© 2007 International Society of Travel Medicine, 1195-1982
Journal of Travel Medicine, Volume 14, Issue 1, 2007, 37–41
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.
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
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@
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.
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
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
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.
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).
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
— — — — — — — — — 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
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 (
9.011, p = 0.011).
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
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,
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.
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-
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.
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-
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.
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.
An Australian report showed that musculoskele-
tal problems made up one ﬁ fth of claims ﬁ led by
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.
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
venous thromboembolism, the latter representing a
signiﬁ cant public health problem in some countries
like New Zealand.
Table 2 Reasons for medical assistance in Bahrain
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)
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.
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
19 – 21
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
ﬁ 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
1. Zukerman J . Vaccine preventable diseases: in princi-
ples and practice of travel medicine . Chichester, UK :
Wiley , 2001 .
2. DeHart RL. Occupational medicine support for in-
ternational air carriers. Aviat Space Environ Med
1990 ; 61 : 67 – 70 .
3. Ladki SM , Tarik S , Mikdashi TS , et al . Arab tourists
and the Lebanese vacation ownership industry: a
quality of life perspective . J Int Hospitality Manage
2002 ; 21 : 257 – 265 .
4. Department of Transportation and Aviation. Airport
trafﬁ c statistics . Kingdom of Bahrain. Bahrain :
Department of Transportation and Aviation , 2004 .
5. Ministry of Health . Health Information Directorate,
Health Statistical Abstract . Manana : Kingdom of
Bahrain , 2003 .
6. Zitter JN , Mazonson PD , Miller DP , et al . Aircraft
cabin air recirculation and symptoms of the common
cold . JAMA 2002 ; 288 : 483 – 486 .
7. Olsen SJ , Chang H-L , Cheung TY-Y, et al . Trans-
mission of the severe acute respiratory syndrome on
aircraft . N Engl J Med 2003 ; 349:2416–2422 .
8. Mangili A , Gendreau MA . Transmission of infec-
tious diseases during commercial air travel . Lancet
2005 ; 365 : 989 – 996 .
9. Crosser JH , Reid D , Fallon RJ , et al . Accumulative
review of studies on travelers, their experience of ill-
ness and implications of these ﬁ ndings . J Infect 1990 ;
21 : 27 – 42 .
10. Sirven JI , Claypool DW , Sahs KL , et al . Is there
a neurologist on this ﬂ ight? Neurology 2002 ;
58 : 1739 – 1744 .
11. Petola H , Gorbach SL . Travelers ’ diarrhea: epide-
miology and clinic aspects . In : Dupont HL , Steffen
R , eds . Textbook of travel medicine and health .
Hamilton, ON : BC Decker , 1997 : 78 – 86 .
12. Katz G , Knobler HY , Laibel Z , et al . Time zone
change and major psychiatric morbidity: the results
of a 6-year study in Jerusalem . Compr Psychiatry
2002 ; 43 : 37 – 40 .
13. Beny A , Paz A , Potasman I . Psychiatric problems in
returning travelers: features and associations . J Travel
Med 2001 ; 85 : 243 – 246 .
14. Leggat PA , Leggat FW . Travel insurance claims
made by travelers from Australia . J Travel Med 2002 ;
9 : 59 – 65 .
J Travel Med 2007; 14: 37–41
Medical Problems Encountered Among Travelers in BIA Clinic
15. McInnes RJ , Williamson LM , Morrison A . Uninten-
tional injury during foreign travel: a review . J Travel
Med 2002 ; 9 : 297 – 307 .
16. Steffen R . Epidemiology: morbidity and mortality in
travelers . In : Keystone JS , Kozarsky PE , Freedman
DO , et al , eds . Travel medicine . St Louis, MO :
Mosby , 2004 : 5 – 12 .
17. Nothdurft HD , Caumes E . Epidemiology of health
risks of travel . In : Zuckerman J , ed . Principles and
practice of travel medicine . Chichester, UK : Wiley ,
2001 : 7 – 14 .
18. Hughes R , Heuser T , Hill S , et al . Recent air travel
and venous thromboembolism resulting in hospital
admission . Respirology 2006 ; 11 : 75 – 79 .
19. Steffan R , Rickenbach M , Wihem V , et al . Health
problems after travel to developing countries . J In-
fect Dis 1987 ; 156 : 84 .
20. McIntosh IB , Swanson V , Power KG , et al . Anxiety
and health problems related to air travel . J Travel
Med 1998 ; 5 : 198 – 204 .
21. DeHart RL . Health issues of air travel [Review] .
Annu Rev Public Health 2003 ; 24 : 133 – 151.