tration of prophylactic measures can help reduce
the morbidity and, at times, mortal risks of infec-
tious illnesses that may be acquired during interna-
tional travel. Even the most up-to-date information
sources, however, may not be able to provide pre-
cise information on specifi c diseases prevalent in
specifi c locales because mechanisms for recogniz-
ing and reporting diseases are often lacking in
developing areas.
19 21
Conclusions
The majority of the problems encountered were
minor, which were managed by the nurse. Availabil-
ity of a physician was important in fi nalizing and as-
sessing critical cases. Upper respiratory tract
infections were the most common reason for those
visiting the clinic. With the emergence of new dis-
eases, like SARS and Avian fl u, caregivers need to be
updated on the most recent diseases related to travel.
The study shows that availability of a nearby clinic
is important, especially when illness necessitates im-
mediate care such as myocardial infarctions and where
rst aid care can be provided before transfer to hospi-
tal. In addition, travelers can always resort to airport
clinics for advice rather than depending on travel bro-
chures that may suffer sometimes from inadequacies.
Declaration of Interests
The authors state that they have no confl icts of
interest.
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The objective of this study was to describe the incidence of disease and injuries associated with travel, etiology, risk factors and medical management in a cross-sectional evaluation of university students, employees and teachers of the Central University of Venezuela, Caracas, Venezuela, who returned from domestic travel. A questionnaire completed by 500 individuals was used to evaluate the incidence of disease and injuries associated with travel, the etiology, risk factors and medical management in university students, employees and teachers of Caracas, Venezuela. From the total who accepted and responded to the interview (460, 92%), 50.8% were females. Almost half of them had some vaccination before travel for: measles 78%, rubella 73.6%, hepatitis B 57%, Yellow fever 53.7%. After travel, 53.9% of the individuals reported disease or injury related with travel, including insect bites (22%), which was reported most commonly. Occurrence of disease and injuries was higher for those who traveled to the jungle (OR=5.23, 95% CI 0.62-43.80), followed by those who travel to two areas (OR=1.82, 95% CI 1.06-3.13). Drinking alcohol during travel was identified in 73.8%, was significantly higher in men (p<0.01), and was associated with car accidents. Finally, 14.8% required medical attention during travel. The results indicated the importance of education and training in travel medicine, a relatively new medical discipline in Venezuela. Venezuela has a significant number of people visiting areas at risk for the acquisition of tropical and non-tropical conditions. Occasionally, travelers were without adequate preventive measures and pre-travel advice which is considered of utmost importance.
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Background: A significant proportion of air travelers experience situational anxiety and physical health problems. Takeoff and landing are assumed to be stressful, but anxiety related to other aspects of the air travel process, anxiety coping strategies, and in-flight health problems have not previously been investigated. Methods: We aimed to investigate frequency of perceived anxiety at procedural stages of air travel, individual strategies used to reduce such anxiety, and frequency of health problems on short-haul and long-haul flights. A questionnaire measuring the occurrence and frequency of the above was administered to two samples of intending travelers during a 3 month period to: (a) 138 travel agency clients, and (b) 100 individuals attending a hospital travel clinic. Results: Of the 238 respondents, two thirds were women. Take-off and landing were a perceived source of anxiety for about 40% of respondents, flight delays for over 50%, and customs and baggage reclaim for a third of individuals. Most frequent anxiety-reduction methods included alcohol and cigarette use, and distraction or relaxation techniques. Physical health problems related to air travel were common, and there was a strong relationship between such problems and frequency of anxiety. Travel agency clients reported more anxiety but not more physical health symptoms overall than travel clinic clients. Women reported greater air-travel anxiety, and more somatic symptoms than men. Conclusions: Significant numbers of air travelers report perceived anxiety related to aspects of travel, and this is associated with health problems during flights. Airlines and travel companies could institute specific measures, including improved information and communication, to reassure clients and thereby diminish anxiety during stages of air-travel. Medical practitioners and travel agencies should also be aware of the potential stresses of air travel and the need for additional information and advice.
