Patterns of Communicable and Non-Communicable Diseases in Pilgrims during Hajj

 

Nurul Diana Dzaraly¹, Nor Iza A. Rahman²*, Nordin Bin Simbak³, Suhaimi Ab. Wahab⁴, Omar Osman⁵, Salwani Ismail⁶, Mainul Haque⁷

¹Masters Student, Faculty of Medicine and Health Science (FPSK), Universiti Sultan Zainal Abidin (UniSZA), 20400 Kuala Terengganu, Malaysia;

²Medical Lecturer and Head of the School of Basic Medical School, FPSK, UniSZA, 20400 Kuala Terengganu, Malaysia;

³Professor and Dean, FPSK, UniSZA, 20400 Kuala Terengganu, Malaysia;

⁴Medical Lecturer and Deputy Dean, PPSP, Hospital Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia;

⁵Professor and Vice Chancellor, Universiti Sains Malaysia, 11800, Pulau Pinang, Malaysia;

⁶Medical Lecturer and Deputy Dean, FPSK, UniSZA, 20400 Kuala Terengganu, Malaysia;

⁷Professor and Head of the Unit of Pharmacology, FPSK, UniSZA,  Kampus Kota, 20400 Kuala Terengganu, Terengganu, Malaysia.

 

ABSTRACT:

Introduction: Hajj is the largest annual gatherings in Islamic world. Hajj pilgrims encounter a great deal of tough physical and mental stress. Overcrowding, extreme temperatures and electrolytes imbalance is common among pilgrims. These factors trigger the increased risk for communicable and non-communicable disease. Objective: The main objective of this study was to determine the patterns of common health problems (CHPs) encountered by pilgrims. Methods: CINAHL, EBSCO Host, PubMed, Google Scholar and Science Direct databases were used to search for articles related to the CHPs faced by the pilgrims which were published from 1998 to 2013. Eligible articles included non-experimental, experimental studies and case reports. The patterns and types of illness among pilgrims have been explored from limited intervention based articles. Only 27 studies were included encompassing with 17, 753 respondents out of 500 articles. Results: The analysis revealed that respiratory diseases (76.2%) were the leading health problems among Hajj-pilgrims followed by skin disease (7.4%), meningococcal disease (3.7%) and heat stroke (3.7%). Conclusion: Respiratory diseases are the most common health problems encountered by Hajj-pilgrims in which influenza gave the highest percentage. However, a definitive conclusion could not be drawn due to lack of existing studies related to this area. The existing evidence was insufficient to support the patterns of illness during mass gathering. Therefore, more studies are advocated to report the incidence of respiratory disease among Hajj-pilgrims.

 

 

INTRODUCTION:

Hajj is the largest annual Muslim mass gatherings for religious and rituals performances which are performed in Mecca, Kingdom of Saudi Arabia (KSA). Every year, more than 2.5 million Muslims from different parts of the world perform Hajj ^[1]. The total number of pilgrims for 2011 was 2,927,717 which were increased in about 5% from the previous year. It has been reported at least 1,828 195 pilgrims were foreign visitors while 1,099,522 pilgrims came from KSA ^[2]. The Hajj is performed in the month of Dhu al-Hijjah which is twelfth and final month of the Islamic calendar ^[3]. Hajj is fifth and final pillars of Islam and obligatory for all adult who fulfill the prerequisite ^[4].

The Hajj-pilgrims need to travel and relocate a number of times ^[5]. Since the Hajj performance follows the Islamic lunar calendar and which is shorter than Gregorian calendar. The date of Hajj will be 10 or 11 days earlier than previous year which requires attention of health policy planner ^[6]. The Hajj pilgrims from various countries arrive in KSA has been steadily increasing every year ^{[2, 7]}. The Hajj congregations obviously become overcrowded and are a major public health challenges ^[8].

 

The recorded temperature during Hajj ranged between 37°C to 45°C ^[9]. Overcrowding and hot climate were major causes of health hazards among hajjis. Hajj-pilgrims encounter a great deal of tough physical and mental stress. Hajjis face multiple health issue like extreme temperatures, intravascular volume and electrolytes disturbances which also increases the risk of communicable and non-communicable diseases ^[10]. The current diseases spotted during performing Hajj including upper respiratory tract infections (URTI), diarrhea, heat stroke, dehydration or electrolyte imbalance^[11]. One in three pilgrims will experience such respiratory symptoms ^[12]. In addition, the close contact and overcrowding aggravate the spread of infection especially URTI especially elderly^[13].

 

URTI were reported among the most common cause of illness among Iranian pilgrims^[14]. Other hazards include stampedes, traffic accidents and fire injuries^[15].  The aim of this study was to determine the pattern of CHPs encountered by Hajj-pilgrims by reviewing previous studies. The result could be beneficial in planning and designing the appropriate prevention on pattern diseases in community Hajj pilgrims.

