Morbidity and mortality amongst Indian Hajj pilgrims: A 3-year experience of Indian Hajj medical mission in mass-gathering medicine

Respiratory viral infections during Hajj seasons

Respiratory viral infections pose a public health concern during mass gathering (MG) events. Sustainable and continuous surveillance of respiratory viruses remains a priority to early identify and prevent potential outbreaks. This article reviews recent literature addressed the prevalence and diversity of circulating respiratory viruses during Hajj pilgrimage, one of the largest planned religious MG events held annually in Saudi Arabia. The variation between studies with respect to study design, sample size, time of sample collection (pre-, during, and pos-Hajj), type of participants (e.g., symptomatic vs. a symptomatic pilgrims), and laboratory procedure was highlighted. The majority of these studies were conducted on the 2019 Hajj season or earlier, prior to the emergence of COVID-19 which had significant impact on the past three Hajj seasons (2020, 2021, and 2022). A summary about key aspects related to organization of Hajj during COVID-19 pandemic and the implementation of exceptional infection control strategies is provided.

Prevalence of emergency cases among pilgrims presenting at King Abdulaziz International Airport Health Care Center at Hajj Terminal, Jeddah, Saudi Arabia during Hajj Season, 1440 H - 2019

Introduction

About 2-3 million pilgrims come to Makkah, Saudi Arabia from all countries to perform Hajj. During the Hajj season of 2019 (1440 H), the total number of pilgrims was 2,489,406, of whom 1,855,027 came from foreign countries. This study aims to investigate the prevalence, pattern, and findings of emergency health problems among pilgrims travelling through King Abdul Aziz International Airport Health Care Center (KAIA-HC) at Hajj Terminal in Jeddah during hajj season of 1440-H.

Methodology

A cross-sectional study was conducted by reviewing the medical records of pilgrims coming for treatment at KAIA-HC, before and after Hajj between 1 Dhul Qi'dah to 29 Dhul Hijjah 1440 AH (Corresponding to 4 July to 31 August 2019 AD). The collected data included demographics, medical history, diagnoses of the emergency health problems, infections, and their findings. Data were analyzed using Epi Info 7 and SPSS 25.

Results

About 296 (3.87%) of 7,643 pilgrims treated at KAIA-HC were emergency cases. Their average age was 43 years (Standard Deviation (SD) ±7.5); 51.3% were females; the highest (45.3%) was between 30 - 59 years age group, both males and females; the highest two nationalities were Indonesian (14.2%) and Egyptian (12.5%). Diagnoses included hypertension 59(19.9%), bronchial asthma 53 (17.9%), and 23 cases (10.5%) were suffering from hypotension. 16 (5.4%) of patients had a myocardial infarction and 10 (3.4%) had cerebrovascular accidents. In 13 cases (4.4%), a chest infection was reported. Diabetes complications (hyperglycemia, hypoglycemia, and diabetic ketoacidosis) were reported in 28 (9.4%) of the cases. There were 28 (9.5%) surgical diagnoses, 13 (4.4%) were cut wounds, 11 (3.7%) were bone fracture and dislocation, and 4 (1.4%) were head trauma. With regard to the findings, 82 (27.7%) were referred to hospitals; 10 (3.3%) cases required Cardio-Pulmonary Resuscitation, seven of whom survived. The most common referral causes were myocardial Infarction amounting 12(4.05%), followed by cerebrovascular accident 10(3.3%) and chest infection in 8 (2.7%). 13 (4.4%) of the total cases died. The most common causes of death were myocardial infarction, asthma, hypertension and hyperglycemia.

Conclusion

Our study emphasizes that emergency cases presented at KAIA-HC were few. Cardiovascular diseases represented the main reason for emergency cases, followed by respiratory diseases. 51% of patients were discharged without the need for a higher level of medical care.

Towards a better understanding between non-Muslim primary care clinicians and Muslim patients: A literature review intended to reduce health care inequities in Muslim patients

Although Muslims are a growing population within many non-Muslim countries, there are insufficient Muslim clinicians to care for them. Studies have shown that non-Muslim clinicians have limited knowledge and understanding of Islamic practices affecting health, which may lead to disparities in the quality of healthcare delivery and outcomes when caring for Muslim patients. Muslims come from many different cultures and ethnicities and have variations in their beliefs and practices. This literature review provides some insights which may strengthen therapeutic bonds between non-Muslim clinicians and their Muslim patients resulting in improved holistic, patient-centered care in the areas of cancer screening, mental health, nutrition, and pharmacotherapy. Additionally, this review informs clinicians about the Islamic perspective on childbirth, end of life issues, travel for Islamic pilgrimage, and fasting during the month of Ramadan. Literature was sourced by a comprehensive search in PubMed, Scopus, and CINAHL along with hand screening of citations. Title and abstract screening followed by full-text screening excluded studies including less than 30% Muslim participants, protocols, or reporting results deemed irrelevant to primary care. 115 papers were selected for inclusion in the literature review. These were grouped into the themes of general spirituality, which were discussed in the Introduction, and Islam and health, Social etiquette, Cancer screening, Diet, Medications and their alternatives, Ramadan, Hajj, Mental health, Organ donation and transplants, and End of life. Summarizing the findings of the review, we conclude that health inequities affecting Muslim patients can be addressed at least in part by improved cultural competency in non-Muslim clinicians, as well as further research into this area.

Community pharmacists' knowledge, prospective and practice towards health related illness at Hajj and Umrah: A cross sectional study

Objectives

To assess the community pharmacists' (CPs) knowledge, attitude, and perception of health-related illness among pilgrims, and to investigate the common diseases and the pattern of medications dispensed by CPs during Hajj and Umrah seasons.

