Diseases pattern among patients attending Holy Mosque (Haram) Medical Centers during Hajj 1434 (2013) ===================================================================================================== * Abdulrahman R. Bakhsh * Abdulfattah I. Sindy * Mostafa J. Baljoon * Khalid O. Dhafar * Zohair J. Gazzaz * Mukhtiar Baig * Basma A. Deiab * Fauzea T. Al Hothali ## Abstract **Objective:** To evaluate the diseases pattern among pilgrims attending the 2 Holy Mosque (Haram) Health Care Centers during the Hajj season 2013 (Hijra 1434). **Methods:** In this cross-sectional study, data was collected from 2 medical centers located in the Holy Mosque in Makkah city, Saudi Arabia, from the first of Dhul-Hijjah to sixteenth Dhul-Hijjah 1434. The present study was completed in 16 days (6th October to 21st October 2013). **Results:** Over 16 days, 1008 patients attended the medical centers during Hajj 1434, (2013), out of which 554 (55%) were males and 454 (45%) were females. Most of the patients were Egyptians (n=242, 24%), followed by Saudis (n=116, 11.5%), Pakistani (n=114, 11.3%), Turkish (n=50, 5%), and other nationalities (n=404). According to age distribution, mostly were in the 51-60 years age group (n=237, 23.5%), followed by other age groups. Out of 1008 patients, 842 (83.5%) patients were treated and subsequently discharged, while 166 patients (16.5%) were referred to the tertiary centers. According to the diseases pattern, most of the patients were suffering from respiratory problems (n=177, 17.6%) followed by skin diseases (n=158, 15.7%), gastrointestinal tract (GIT) diseases (n=133, 13.2%), and others. **Conclusion:** Most of the patients were suffering from respiratory problems followed by skin and GIT diseases, and <25% of patients were referred to tertiary care centers. The Hajj (pilgrimage) is a distinctive event for Muslims, for this more than 2.5 million Muslims come from all over the world on the twelve lunar month of Islamic calendar to Makkah, Kingdom of Saudi Arabia (KSA). The actual Hajj is performed in 5 days from the 8th-13th of Dhul-Hijjah, but the Saudi government issues the visa for 40 days, so that pilgrims can visit other sacred places in Makkah and the region of Al-Madinah Al-Munawarah. Hajj flights start arriving 20-25 days before the actual Hajj dates. Hajj is one of the 5 basic principles of Islam, obligatory only for those who have the ability to travel and for those who can afford the journey, which they have to perform at least once in their lifetime. In performing the Hajj rituals, pilgrims travel from one Holy site to another on foot or occasionally by bus, and due to congestion vehicles travel only a few kilometers distance in several hours, which results the physical exertion and possible exacerbation of preexisting diseases (such as cardiovascular, diabetes mellitus, and renal diseases).1-3 During Hajj, congestion, exhaustion, sometimes excessive temperatures, and disturbances in the body fluid and electrolytes are some of the contributing factors that lead to some illness. Additionally, due to overcrowding, pilgrims are at augmented risk for transmission of communicable diseases.4,5 The provision of health care facilities to 2.5 million people who gather for a short period of time in a relatively smaller area is a huge challenge for the concerned authorities. There are several studies available related to the health issues of pilgrims and Hajj pilgrimage.4,6-8 The present study reviews the burden of patients from 2 health care centers situated inside the Holy Mosque (Haram), during the first 16 days of the Dhul-Hijjah. Inside the Holy Mosque, these 2 emergency centers are operating 24 hours and the staff work in 2 shifts (12 hours a day). Both centers are equipped to deal with critical cases with all necessary emergency equipment available for monitoring, and crash carts with defibrillators, and portable ventilators. All emergency medicines are available in both centers. Mild cases are treated and discharged while severe cases requiring further management are transferred to hospitals in Makkah. Therefore, this study aimed to evaluate the diseases pattern presenting to Haram health care centers and to find out the number of referral cases to other hospitals. The data of the present study will contribute substantially to future planning to make available the best possible medical facilities in the Haram medical