 

MATERIALS AND METHODS:

Search Strategy and Selection Criteria

EBSCO Host, PubMed, Medline, Google Scholar, Science Direct and Springer Link were used to search for articles published related to health problems from 1998 to 2012. The combinations of specific keywords were utilized to retrieve the articles: (pilgrims, Hajj, health problem and pattern). Only twenty seven had met the specific inclusion criteria: the subjects were Hajj-pilgrims; the type of study was experimental or non-experimental study; available full article in English. The outcome of studies was subsequently based on most CHPs encountered by Hajj-pilgrims.

 

Data Collection and Analysis

Demographic distributions of all respondents in the studies chosen were well summarized according to author, year and mean age, meanwhile the subsequent information gathered were sample size, study design, pattern of health problems, result and comment (Table 1). All the information from selected articles was tabulated into those tables.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 1: The Flow of Articles Selection

 

 

Table 1: Experimental Studies Based on Pattern of Common Health Problem during Hajj

Author/ (year)	Objectives,  Method, and Sample Size (n)	Result
Alzahrani et al. (2012)	Pattern of diseases among pilgrims seeking medical services. Descriptive study.  ( n = 4136)	Respiratory diseases (60.8%), musculoskeletal (17.6%), skin (15.0%) gastrointestinal (13.1%)
Mandourah et al.  (2012)	An account of pneumonia –related critical illness among hospitals providing medical care to Hajj pilgrims. Prospective cohort study.   (n = 452)	Pneumonia was the primary cause of critical illness in 123 (27.2%)
Memish et al. (2012)	The prevalence of different respiratory viruses among healthcare worker. Cross-sectional study. ( n = 184)	Two types of viruses were detected : rhinoviruses and Coronaviruses 229E
Moattari et al. (2012)	The attack rate of seasonal and pandemic influenza among returning Iranian pilgrims after the 2009 Hajj. Cross-sectional study. ( n = 275)	9.1% pilgrims had influenza
Ziad et al. (2012)	Pilgrims’ attendance at the Hajj was associated with an increase of acquiring influenza. Cross-sectional study. (n = 519)	Influenza A was 0.1-0.2% among the pilgrims
Ziyaeyan et al. (2012)	Prevalence of A (H1N1) among returning Iranian pilgrims. Cross-sectional study. ( n = 305)	Influenza A (1.6%)
Asghar et al. (2011)	Common causes of bacterial pneumonia during the 2005 Hajj season and to relate the findings with clinical conditions. Cross-sectional study. (n = 141)	Clinically suspected pneumonia 53.9% were confirmed positive.
Mimish et al.  (2011)	Electrocardiographic changes in exposed to high outdoor temperature with heat stroke and heat exhaustion. Case control study. (n = 62)	Sinus tachycardia and ischemic changes.
Mirza et al. (2011)	Predictors of asthma exacerbations during the Hajj. Cohort study.     (n = 58)	There were 31-46.6% suffered from mild to moderate asthma attack
Alborzi et al. (2009)	Incidence of the common respiratory viruses among Iranian pilgrims. Cross-sectional study.  (n = 255)	Viral agents (25%) of nasal specimens
Rashid et al. (2008)	Burden of influenza and RSV in asymptomatic British pilgrims during Hajj. Cross-sectional study. (n = 202)	Influenza or RSV with 18%
Rashid et al. (2008)	Rates of influenza virus, rhinovirus, RSV, hMPV, adenovirus, and parainfluenza virus infection among UK and Saudi pilgrims. Comparative study. (n = 260)	25% UK and Saudi pilgrims
Shakir et al. (2006)	Pattern of patients attending the Out Patient Department (OPD) during the Hajjseason. Descriptive study.  (n= 3876)	Respiratory disease 41%
Wilder-Smith et al. (2005)	Risk of M. Tuberculosis infection among Hajj pilgrims. Prospective study.  (n = 357)	Hajjis were 41.7% negative and 42.6% positive
Al-Ghamdi et al. (2003)	Pattern of admission during mild weather. Prospective study.              (n = 160)	Respiratory diseases 57%, 19.4%, and GIT 6.3%
Bulkhy et al. (2003)	Serogroup of the locally circulating starins of N.meningitis. Longitudinal study.  (n = 327)	Serogroup W135 40% of all recovered pre-Hajj
Wilder-Smith et al. (2003)	Incidence of pertussis among adult Hajj pilgrims. Prospective study. (n = 358)	Acquired pertussis1.4%
Fatani et al. (2002)	Aetiology of primary and secondary pyoderma. Prospective study. (n = 80)	Pyoderma patient 52.5%
Fatani et al. (2000)	Common skin disease seen in a 15-day period (Hajj pilgrims). Retrospective study. ( n= 731)	Dermatitis 23.6%
Yousuf et al. (1999)	Prevalence of respiratory diseases among admitted Hajj pilgrims. Retrospective study. (n = 798)	Respiratory diseases 55%
El-Sheikh et al. (1998)	Incidence and type of RTI-causing bacteria and viruses during a period of epidemic infections. Prospective study. (n = 1156)	Klebsiellapneumoniae 15.1%, Haemophilus influenzae and Streptococcus pneumoniae 12.3%
Fasihuddin et al. (2006)	Aetiology, clinical features and the outcomes. Cross-sectional         (n = 81)	Gram-negative bacilli were identified as causative organism in 21%, Streptococcus pneumoniae in 9.9%, Mycobacterium tuberculosis in 3.7%