Article
The proportion of travellers who fall ill varies from 15 to 43%. In general, diarrhoea and gastrointestinal infections account for 50–65% of health problems, followed by upper respiratory tract infections (14–30%), fever (12–15%) and skin disorders (10–12%). Sexually transmitted diseases account for 0.5–2% or more. Malaria in travellers remains important and there are approximately 10,000 reported cases of imported malaria each year in Europe alone.Emerging and re-emerging infectious diseases and increasing resistance to antibiotics and malaria are important.While the reasons for international travel are mainly tourism, business and education, in some regions of the world, migrant workers, refugees and asylum seekers contribute substantially to international migration. Migration contributes to the biological interplay between pathogens and their hosts as well as genetic exchange between different infectious agents including altered virulence and sensitivity to therapeutic drugs.The main causes of death in travellers are cardiovascular conditions, road and other accidents, and drowning. Infections appear to be an uncommon cause of death (2–3%).
Article
Currently, Lebanon is witnessing a shift in Arab tourists’ demands from residing in expensive and space-restricted hotel rooms to more comfortable and economically affordable timeshare vacation homes. This paper evaluates the needs, demands, and social life practices of Arab tourists and discusses their effect on the Lebanese vacation ownership industry. The quality of life of Arab tourists visiting Lebanon has been more fulfilled through ownership and residency in custom built timeshare vacation homes than residing in space-limited hotel rooms.
Article
Although aviation medical support to flight deck crews and cabin staff has been the subject of numerous articles, information about occupational medical support to ground crews, maintenance personnel, and other behind-the-lines personnel who help to "keep them flying" has rarely been presented. This report discusses the occupational medical support provided by six major U.S. international air carriers. Each carrier arranges for medical support of employees through a variety of health care systems, ranging from an airline medical department to total use of contract medical services. Approximately 70% of the airline personnel are non-flying and consequently come under the provisions of classical occupational medical services. Further, many of the flying personnel who may have sustained injuries or illnesses as a result of their aviation occupation also are managed in classical occupational medicine terms. Several airline medical directors interviewed estimate that 65% or more of their professional time is concerned with classical occupational medicine activities rather than aviation medicine programs as usually defined. A major challenge to international air carriers is the numerous jurisdictional arenas concerned with workers' compensation regulations and law under which they operate.
Article
A cumulative review of illness experienced by 13,816 travellers returning to Scotland since 1977, shows an overall attack rate of 36%. Alimentary complaints predominated; 18% of travellers had these alone and a further 10% had other symptoms as well as their gastro-intestinal disorder. Higher attack rates were noted in those taking package holidays. Inexperience of travel, smoking, more southerly travel and younger age (particularly those between 20- and 29-years-old) were other contributing factors. A similar pattern emerged from a I year study of hospital in-patients with travel related admissions. Serological studies of 470 travellers showed that 20% had incomplete immunity to poliomyelitis; 25% of those tested (312 travellers) had serological evidence of typhoid immunisation, I.9% (of 760 travellers) had antibodies to Legionella pneumophila, 64% (5II travellers tested) had antibodies to hepatitis A, 87% (288 tested) had adequate levels of tetanus antitoxin but only 40% of the 225 travellers tested had adequate levels of diphtheria antitoxin. Amongst a subgroup of 645 travellers the travel agent was the most frequently consulted source of pre-travel health advice. This carries particular significance for the dissemination of relevant advice in view of the inadequacies found from study of the health information in travel brochures. These findings, viewed against the perspective of the continuing growth in international travel, means that travellers, the medical profession, the travel trade, health educators, global health agencies and health authorities in those countries accepting and encouraging tourists, will be required to recognise the health implications of further tourism development if this problem of illness associated with travel is to be brought under control.
Article
Travelers to developing countries participated in a follow-up study of the health risks associated with short (less than three months) visits to these nations. Travelers to the Greek or Canary Islands served as a control cohort. Participants completed a questionnaire to elicit information regarding pretravel vaccinations, malaria prophylaxis, and health problems during and after their journey. Relevant infections were confirmed by the respondent's personal physician. The questionnaire was completed by 10,524 travelers; the answer rate was 73.8%. After a visit to developing countries, 15% of the travelers reported health problems, 8% consulted a doctor, and 3% were unable to work for an average of 15 days. The incidence of infection per month abroad was as follows: giardiasis, 7/1,000; amebiasis, 4/1,000; hepatitis, 4/1,000; gonorrhea, 3/1,000; and malaria, helminthiases, or syphilis, <1/1,000. There were no cases of typhoid fever or cholera.