centers and other referral hospitals according to the pattern of diseases. ## Methods This observational study was undertaken by the Department of Quality Management and Patient Safety, Directorate General of Health Affairs, Makkah region, Ministry of Health, Saudi Arabia. We collected the data from 2 medical centers inside the Haram area in Makkah city, Saudi Arabia. The data from the 2 medical centers was collected from 1st Dhul-Hijjah to 16th Dhul-Hijjah 1434 (6th October to 21st October 2013). Both medical centers were well equipped including a few intensive care beds to cater for the incoming patients and limited stay facilities. The patients requiring advanced medical treatment or extended hospitalization were shifted to other tertiary care hospitals in Makkah. By employing the convenience-sampling technique, all patients who attended the Holy Mosque health care facility were included in the study. A specially-designed performa was used to collect the data of patients’ attending the medical centers facilities, which was approved by the local and regional authorities of the Ministry of Health. The study was performed according to the principles of Helsinki Declaration. The performa included the name, gender, nationality, presenting complains and provisional diagnosis, time of arrival and departure from the medical centers, outcome of the treatment, either discharged or referred to the tertiary care hospitals. The Statistical Program for Social Sciences (SPSS) Version 13 (SPSS Inc, Chicago, IL, USA) was used for all statistical analysis and frequencies and percentages of the collected data were calculated. ## Results A total of 1008 patients attended the 2 health care centers during the Hajj seasons 1434 (2013), out of which 554 (55%) were men and 454 (45%) women. Most of the patients were Egyptians (n=242, 24%), followed by Saudi (n=116, 11.5%), Pakistani (n=114, 11.3%), Turkish (n=50, 5%), and other nationalities (n=404) (Table 1). According to the age-wise distribution, most patients were in the age group of 51-60 years, followed by 41-50 years, and other age groups (Table 1). View this table: [Table 1](http://smj.org.sa/content/36/8/962/T1) Table 1 Demographic characteristics of 1008 patients, attended the Haram centers health care facilities from the first of Dhul-Hijjah to sixteenth Dhul-Hijjah 1434 (6th October to 21st October, 2013) (N=1008). Out of 1008 patients, 842 (83.5%) were discharged after treatment, while 166 patients (16.5%) were referred to tertiary care centers after initial treatment. Most of the patients were referred to Ajyad Hospital, followed by the King Abdulaziz Hospital, and other hospitals. Table 2 shows the outcome of the patients who attended the Haram Medical Centers and the percentage referred to other hospitals. According to the diseases pattern, most of the patients were suffering from respiratory problems followed by diseases of the skin, GIT, rheumatology, and others (Table 2). Out of these 16 days, the maximum number of patients attended the out patient department (OPD) on the 13th of Dul Hijjah (n=106, 10.5%) followed by 12th day (n=103, 10.2%), 3rd day (n=103, 10.2%), and others (Figure 1). View this table: [Table 2](http://smj.org.sa/content/36/8/962/T2) Table 2 System based and complaints based distribution of patients and number of patients referred to other hospitals from Haram centers health care facilities (N=1008). ![Figure 1](http://smj.org.sa/https://smj.org.sa/content/smj/36/8/962/F1.medium.gif) [Figure 1](http://smj.org.sa/content/36/8/962/F1) Figure 1 Number of patients presenting to the Haram health care centers from first of Dhul-Hijjah to sixteenth Dhul-Hijjah 1434 (6th October to 21st October, 2013) (N=1008). ## Discussion Saudi Arabia is unique in the Islamic world where the world’s largest mass gathering occurs every year. The Ministry of Health of Saudi Arabia endeavor to deliver the best possible health care facilities to pilgrims. The present study provides data of 16 days from the 2 health care centers located inside the Holy Mosque (Haram) area. We found that most of the patients were suffering from respiratory problems followed by the diseases of the skin, GIT, rheumatology, cardiovascular, orthopedic, endocrinology, urology, and others. These results are similar to several other studies.1,9 The present data is contrary to Khan et al,3 they reported that the 4 common reasons for