 

Table 2: Non-Experimental Studies Based on Pattern of Common Health Problem during Hajj

Author/(Year)	Objectives,  Method, and Sample Size (n)	Result
Saeed et al. (2012)	The prevalence of three symptoms of interest diarrhoea, acute respiratory infection and jaundice. Cross- sectional study. ( n = 1659)	Acute respiratory infection 1.4% at pre-transit to 4% at transit area and 37% during Hajj
Zakuan et al. (2010)	The association between pre-morbid conditions and influenza like illness (ILI) among Hajj pilgrims. Cross-sectional study. (n = 276)	Underlying asthma was significantly associated with severe ILI
Al-Asmary et al. (2007)	The prevalence of acute respiratory tract infection (ARI) among personnel serving during Hajj. Case-control study. ( n = 250)	The attack rate for acute respiratory infection 25.6%
Gautret et al. (2008)	The incidence of febrile cough among adult Muslim during Hajj. Prospective epidemiology study. (n = 580)	Diabetes mellitus 22.8%, Hypertension 25.3
Gautret et al. (2007)	Investigate prospectively the occurrence of common health hazard in French pilgrims during Hajj 2007. Prospective cohort study.            (n = 545)	Cough 51%, followed by headache, heat stress, and fever

 

RESULTS:

A total of 27 studies related to patterns of CHPs which encountered by Hajj-pilgrims meeting the specific inclusion criteria for this study were used for analysis from 1998 to 2012. The majority of related articles were published in different prestigious journals around the world. The studies were carried in KSA (55.5%), Iran (11.1%), Singapore (7.4%), France (7.4%), United Kingdom (UK) (7.4%), Malaysia (3.7%), Afghanistan (3.7%) and Pakistan (3.7%).

 

Demographic Characteristics of Hajj Pilgrims

The total number of subjects based on the selected articles published starting from year 1998 until 2012 is 17, 753. Hajis’ age was from 18 to 99 years old. Older Hajjis were in high risk group to be infected early because of weak immune systems. Eighteen out of 27 studies had highlighted that the increased rate of CHPs encountered was predominant by males (65%) pilgrims compared to females (35%). However, it is reported that pertussis involved a huge number of female Hajjis with 64% ^[16]. Nevertheless, the distribution of the pilgrim’s gender was not documented in two of the selected articles ^{[13, 17]}. The nationality of the respondents was dominated by KSA national as most of the studies were carried out in KSA. Since the majority of articles were focused on Hajj-pilgrims; healthcare worker and medical mission personnel also have been included as a subject in two related articles as well ^[18-19].

 

Study Design and Method

Regarding the study design of the selected articles; most of the studies were based on cross-sectional studies (40.7%), followed by prospective studies (25.9%), retrospectives (7.4%), descriptive (7.4%), case control (7.4%), comparative (3.7%), cohort (3.7%) and longitudinal (3.7%). Various kinds of instruments were used in the quantitative studies. Majority of the studies performed the laboratory tests in order to evaluate the disease conditions of CHPs among Hajj-pilgrims. Sputum culture and X-rays were listed as the basic tests to detect the variety of bacteria isolated.  Five studies used questionnaires as a tool to investigate the occurrences of CHPs among pilgrims.

 

Health Problems

Out of 27 selected studies, 22 of articles had concluded that respiratory diseases (76.2%) were the main CHPs encountered by Hajj-pilgrims and main reason for hospital admission (Table 1 and 2). Respiratory diseases are listed includes: pneumonia, influenza, chronic obstructive pulmonary disease (COPD), URTI and bronchial asthma ^{[3, 13, 16, 17, 20]}. Four articles had revealed that pneumonia being the most frequent disease recorded in their studies. In regards to causative organism for pneumonia, Haemophilus influenza (20.3%) was the common frequent organism isolated in sputum culture followed by Klebsiella pneumonia (17.6%), Streptococcus pneumonia (16.2%) and Staphylococcus aureus (9.5%) ^{[10, 13, 21-22]}.

 

Regarding viral respiratory infection, 7 articles had identified viral respiratory infections as the second leading patterns cause of CHPs encountered by Hajj-pilgrims. Influenza, rhinovirus adenovirus and syncytial virus were commonly encountered ^{[13, 23-26]}. Immunofluorescence and monoclonal antibodies test were used to determine the causative agent.

 

One study reported about the outbreak of Neisseria meningitidis serogroup W135 in 2000 ^[27]. Another study ^[28] conducted among Hajjis revealed that there is the high risk of pulmonary tuberculosis (PTB) and 10% of them had a significant rise in MTB titre. Three articles had revealed the pattern of common admission to hospitals ^{[3, 29-30]}. The similar finding which had been discussed in those articles where respiratory diseases were recorded as most CHPs during Hajj performances. Besides, those articles had highlighted similar findings which stated that problems related to genitourinary, musculoskeletal and cardiovascular systems were revealed as the second most CHPs encountered by pilgrims after respiratory diseases ^{[3, 29-30]}. Lastly, two studies had focused on the incidence of skin diseases among pilgrims while only in one study where the health problem as related to heat stroke and heat exhaustion patterns ^[31-33].

