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a regional center for tourism, business, education, and medical tourism ... 2001 to 2002 in a 250-bed, five-star Beirut hotel with an occupancy ... of illness necessitating an emergency call was 0.2% per ... Beirut Medical Center, Beirut, Lebanon.
Medical Conditions Affecting Well-Accommodated Travelers in Lebanon Bassem Saab and Umayya Musharrafieh There are no data on the prevalence of common diseases affecting travelers to Lebanon. Between 2001 and 2002, one among nine physicians was consulted on guests who needed medical attention in a five-star Beirut hotel. Physicians were consulted 114 times. The mean age of the patients was 36.6 years. Gastroenteritis (50.9%) followed by respiratory problems (25.4%) were the leading causes for consultation.

to take care of the guests, received the complaint by phone.The other three physicians were an ophthalmologist and two general practitioners. When called, the physician would evaluate the severity of the conditions according to the medical history given and symptoms and would immediately decide whether physical examination was mandatory or whether advice could be offered over the phone.

Being ill abroad can be a frightening and challenging situation; however, good pretravel preparation should ensure some level of security about its management. Despite the fact that learning self-treatment regimens for minor ailments is important, travelers sometimes face unexpected illness that impact their lives even in their homeland. Finding competent physicians, easily accessible medical care, and available drugs remain issues to consider when visiting developing countries. Lebanon, with a surface of 10,452 km2 and an estimated population of 3.5 million, has regained its role as a regional center for tourism, business, education, and medical tourism in the Middle East. In 2002 the total number of arrivals to Lebanon from all continents was 956,464.Tourists most often originated from Arab countries (41.5%) and Europe (30.7%).The rest came from America (12.8%),Asia (7.8%), Oceania (4.2%), and Africa (3%).1 The medical facilities (147 hospitals, 7 of them exceeding 200 beds) are well equipped and distributed throughout the country, with three physicians per 1,000 people.

Results Physicians were consulted 114 times; thus, the risk of illness necessitating an emergency call was 0.2% per guest night.The mean age of patients was 33.6 years with a range of 3 to 82 years. Males accounted for 52% of the cases. Forty-nine percent of the medical complaints occurred between 6:00 pm and 6:00 am. Thirty-five patients were seen and examined by general practitioners, and the rest were mainly handled by family physicians. In 89% of cases, the physician had to examine the sick guest, whereas in 11% of cases, the problem was dealt with by phone.The total number of problems necessitating medical examinations was 103.The complaints were gastroenteritis (50.9%), respiratory problems (25.4%), headache (7.8%), anxiety (2.9%), gynecologic problems (2.9%), and trauma (1.9%). Other less prevalent diagnosed conditions were tendinitis, conjunctivitis, soft tissue infections, arterial embolus, intestinal ischemia, and death on arrival.Two patients were hospitalized, and the physician’s actions were life saving for both. One of these patients had intestinal ischemia with the cecum strangulated by the stomach, a rare condition, reported in only five reports in the literature.2

Methods To examine the frequency, type, and severity of medical complaints, a cohort study was conducted from 2001 to 2002 in a 250-bed, five-star Beirut hotel with an occupancy rate of 60%. In cases of illness, one among nine physicians, six of them family physicians appointed Bassem Saab, MD, and Umayya Musharrafieh, MD: Department of Family Medicine, American University of Beirut Medical Center, Beirut, Lebanon. Reprint requests: Umayya Musharrafieh, MD, American University of Beirut Medical Center, PO Box 113–6044, Beirut, Lebanon.

Discussion The complaints of travelers in this sample varied,with gastroenteritis leading the list in terms of frequency.The

J Travel Med 2005; 12:164–166.