admission were diabetes mellitus (31.9%), hypertension (37.2%), cardiac diseases (31.8%), and chronic lung diseases (14.9%). A discrepancy in the result is due to the different type of setups; they reported the diseases pattern among admitted patients during Hajj season in a tertiary care hospital in Makkah, while the present study reported data from the OPD of Haram Medical Centers. The present study and other previous studies4,7,10 reported that upper respiratory tract infections (URTIs) were the most common disease in pilgrims. There are many contributing factors for increasing URTIs, such as direct contact with affected individuals, climate change, and limited and overcrowded space.11,12 Al-Tawfiq & Memish13 described that the most frequent diseases during Hajj are the URTIs. Mandourah et al4 reported that in 2 successive Hajj seasons, pneumonia was the cause of admission to intensive care unit (ICU) in 27% critically ill patients. Many studies have described that during Hajj, URTIs are the principal category of infections,14-16 and the reason of serious sepsis and septic shock requiring admission to the ICU.6 Al-Jasser et al17 described that among domestic hajjis from Saudi Arabia, URTI was the common health problem followed by diarrheal symptoms. Almalki,8 described that during the Hajj season in 2011, there were 111 pilgrims admitted to Makkah region hospitals with cardiovascular diseases. In the present study, no patients arrived at the OPD with heat stroke as it was mild weather during October. Similar results were described by other studies, which were conducted in the winter season.9,14,15 Preventive measures can play an important role in controlling URTIs. It is recommended to employ individual shielding procedures such as vaccination, chemoprophylaxis, repeated hand washing/sanitizing, and wearing of a face mask.18 Using a face mask does not prevent infection completely, but it may lessen contact to droplet nuclei, believed to be one of the major means of spread of most URTIs.19 The male:female ratio in our study was 1.22:1, which is similar to Khamis9 and other studies.3,10,20 Most of the patients were treated and subsequently discharged, while <25% of the patients were referred to tertiary care centers after initial treatment. The volume of patients was referred to the Ajyad Hospital, Makkah followed by the King Abdulaziz Hospital, and others. The results indicate the need for more staff, patients’ beds, and medicines. We found that most patients attending the Haram medical center facilities belonged to the age group 41-60 years (43.7%). This figure was similar to the previous study14 that found 38.1% were admitted to the ICU at the group age of 41-60 years. The same study also reported that a large number of ICU admitted patients (92%) were older than 40 years.14 Khan et al3 also described that most of the patients admitted during Hajj were of older age, and they observed that it was the one of the risk factors linked with a high death rate. The reason may be that this age group become monetarily capable to perform Hajj, after saving money for several years for Hajj journey, and more importantly their children have grown up, and are not dependent on them. The probability of contracting diseases, developing more grave medical complications, and comparatively higher rates of death found in elderly pilgrims.14 According to geographical distribution, most of the patients were Egyptians, followed by Saudis, Pakistani, Turkish, Indians, and other nationalities. These results were similar to the figures from other studies.9,14 The reason for similar percentages could be that the number of pilgrims from these countries are of large numbers, so comparatively they attended more health care facilities as compared with other countries pilgrims. Out of these 16 days, the maximum number of patients attended the OPD on the 13th, 12th, and 3rd day of Dhul Hijjah. The reason for large number of patients on 12th and 13th day could be that after performing most of the Hajj ritual, elderly people have become exhausted and their chronic diseases are aggravated because of changes in their daily pattern of wake and sleep, dietary change, and walking long distances. Several studies have found that most of the patients hospitalized during Hajj were of old age, and with high occurrence of chronic diseases.3,8,14 A study among pilgrims,16 suggested that