Article
A significant proportion of air travelers experience situational anxiety and physical health problems. Take-off and landing are assumed to be stressful, but anxiety related to other aspects of the air travel process, anxiety coping strategies, and in-flight health problems have not previously been investigated. We aimed to investigate frequency of perceived anxiety at procedural stages of air travel, individual strategies used to reduce such anxiety, and frequency of health problems on short-haul and long-haul flights. A questionnaire measuring the occurrence and frequency of the above was administered to two samples of intending travelers during a 3 month period to: (a) 138 travel agency clients, and (b) 100 individuals attending a hospital travel clinic. Of the 238 respondents, two thirds were women. Take-off and landing were a perceived source of anxiety for about 40% of respondents, flight delays for over 50%, and customs and baggage reclaim for a third of individuals. Most frequent anxiety-reduction methods included alcohol and cigarette use, and distraction or relaxation techniques. Physical health problems related to air travel were common, and there was a strong relationship between such problems and frequency of anxiety. Travel agency clients reported more anxiety but not more physical health symptoms overall than travel clinic clients. Women reported greater air-travel anxiety, and more somatic symptoms than men. Significant numbers of air travelers report perceived anxiety related to aspects of travel, and this is associated with health problems during flights. Airlines and travel companies could institute specific measures, including improved information and communication, to reassure clients and thereby diminish anxiety during stages of air-travel. Medical practitioners and travel agencies should also be aware of the potential stresses of air travel and the need for additional information and advice.
Article
Travelers may return from the tropics with psychological problems. The literature regarding features and associations of these psychological problems is limited. Case histories of 15 consecutive returning travelers seen at our psychiatric service during the last 8 years. The median age of this group was 25 years, 10 were males, and the length of trip ranged from 10 days to 8.5 months. None of these travelers had prior psychopathology. The most common presentation was anxiety (with or without depression, n = 11), 3 suffered from acute psychosis, and 1 had pure depression. Eight of the travelers have used illicit drugs, which in 5 cases probably served as a trigger. Antimalarials may have played a role in 3 travelers. Six travelers needed antidepressants and supportive therapy, 3 neuroleptics, and 1 psychotherapy. These treatments lasted for 6 months and over in 6 of the travelers. Psychiatric problems among travelers to the tropics are multifarious in nature, multifactorial, have a strong relation to drug abuse, and may require a long and intensive therapy. Travelers should be better educated about the risks of using illicit drugs.
Article
Psychiatric morbidity among foreign tourists is usually connected to external factors such as unfamiliar surroundings, language problems, and special religious experiences, as well as biological factors such as dyschronism of circadian rhythms. Long-range flights through several time zones are typically followed by symptoms of jet lag such as fatigue, severe sleep schedule disturbance, impairment of cognitive functions, and even mild depression. Jet lag is generally attributed to a conflict between external time cues and internal biological rhythms. This study examined the possible association between jet lag and psychiatric morbidity among long-distance travelers hospitalized in the Jerusalem Mental Health Center, Kfar Shaul Hospital between 1993 and 1998. This was a prospective open-label study. Patients (n = 152) were divided into two groups based on the number of time zones crossed in the flight to Israel: group I, seven time zones or more (n = 81); and group II, three time zones or less (n = 71). The direction of flight was mainly eastbound. After controlling the two groups for demographic and religious background, past psychiatric history, and diagnosis on admission (P > 0.1, Fisher's exact test), the possible association between jet lag and psychotic or major affective disorder was evaluated according to the following criteria: (1) absence of major mental problems before the flight or good remission of an existing disorder 1 year or more before flight; and (2) the appearance of psychotic or major affective syndromes during the first 7 days after landing. The number of first psychotic/major affective episodes in both groups presumed as associated with jet lag was found similar (P =.5), whereas the number of relapses conjoint with jet lag in the seven or more time zone group was significantly higher (P =.04). The results suggest that the dyschronism of circadian rhythms and jet lag possibly play a role in the exacerbation of major psychiatric disorders.