 

DISCUSSION:

This brief review is intended to provide a structured analysis of published articles on patterns of health problems over the past twenty years with regards to Hajj pilgrim. Patterns of health problems, challenges for pilgrims during pilgrimage, related outcomes and suggestions for future investigators are highlighted.

 

The overall assessment had shown that more than 55.5% of the studies were carried out in KSA hospitals. It was reported that from the total number of pilgrims for 2011; at least 1.8 million were foreign visitors, while 1.1 million came from within KSA herself ^[34]. The percentage of both gender showed a great clear difference; male (65%) and females (35%). Men are usually responsible for taking great care of their family since they were physically fit and tough pilgrims. Majority of women or elderly pilgrims will assign men pilgrims during ramī aj-jamarāt (The Stoning of the Devil) rituals performance. All these factors actually could explain the higher proportion of males sufferings compared to females ^[29].

 

In terms of age, all ages were involved in this review and the pilgrims aged fifty years old and above were mostly affected. In general, elderly pilgrims were susceptible to get the infection due to decrease immune responses and aggravated by other factors such as exertions, lack of sleep and disturbances in dietary schedule ^{[5, 11]}. According to WHO, pneumococcal disease affects people of all ages, but children younger than five years and adults age 65 years and above were at increased risk because the immune system of the individuals at this age starts to decline ^[35].

 

Pattern of CHPs

Respiratory Tract Infections

URTIs were considered as the predominant CHPs which encountered by Hajj-pilgrims. URTIs are common illness in of KSA and also hospital admission. URTIs continues to be the increasing burden of diseases among Hajj-pilgrims but there is still lack of studies being conducted to overcome these problems ^[36].

 

Pneumonia is a common and potentially life-threatening illness which is categorized as one of the major global health problems particularly among elderly group who perform ^[37].  Researchers had implemented a prospective study in two different hospitals during Hajj where had identified respiratory diseases as the most common cause of hospital admission (57%), with pneumonia being the leading reason for hospitalisation (39%) ^[3]. The factor listed among pneumonia patients during Hajj were community acquired pneumonia (CAP) (66.7%), aspiration-related (25%), tuberculosis (4.9%) and nosocomial (3.3%) ^[10].

 

CAP is one of the most common infectious diseases which are addressed by clinicians causing mortality and morbidity worldwide. In United States, CAP was classified as fifth leading cause of death especially older people aged 65 years and above ^[38]. The overall mortality rate among pilgrims with pneumonia during Hajj period was 14.8% which is similar to the mortality rates in West. Gram-negative bacilli were identified as the common causative agents for pneumonia with 21% followed by Streptococcus pneumoniae in 9.9% and Mycobacterium tuberculosis ^[21].

 

Viral respiratory tract infections particularly with influenza were indicated as another CHPs ^[39]. The studies reflected 50% was influenza B, 24.1% was herpes simplex virus, 12.9% was respiratory syncytial virus (RSV), and 5.6% was influenza A ^[40]. It also had been supported by the studies with similar findings of viral pathogens with influenza A and adenovirus being the most common ^[13].

 

The studies conducted by researchers which involves approximately 205 patients using real-time polymerase chain reaction (RT-PCR) revealed that influenza A give 56.7% (21/37) of the confirmed cases, RSV with 24% and influenza B with 18.9% ^[24]. The government of KSA recommend influenza vaccine to all hajjis especially with predisposing diseases and ages 65 years or above. Recent analysis regarding UK pilgrims demonstrated that the rate of influenza among vaccinated group (7%) was lower as compared to unvaccinated group (14%) respectively ^[26]. The KSA authority had recommended the use of facemask as to reduce the airborne transmission of diseases especially during Hajj. 

 

The study conducted on Singaporean pilgrims was tested with a whole blood assay (QuantiFERON TB assay) in order to identify the immune response to tuberculosis (TB). The test was carried out before departure which involved approximately a total of 357 of pilgrims. A total of 149 of pilgrims were found to be negative ^[28]. Besides, the prevalence of Multi-Drug-Resistance (MDR) TB actually 3 times higher in KSA especially in cities of pilgrims such as Mecca, Medina and Jeddah ^[41].

 

The current swine flu virus (H1N1) pandemic was first recognized and reported in Mexico City in February 2009, which spread rapidly throughout the world. In 2009 Hajj season, WHO declared approximately 300,000 laboratory confirmed cases of H1N1 with 3,917 deaths in 191 different countries ^[42]. It is reported that low percentage of H1N1 prevalence among group of healthy pilgrims during the time of a declared (H1N1) pandemic. The result revealed the prevalence of pandemic H1N1 was 0.2% (n=1) among arriving pilgrims and 0.1% (n=2) among departing    pilgrims ^[43].