older aged people (46-60 years) had a higher risk of severe asthmatic attack. It was suggested that to decrease the health related issues among pilgrims, comprehensive health education programs should be planned for all those who intended to perform Hajj to enhance their awareness of protective measures against URTIs, diarrheal diseases, injuries, and exacerbations of chronic diseases for domestic pilgrims,’15 and for foreign pilgrims in their own countries. A full medical checkup prior to arrival in Saudi Arabia should also assist in correct medication reconciliation. ### Study limitations The present study shows the results from the 2 health care centers located inside the Holy Mosque while thousands of pilgrims take treatment from the Mina and Arafat health care facilities and other hospitals situated in Makkah city. Therefore, the pattern of diseases does not reflect the actual pattern of diseases found in the pilgrims. In conclusion, most of the patients were suffering from respiratory problems followed by skin and GIT diseases, and <25% of patients were referred to the tertiary care centers. The present data can be used by the policy makers and health care facility providers in improving the health care facilities during Hajj. We recommended that a thorough pre-Hajj health assessment should be carried out in pilgrims in their respective countries. This step would not only reduce the chances of worsening of their chronic disease by taking appropriate treatment, but it would also help in identifying the underlying new problems and information on the complications of their chronic diseases. It would substantially contribute to reducing the burden of health related issues and mortality rate during Hajj. ## Acknowledgment *Authors would like to thank, for their intellectual contributions, the members of Bait Al-Khibra (House of Expertise) at King Abdulaziz University, Jeddah, Saudi Arabia especially the Scientific Advisor Professor Hamed Habib (former Dean, Rabigh Medical College). The authors also would like to thank the General Directorate of Makkah Region Health Affairs for providing approval and facilitating data collection.* ## Footnotes * **Disclosure.** Authors have no conflict of interests, and the work was not supported or funded by any drug company. * Received April 23, 2015. * Accepted June 24, 2015. * Copyright: © Saudi Medical Journal This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ## References 1. Dzaraly ND, Iza N, Rahman A, Simbak NB, Ab Wahab S, Osman O, et al. (2014) Patterns of communicable and non-communicable diseases in Pilgrims during Hajj. Research Journal of Pharmacy and Technology 7:1052–1059. 2. Alakkas Z, Yousef A, Alswat KA (2015) The association of previous Hajj performance on the diabetes preparation during the hajj season. Int J Clin Endocrinol Metab 1:1–6. 3. Khan NA, Ishag AM, Ahmad MS, El-Sayed FM, Bachal ZA, Abbas TG (2006) Pattern of medical diseases and determinants of prognosis of hospitalization during 2005 Muslim pilgrimage Hajj in a tertiary care hospital. A prospective cohort study. Saudi Med J 27:1373–1380. [PubMed](http://smj.org.sa/lookup/external-ref?access_num=16951776&link_type=MED&atom=%2Fsmj%2F36%2F8%2F962.atom) 4. Mandourah Y, Al-Radi A, Ocheltree AH, Ocheltree SR, Fowler RA (2012) Clinical and temporal patterns of severe pneumonia causing critical illness during Hajj. BMC Infect Dis 12:117. [CrossRef](http://smj.org.sa/lookup/external-ref?access_num=10.1186/1471-2334-12-117&link_type=DOI) [PubMed](http://smj.org.sa/lookup/external-ref?access_num=22591189&link_type=MED&atom=%2Fsmj%2F36%2F8%2F962.atom) 5. Abubakar I, Gautret P, Brunette GW, Blumberg L, Johnson D, Poumerol G, et al. (2012) Global perspectives for prevention of infectious diseases associated with mass gatherings. Lancet Infect Dis 12:66–74. [CrossRef](http://smj.org.sa/lookup/external-ref?access_num=10.1016/S1473-3099(11)70246-8&link_type=DOI) [PubMed](http://smj.org.sa/lookup/external-ref?access_num=22192131&link_type=MED&atom=%2Fsmj%2F36%2F8%2F962.atom) [Web of Science](http://smj.org.sa/lookup/external-ref?access_num=000298515900021&link_type=ISI) 6. Baharoon S, Al-Jahdali H, Al Hashmi J, Memish ZA, Ahmed QA (2009) Severe sepsis and septic shock at the Hajj: etiologies and outcomes. Travel Med Infect Dis 7:247–252. [CrossRef](http://smj.org.sa/lookup/external-ref?access_num=10.1016/j.tmaid.2008.09.002&link_type=DOI) [PubMed](http://smj.org.sa/lookup/external-ref?access_num=19717109&link_type=MED&atom=%2Fsmj%2F36%2F8%2F962.atom) 7. Memish ZA, Assiri A, Turkestani A, Yezli S, Al Masri M, Charrel R, et al. (2015) Mass gathering and globalization of respiratory pathogens during the 2013 Hajj. Clin Microbiol Infect 21:571.e1–571.e8. [CrossRef](http://smj.org.sa/lookup/external-ref?access_num=10.1016/j.cmi.2015.02.008&link_type=DOI) 8. Almalki WH (2012) The prevalence of cardiovascular diseases and role of protective measures among hajj pilgrims 1432 (2011). Pakistan Journal of Pharmacology 29:29–34. 