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relatively young age group in this study can be attributed to the fact that the hotel was catering for airline crews. Many travelers to developing countries report diarrhea, with most episodes resolving during or shortly after travel, often in response to antimicrobial and antimotility agents.3 In Lebanon Salmonella and Shigella are among the leading microbial causes of infectious diarrhea,4 whereas Campylobacter seems to cause diarrhea only rarely.5 Hotel and restaurant supervisors should be alerted to this high rate, and a more stringent application of food precautions and stool screening of food handlers, especially during summer seasons, should be strictly implemented and followed. In a developing country, even travelers staying in good accommodations have a risk of getting travelers’ diarrhea since exposures outside decent accommodations remain high. On the other hand, travelers should also be educated about the need to follow food hygiene when eating and drinking, even when vaccinated against endemic infectious diseases such as typhoid. Before the epidemic of severe acute respiratory syndrome (SARS), respiratory infections were not commonly considered important causes of travel-related morbidity and mortality. However, Steffen and colleagues have demonstrated that respiratory infections are common in the traveling population.6 In our series, respiratory illnesses ranked second in frequency of medical complaints, but none of the patients needed to be admitted to hospital. Physicians should be encouraged to update their patients’ immunization status against influenza and pneumococcal disease prior to travel, whenever indicated. Besides the common respiratory pathogens, tuberculosis remains endemic, especially in areas of Beirut and Northern Lebanon.7 Anxiety was also encountered in this series.Travel stress caused by disrupted schedules, jet lag, crowding, lack of privacy, and culture shocks can be significant.A holiday that is supposed to be relaxing and a time to “kick back” can be associated instead with phobias, insomnia, and panic attacks.8 Although trauma is a common problem faced by travelers, doctors were only consulted on two such related cases. One elderly lady was mugged and developed an occipital hematoma, and the other patient had a laceration. Possible reasons for the low number of reported trauma conditions are that trivial cases are not brought to the attention of the physician, and patients with serious cases, such as those involved in motor vehicle accidents, are usually taken immediately to the hospital. In the cases reported in this paper, two patients required urgent operations. This illustrates that serious medical conditions are to be considered in the differential diagnosis, especially in high-risk patients.

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Most of the conditions encountered were easily handled by family physicians; they were able to perform diagnoses, provide appropriate preventive and therapeutic measures, and counsel for risk reduction. One asset of having a family physician was the ability to treat children and adults, men and women, and a wide variety of complaints. The physicians did not examine 11% of the patients. This figure is believed to be exceptionally low.The diagnoses in many cases were upper respiratory tract infections or uncomplicated enteritis that could be dealt with without an examination and without close observation. In Lebanon there is no law that allows physicians to charge for a telephone consultation.The financial reward may have prompted physicians to examine patients who could have received medical care by phone.Also, sometimes a traveler insists on having a physician examine him or her, thinking that being examined by a doctor will hasten the recovery. Conclusions Maintaining health during travel requires common sense and some knowledge of the health risks in the country of destination. Travelers are at risk of developing common and serious illnesses and even dying during travel. The availability of good and adequate medical care is important. With their global approach, family physicians who are well acquainted and trained in travel medicine can offer good medical care to travelers and can divert them to specialty care when needed. Acknowledgments We would like to thank all the physicians who contributed to the care, follow-up, and medical assistance of the guest travelers. Declaration of Interests The authors have no financial or other interests to disclose. References 1. 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. 2. Rich PB, Burke L, Cairns BA. Hernia of right colon and cecum through the foramen of Winslow and lesser omentum. J Am Coll Surg 2002; 194:230.

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3. Castelli F, Pezzoli C,Tomasoni L. Epidemiology of travelers’ diarrhea. J Travel Med 2001; 8(Suppl 2):S26–S30. 4. Musharrafieh U, Bizri AR, Hajj I. Health risks to travelers to Lebanon. J Travel Med 2003; 10:280–285. 5. Talhouk R, El Dana R,Araj GE, et al. Prevalence, antimicrobial susceptibility, and molecular characterization of Campylobacter isolates from human and poultry in Lebanon. J Med Liban 1998; 46:311–316. 6. Steffen R, Rickenbach M,Wihem V, et al. Health problems

after travel to developing countries. J Infect Dis 1987; 156:84–91. 7. Araj GF, Itani LY, Kanj NA, Jamaleddine GW. Comparative study of anti-tuberculosis drug resistance among Mycobacterium tuberculosis recovered at the American University of Beirut Medical Center: 1996–98 vs.1994–1995. J Med Liban 2000; 48; 18–22. 8. McIntosh IB, Swanson V, Power KG, et al.Anxiety and health problems related to air travel. J Travel Med 1998; 5:198–204.

The remains of Kinniya District hospital after the tsumani. Submitted by Eli Schwartz, MD.