 

Even though there is no original article reported about Middle East respiratory syndrome conronovirus (MERS-CoV) during Hajj performance, but it’s still the latest biggest concerns especially for pilgrims when it’s was first reported in 2012 ^[44].  MERS-CoV is a novel virus that was first isolated from a Jordan’s patient, presenting with a severe acute respiratory infection in April 2012. WHO also reported two cases of severe community-acquired pneumonia caused by a novel human b-coronavirus, (MERS-CoV) in September 2012. Besides, total of 114 cases of laboratory-confirmed infection with MERS-CoV were reported in Middle East and Europe as well including 54 of total deaths was recorded^[45].The exactly epidemiology of MERS-CoV is yet unknown including natural host and reservoir as well. Transmission seems to occur primarily among household contact and health care facilities based on an outbreak of 23 confirmed and 11 cases in four health care facilities which were reported in eastern province of Saudi Arabia during April and May 2013 ^[46].

 

Even though, WHO guarantees the risk of infection with MERS-CoV among pilgrims performing Hajj 2012 is very low, international community still concern about the possible potential for an outbreak. Until now, the cases which involved MERS-CoV were not reported during Hajj 2012, but the study from Marseillle, Hajj pilgrims from France showed a high rate of acquisition of other respiratory viruses ^[47]. WHO recommends adult aged 65 years and above, individual with chronic diseases and immunocompromised to postpone their plan for performing Hajj ^[48].

 

Meningococcal Disease

Meningococcal meningitis can be defined as an infection which is caused by the bacterium Neisseria meningitidis. The first international outbreak of N. meningitidis serogroup W135 was reported during 2000. The carriage rate was 4.7% of 327 samples of throat culture ^[27]. The tense environments like physically overcrowded, high humidity and dense air pollution have been reported to raise the carrier rates for meningococcal disease as high as 80% ^[49]. Saudi authority provides the best vaccines protection mandatory guideline such as quadrivalent polysaccharide vaccination (A,C,Y,W135) for the prevention of meningococcal disease for pilgrims and workers.

 

 

Skin Infections

Makkah is one of the hottest places in the world with the temperature range of 38 to 42°C. A bacterial skin infection is one of the CHPs during Hajj ^[32]. Study revealed that 80 pyoderma patients were reported during Hajj. Among pyoderma cases 52.5% were primary and 47.5% were secondary pyoderma. Impetigo was leading cause of primary pyoderma where Staphlococcus aureus responsible as main causative agents and followed by Stretococcus pyogenes ^[32]. Dermatitis (23.6%) was indicated as the most common skin diseases followed by pyoderma (11.2%), intertrigo (10.7%) and urticarial (5.7%) based on previous study with similar finding. Middle age group and elders may have contributed to a high incidence of intertrigo and fungal infections ^[31].

 

Environmental Heat Injury

The extremely high temperatures particularly in summer, radiated heat directly from sun, heat from vehicles and internal heat were determined as the main factor listed of heat stress ^[50]. The prolonged exposure towards high outdoor temperature can lead to heat exhaustion or heat stroke among pilgrims. One study about electrocardiographic finding in heat stroke and exhaustion reported that increase of heart rate is significantly attributed to the higher core temperature in heat stroke and heat exhaustion group ^[33].

 

Cardiovascular Diseases

Over the past few years, cardiovascular disease is an important cause of ICU and mortality rate particularly during Hajj ^{[3, 51]} Study revealed chronic obstructive pulmonary diseases (COPD) as the second leading cause of hospital admission during Hajj after pneumonia. This is supported by Saudi Statistic, 2005; cardiovascular disease is one the most common cause of death during Hajj performance with the percentage of 43% ^[52]. In 2004, myocardial infection was categorized as the major cause of hospital admissions specifically into CCU by seven different of hospitals in Makkaa ahead of pneumonia, asthma, COPD, and pulmonary oedema ^[11]. The physical stress may contribute as a main factor in precipitating IHD due to massive overcrowding during Hajj especially for those who had pre-existing cardiac disease history ^[5].

 

Despite the overall findings in this review, there were several drawbacks that need to be mentioned. First, the limited access online database which focused article published in English-language. Second, as highlighted earlier, since the majority of studies have been conducted in Saudi Arabia, our findings may not represent total Hajj pilgrims from different population. Besides, most of studies had focused on respiratory disease finding which gives a limitation for discover other health problems. 

 

Despite of the limitations mentioned, this study found that respiratory diseases are the most CHPs encountered by Hajj pilgrims with influenza and pneumonia as the predominant infection. Acknowledge the pattern of common health especially during Hajj performance gives such important information either Saudi Arabia government or related countries authorities in providing health policy makers and health service towards pilgrims. Since elderly and immunocompromised pilgrims were susceptible to tend have an infection, the pilgrims’ countries origin should be focused more on providing pre-departure vaccination and even free health service during Hajj performance. Vaccination also can be considered as the first step closer in preventing infectious diseases especially when more than 2 million of pilgrims will participate simultaneously in this mass gathering.  Pilgrims remain in close proximity such in crowded tents or rooms for at least several days or weeks were the main course. The statistical analysis regarding the pattern of diseases will provide better management particularly for involving countries authorities. Plus, the optimal latest information regarding common health problem provides the best solution for medications intake and treatment management as well. Therefore, well designed prospective studies need to be conducted to safeguard Hajj-pilgrims. 