9. Khamis NK (2008) Epidemiological pattern of diseases and risk behaviors of pilgrims attending mina hospitals, hajj 1427 h (2007 g). J Egypt Public Health Assoc 83:15–33. [PubMed](http://smj.org.sa/lookup/external-ref?access_num=18992201&link_type=MED&atom=%2Fsmj%2F36%2F8%2F962.atom) 10. Alzahrani AG, Choudhry AJ, Al Mazroa MA, Turkistani AHM, Nouman GS, Memish ZA (2012) Pattern of diseases among visitors to Mina health centers during the Hajj season, 1429 H. J Infect Public Health 5:22–34. [CrossRef](http://smj.org.sa/lookup/external-ref?access_num=10.1016/j.jiph.2011.10.003&link_type=DOI) [PubMed](http://smj.org.sa/lookup/external-ref?access_num=22341840&link_type=MED&atom=%2Fsmj%2F36%2F8%2F962.atom) 11. Chin J (2000) Control of communicable diseases manual (American Public Health Association, Washington (DC)), 17th ed, p 425. 12. Al-Tawfiq JA, Zumla A, Memish ZA (2013) Respiratory tract infections during the annual Hajj: potential risks and mitigation strategies. Curr Opin Pulm Med 19:192–197. [CrossRef](http://smj.org.sa/lookup/external-ref?access_num=10.1097/MCP.0b013e32835f1ae8&link_type=DOI) [PubMed](http://smj.org.sa/lookup/external-ref?access_num=23429098&link_type=MED&atom=%2Fsmj%2F36%2F8%2F962.atom) 13. Al-Tawfiq JA, Memish ZA (2012) The Hajj: updated health hazards and current recommendations for 2012. Euro Surveill 17:20295. [PubMed](http://smj.org.sa/lookup/external-ref?access_num=23078811&link_type=MED&atom=%2Fsmj%2F36%2F8%2F962.atom) 14. Madani TA, Ghabrah TM, Albarrak AM, Alhazmi MA, Alazraqi TA, Althaqafi AO, et al. (2007) Causes of admission to intensive care units in the Hajj period of the Islamic year 1424 (2004). Ann Saudi Med 27:101–105. [CrossRef](http://smj.org.sa/lookup/external-ref?access_num=10.4103/0256-4947.51528&link_type=DOI) [PubMed](http://smj.org.sa/lookup/external-ref?access_num=17356316&link_type=MED&atom=%2Fsmj%2F36%2F8%2F962.atom) 15. Madani TA, Ghabrah TM, Al-Hedaithy MA, Alhazmi MA, Alazraqi TA, Albarrak AM, et al. (2006) Causes of hospitalization of pilgrims in the Hajj season of the Islamic year 1423 (2003). Ann Saudi Med 26:346–351. [PubMed](http://smj.org.sa/lookup/external-ref?access_num=17019102&link_type=MED&atom=%2Fsmj%2F36%2F8%2F962.atom) [Web of Science](http://smj.org.sa/lookup/external-ref?access_num=000241850800002&link_type=ISI) 16. Mirza TA, Fillimban A, Maimini O, Khiyat EY, Dhafar KO, Farooq MU, Gazzaz ZJ (2011) Predictors of asthma severity during the pilgrimage to Mecca (Hajj). Pol Arch Med Wewn 121:327–331. [PubMed](http://smj.org.sa/lookup/external-ref?access_num=21876484&link_type=MED&atom=%2Fsmj%2F36%2F8%2F962.atom) 17. Al-Jasser FS, Kabbash IA, AlMazroa MA, Memish ZA (2012) Patterns of diseases and preventive measures among domestic Hajjis from Central, Saudi Arabia. Saudi Med J 33:879–886. [PubMed](http://smj.org.sa/lookup/external-ref?access_num=22886122&link_type=MED&atom=%2Fsmj%2F36%2F8%2F962.atom) 18. Choudhry AJ, Al-Mudaimegh KS, Turkistani AM, Al-Hamdan NA (2006) Hajj-associated acute respiratory infection among hajjis from Riyadh. East Mediterr Health J 12:300–309. [PubMed](http://smj.org.sa/lookup/external-ref?access_num=17037698&link_type=MED&atom=%2Fsmj%2F36%2F8%2F962.atom) 19. Centers for Disease Control and Prevention (2008) Recommendations for the Prevention of Influenza. MMWR Morb Mortal Wkly Rep 57:1–60. [PubMed](http://smj.org.sa/lookup/external-ref?access_num=18185492&link_type=MED&atom=%2Fsmj%2F36%2F8%2F962.atom) 20. Al-Ghamdi SM, Akbar HO, Qari YA, Fathaldin OA, Al-Rashed RS (2003) Pattern of admission to hospitals during muslim pilgrimage (Hajj). Saudi Med J 24:1073–1076. [PubMed](http://smj.org.sa/lookup/external-ref?access_num=14578971&link_type=MED&atom=%2Fsmj%2F36%2F8%2F962.atom) [Web of Science](http://smj.org.sa/lookup/external-ref?access_num=000186666500008&link_type=ISI)