 

ACKNOWLEDGEMENT:

This study obtained no funding.  Authors do not have any conflict of interest. 

 

REFERENCES:

1.       Ebrahim SH, Memish ZA, Uyeki TM, et al. Pandemic H1N1 and the 2009 Hajj. Science. 2 (326); 2009: 938–940.  Available from: URL: http://www.sciencemag.org/content/326/5955/938  

2.       Royal Embassy of Saudi Arabia (RESA). 2011. Available from: URL:  http://www.saudiembassy.net/latest_news/news11061102.aspx    

3.       Al-Ghamdi SM, Akbar HO, Qari YA, Fathaldin OA, Al-Rashed, RS. Pattern of admission to hospitals during muslim pilgrimage (Hajj). Saudi Med J. 24 (10); 2003:  1073–76. Available from: URL: http://smj.psmmc.med.sa/index.php/smj/article/viewFile/ 4561/2335

4.       Gatrad AR, Sheikh A. Hajj: journey of a lifetime. Br Med J. 330 (7483); 2005: 133-137. Available from: URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC544433/pdf/bmj33000133.pdf

5.       Ahmed QA, Arabi YM, Memish ZA. Health risks at the Hajj. Lancet. 367; 2006: 1008–15. Available from: URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC544433/

6.       El Bashir H, Rashid H,  Memish ZA,  Shafi S. Health at Hajj and Umra Research Group: Meningococcal vaccine coverage in Hajj pilgrims. Lancet. 369; 2007: 1343. Available from: URL: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(07)60625-4/fulltext

7.       Khan K, Memish ZA, Chabbra A, et al. Global Public Health Implications of a Mass Gathering in Mecca, Saudi Arabia During the Midst of an Influenza Pandemic.  J Travel Med. 17(2); 2010: 75–81. Available from: URL: http://www.ncbi.nlm.nih.gov/ pubmed/20412172

8.       Asghar AH. Frequency and antimicrobial susceptibility patterns of bacterial pathogens isolated from septicemic patients in Makkah hospitals. Saudi Med J. 27 (3); 2006: 361-367. Available from: URL: http://smj.psmmc.med.sa/index.php/smj /article/viewFile/3564/1338                

9.       Mimesh SA, Al-Khenaizan S, Memish ZA. Dermatologic changes of pilgrimage. Clin Dermatol. 26; 2008: 52–61. Available from: URL: http://www.researchgate.net/publication /5571089_Dermatologic_challenges_of_pilgrimage

10.     Mandourah Y, Al-Radi A, Ocheltree AH, Ocheltree SR, Fowler RA. Clinical and temporal patterns of severe pneumonia causing illness during Hajj. BMC Infect Dis. 12; 2012: 117. Available from: URL: http://www.biomedcentral.com/1471-2334/12/117

11.     Madani TA, Ghabrah TM, Albarrak AM, et al. Causes of admission to intensive care units in the Hajj season of the Islamic year 1424 (2004). Ann Saudi Med. 27; 2007: 101–105. Available from: URL: http://www.researchgate.net/publication /6451514_Causes_of_admission_to_intensive_care_units_in_the_Hajj_period_of_the_Islamic_year_1424_(2004)

12.     Gatrad  AR,  Shafi S, Memish ZA, Sheikh A. Hajj and the risk of influenza. Br Med J. 33; 2006:  1182–1183. Available from: URL:  http://www.bmj.com/content/333/7580/1182.full.pdf+html

13.     El-Sheikh SM, El-Assouli SM, Mohammed KA,  Albar M. Bacteria and viruses that causes respiratory tract infections during the pilgrimage (Haj) season in Makkah, Saudi Arabia. Trop Med Int Health. 3(3); 1998: 205–09. Available from: URL: http://www.researchgate.net/publication/13691513_Bacteria_and_viruses_that_cause_respiratory_tract_infections_during_the_pilgrimage_(Haj)_season_in_Makkah_Saudi_Arabia

14.     Meysamie A, Ardakani HZ, Razavi SM, Doroodi T. (2006). Comparison of mortality and morbidity rates among Iranian pilgrims in Hajj 2004 and 2005. Saudi Med J. 27 (7): 1049-   1053. Available from: URL: smj.psmmc.med.sa/index.php/smj/ article/viewFile/3733/1507

15.     British Broadcasting Corporation (BBC) News. 2006. Available from: URL: http://news.bbc.co.uk/2/hi/middle_east/6164337.stm

16.     Wilder-Smith A, Earnest A, Ravindran S, Paton NI. High incidence of pertussis among Hajj pilgrims. CID. 37; 2003: 1270-2. Available from: URL: http://cid.oxfordjournals.org/content /37/9/1270.full

17.     Yousuf M. Pattern of respiratory diseases among Hajj pilgrims visiting Madinah Al-Munawarrah. Pak J Chest Med. 5 (4); 1999: 7-10. Available from: URL: http://www.researchgate.net/ publication/215806551_Pattern_of_Respiratory_diseases_among_Haj_pilgrims_visiting_Madinah_Al-Munawarah

18.     Memish ZA, Venkatesh  S, Ahmed  QA. Travel epidemiology: Saudi perspective. Int J Antimicrob Agents. 21(2); 2003:  96–101. Available from: URL:http://www.sciencedirect. com/science/article/pii/S0924857902003643

19.     Al-Asmary S, Al-Shehri AS, Abou-Zeid A, Abdel-Fattah M, Hifnawy T, El-Said T. Acute respiratory tract infections among Hajj medical mission personnel, Saudi Arabia. Int J Infect Dis. 11; 2007: 268-272. Available from: URL:http://intl.elsevier health.com/journals/ijid

20.     Mirza TA, Fillimban A, Maimini O, Khiyat EY, Dhafar KO, Farooq MU, Gazzaz ZJ. Predictors of asthma severity during the pilgrimage to Mecca (Hajj). Pol Arch Med Wewn. 121 (10); 2011: 327-332. Available from: URL:http://allegro.cartel color.com/sites/default/files/pamw_2011-10_57-Farooq_0.pdf

21.     Fasihuddin S, Tauheed H, Beheiry HM, Sanan SO, Dewan H. A study of Pneumonia during Hajj. SGH Med Jour. 1(2); 2006: 150-155. Available from: URL:http://www.ncbi.nlm.nih.gov/ pmc/articles/PMC3121282/

22.     Asghar AH, Ashshi AM, Azhar EI, Bukhari SZ, Zafar TA, Momenah AM. Profile of bacterial pneumonia during Hajj. Indian J Med Res. 133; 2011: 510–513. Available from: URL: http://www.researchgate.net/publication/51175189_Profile_of_bacterial_pneumonia_during_Hajj

23.     Gautret P, Soula G, Delmont J, Parola P, Brouqui P. Common health hazards in French pilgrims during the Hajj of 2007. A prospective cohort study. J Travel Med. 16(6): 2009: 377-81. Available from: URL: www.ncbi.nlm.nih.gov/pubmed/19930376

24.     Rashid H, Shafi,  Booy, RS, El Bashir H, Ali K,  Zambon, MC, et al. Influenza and respiratory syntical virus infection in British pilgrims. Emerg Health Threats J. 1(2); 2008: 2-5. Available from: URL www.eht-journal .org

25.     Alborzi A, Aelami MH, Ziyaeyan M, Jamalidoust M, Moeini M, Pourabbas B, Abbasian A. Viral etiology of acute respiratory among Iranian Hajj pilgrims. J. Travel Med. 16(4); 2009: 239-242. Available on http://onlinelibrary.wiley.com/doi/10.1111/ j.1708-8305.2009.00301.x/pdf

26.     Rashid H, Shafi S, Haworth, E, El Bashir H, Memish ZA, Sudhanva M,  et al.. Viral respiratory infectious at the Hajj: Comparison between UK and Saudi pilgrims. Clin Microbiol Infect. 14; 2008: 569-74. Available from: URL: http://onlinelibrary.wiley.com/doi/10.1111/j.1469-0691.2008. 01987.x/pdf on 12/8/14

27.     Balkhy HH, Memish ZA, Osaba AO. Meningcoccal carriage among local inhabitants during pilgrimage 2000-2001. Int J Antimicrob Agents. 21; 2003: 107-111. Available from: URL: www.isochem.org.

28.     Wilder-Smith A, Foo W, Earnest A, Paton NI: High risk of Mycobacterium tuberculosis infection during the Hajj pilgrimage. Trop Med Int Health. 10(4); 2005: 336–339. Available from: URL: http://onlinelibrary.wiley.com/doi/10.1111/j.1365-3156.2 005.01395.x/pdf

29.     Alzahrani AG, Choudhry AJ, Al Mazroa MA, Turkistani AHM, Nouman GS, Memish ZA. Pattern of diseases among visitors to Mina health centers during the Hajj season, 1429 H. Journal of Infection and Public Health. 5; 2012: 22-34. Available on http: //Elsevier.com/locate/jiph

30.     Shakir HAS, Gazzaz ZJ, Dhaffar KO, Shahbaz J. Outpatient services during (1423) Hajj season. Sultan Qaboos Uni Med J. 6(1); 2006: 47-50. Available from: URL:http://www. researchgate.net/publication/51484735_Outpatient_Services_during_(1423h)_Hajj_Season

31.     Fatani MI, Al-Afif KA, Hussain H. Pattern of skin diseases among pilgrims during Hajj season in Makkah. Int J Dermatol. 39; 2000:  493-496. Available from: URL: www.researchgate.net /...skin_diseases.../02e7e52604b788eb7b000000

32.     Fatani MI,  Bukhari SZ, Al-Afif KA, Karima TM, Abdulghani MR, Al-Kaltham MI. Pyoderma among Hajj pilgrims in Makkah. Saudi Med J. 23 (7); (2002): 782-785. Available from: URL:  http://smj.psmmc.med.sa/index.php/smj/article/download/4116/1890

33.     Mimish, L. Electrocardiograph findings in heat stroke and exhaustion: A study on Makkah pilgrims. J Saudi Heart Assoc. 24; 2012: 35-39. Available from: URL:http://www.sciencedirect. com/science/article/pii/S1016731511002119

34.     Central Department of Statistic and Information (CDSI). 2011. Available from: URL: http://www.cdsi.gov.sa/english/

35.     World Health Organisation (WHO). 2010. International Travel and Health. Chapter 6. Available from: URL: whqlibdoc.who.int/publications/2007/9789241580397_eng.pdf

36.     Alzeer AH. Respiratory tract infection during Hajj. Ann Thorac Med. 4(5); 2009: 50–53. Available from: URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2700482/

37.     Mandell LA, Wunderink, RG, Anzueto AA, Bartlett JG, Campbell GD, Dean NC,  Dowell SF, File TM, Musher DM, Niederman MS,  et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 44; 2007: 27–72. Available from: URL: http://cid.oxfordjournals.org/content/44/Supplement_2/S27.full

38.     Burke AC.  Infectious disease division in critical care medicine. Infectious Disease & Therapy Series, New York.  2009

39.     Freedman DO, Leder K. Influenza: changing approaches to prevention and treatment in travelers. J Travel Med. 12; 2005: 36–44. Available from: URL: http://onlinelibrary.wiley.com/doi/ 10.2310/7060.2005.00007/pdf 

40.     Balkhy HH, Memish ZA, Bafaqeer S, Almuneef MA. Influenza a common viral infection among Hajj pilgrims: time for routine surveillance and vaccination. J Travel Med. 11(2); 2006: 82–86. Available from: URL: http://www.researchgate.net/ publication/8596666_Influenza_a_common_viral_infection_among_Hajj_pilgrims_time_for_routine_surveillance_and_vaccination

41.     Khan MY,  Kinsara  AJ, Osoba A, et al. (2001). Increasing resistance of M. tuberculosis to anti-TB drugs in Saudi Arabia. Int J Antimicrob Agents. 17(5); 2001: 415–418. Available from: URL: http://www.sciencedirect.com/science/article/ pii/S0924857901002989

42.     World Health Organization (WHO). 2009. Global Alert and Response. Pandemic H1N1 update- 67. Available from: URL: [http://www.who.int/csr/don/2009_09_25/en/index. html].

43.     Memish Z.A, Assiri A.M,  Hussain R, Alomar I, Stephens G. Detection of respiratory viruses among pilgrims in Saudi Arabia during the time of a declared Influenza A(H1N1) Pandemic. J Travel Med. 19(1); 2012: 15–2. Available from: URL: http://www.researchgate.net/publication/51922829_The_prevalance_of_respiratory_viruses_among_healthcare_workers_serving_pilgrims_in_Makkah_during_the_2009_influenza_A_(H1N1)_pandemic/file/32bfe50e495caab336.pdf

44.     Shuman EK. Middle East Respiratory Syndrome and the upcoming Hajj. Int J Occup Environ Med. 4(4); 2013: 169-171. Available from: URL: www.theijoem.com.

45.     CDC. Middle East Respiratory Syndrome. 2013, Available from: URL: www.cdc.gov /coronavirus/mers (Accessed September 10, 2013)

46.     Assiri A, McGeer A, Perl T, et al. Hospital outbreak of Middle East Respiratory Syndrome Coronavirus. N Eng J Med. 369(5); 2013: 407-16. Available from: URL: http://www.nejm.org/doi /full/10.1056/NEJMoa1306742

47.     Benkouiten S, Charrel R, Belhouchat K, et al.. Circulation of respiratory viruses among pilgrims during the 2012 Hajj pilgrimage. Clin Infect Dis. 57; 2013: 992-1000. Available from: URL: http://cid.oxfordjournals.org/content/early/2013/07/08/ cid.cit446.short

48.     World Health Organization (WHO). 2013. Interim travel advice on MERS-CoV for pilgrimages to the King- dom of Saudi Arabia. Available from: URL: www.who.int/ith/updates/ 20130605/en/

49.     Novelli V, Lewis R, Dawood S. Epidemic group A meningococcal disease in hajj pilgrims. Lancet. 2(8563); 1987: 863. Available from: URL:http://www.thelancet.com/journals /lancet/article/PIIS0140-6736(87)91056-7/fulltext

50.     Noweir MH,  Bafail  AO, Jomoah  IM. Study of heat exposure during Hajj (pilgrimage). Environ Monit Assess.  147(1-3); 2008: 279–295. Available from: URL: http://connection. ebscohost.com/c/articles/35119599/study-heat-exposure-during-hajj-pilgrimage

51.     Al Shimemeri A. Cardiovascular disease in Hajj pilgrims. J Saudi Heart Assoc. 24; 2012: 123–127. Available from: URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3727516/ 

52.     Health Statistics: Saudi Ministry of Health. 2005. Available from: URL: http://www.moh.gov.sa

 

 

 

 

Received on 12.06.2014                Modified on 25.07.2014

Accepted on 30.07.2014                © RJPT All right reserved