Method

A cross-sectional study was carried out in Riyadh, Saudi Arabia over two months in 2022, through electronic platform using prevalidated questionnaires adopted from the literature. The questionnaires were divided into 4 sections assessing the CP's knowledge, attitude, and perception about health-related illness, common dispensed agents, and required vaccination during Hajj and Umrah.

Results

A total of 544 CPs, mostly between the age of 31-40 (69.9%), participated in this research. About 87.9% of the CPs received a pilgrim after performing their rituals coming to the pharmacy complaining of infection or health problem. In this study, 99.8%(n = 544), 99.6%(n = 543), and 92.7% (n = 505) of the CPs identified influenza, food poisoning, and diarrhea/gastroenteritis as the most common issues during the Hajj & Umrah season respectively. As results, anti-diarrheal agents (96.3%), painkillers (87.3%), inhalers (89.4%), and sunscreens (88.3%) were the most requested pharmaceutical agents. Additionally, 96.7%(n = 527) of the CPs agreed that vaccination is safe to be given to Hajj and Umrah pilgrims particularly for those aged ≥ 65 years, and 89.4%(n = 487) of them reported awareness of vaccines that are required by Saudi Ministry of Health. Both Influenza and meningococcal meningitis vaccines were identified by 99.8% of the CPs, but polio vaccine was identified by 33.9%.

Conclusion

Community pharmacists provided pharmaceutical care services for Hajj and Umrah pilgrims. The majority of CPs had adequate knowledge about viral diseases during Hajj and Umrah and their requirement for vaccination.

Risk factors for heat-related illnesses during the Hajj mass gathering: an expert review

Human exposure to a hot environment may result in various heat-related illnesses (HRIs), which range in severity from mild and moderate forms to life-threatening heatstroke. The Hajj is one of the largest annual mass gatherings globally and has historically been associated with HRIs. Hajj attracts over two million Muslim pilgrims from more than 180 countries to the holy city of Makkah, Kingdom of Saudi Arabia. Several modifiable and non-modifiable factors render Hajj pilgrims at increased risk of developing HRIs during Hajj. These include characteristics of the Hajj, its location, population, and rituals, as well as pilgrims' knowledge of HRIs and their attitude and behavior. Makkah is characterized by a hot desert climate and fluctuating levels of relative humidity. Pilgrims are very diverse ethnically and geographically, with different adaptations to heat. Significant proportions of the Hajj population are elderly, obese, and with low levels of fitness. In addition, many have underlying health conditions and are on multiple medications that can interfere with thermoregulation. Other factors are inherent in the Hajj and its activities, including crowding, physically demanding outdoor rituals, and a high frequency of infection and febrile illness. Pilgrims generally lack awareness of HRIs, and their uptake of preventive measures is variable. In addition, many engage in hazardous behaviors that increase their risk of HRIs. These include performing rituals during the peak sunshine hours with no sun protection and with suboptimal sleep, nutrition, and hydration, while neglecting treatment for their chronic conditions. HRIs preventive plans for Hajj should incorporate measures to address the aforementioned factors to reduce the burden of these illnesses in future Hajj seasons. Lessons from the Hajj can be used to inform policy making and HRIs preventive measures in the general population worldwide.

The Impact of Classical Cardiovascular Risk Factors on Hospitalization and Mortality among Hajj Pilgrims

Background

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality during Hajj. The objective of the present study was to examine the effect of classical cardiovascular disease risk factors on mortality and hospitalization among Hajj pilgrims from East Java, Indonesia, during 2017, 2018, and 2019.

Methods

This study was a retrospective cohort of Hajj pilgrims from East Java, Indonesia, from 2017 to 2019. The data on risk factors were obtained from the pre-embarkation Hajj screening records. The diagnosis of hospitalization and cause of death during the Hajj period were obtained from the medical report and hospital/flight doctor death certificate.

Results

A total of 72078 eligible subjects were included in this study. 33807 (46.9%) were men, and 38271 (53.1%) were women, and the majority (35%) were aged between 50 and 59 years. A total of 42446 pilgrims (58.9%) were classified as high risk due to underlying health conditions such as hypertension, diabetes, or if they were aged 60 years or older. The overall hospitalization rate is 971 per 100,000 pilgrims and the overall death rate is 240 deaths per 100,000 pilgrims. Multivariate analysis using logistic regression showed that male gender, age > 50 years, hypertension grade II-III, diabetes, overweight, and obesity were associated with a higher risk of hospitalization. Moreover, male gender, diabetes, and overweight were associated with a higher risk of mortality. Of all hospitalized patients, 92 patients (13.1%) had an initial diagnosis of CVD, and CVD is the main cause of mortality (38.2%) of pilgrims.

Conclusion

Pilgrims with classical cardiovascular risk factors were associated with increased hospitalization and mortality.

Respiratory pathogens among ill pilgrims and the potential benefit of using point-of-care rapid molecular diagnostic tools during the Hajj

We investigated respiratory pathogens among ill Hajj pilgrims from Marseille. We also discuss the potential role of point-of-care (POC) rapid molecular diagnostic tools for this purpose. Clinical data were collected using a standardised questionnaire. Influenza A and B viruses, human rhinovirus and human coronaviruses, Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae and Klebsiella pneumoniae were investigated using real-time PCR in respiratory samples obtained during travel, at the onset of symptoms. 207 participants were included. A cough, expectoration, rhinitis and a sore throat were the most frequent respiratory symptoms, followed by loss of voice and dyspnoea. 38.7% and 25.1% of pilgrims reported a fever and influenza-like symptoms, respectively. 59.4% pilgrims received antibiotics. Rhinovirus (40.6%) was the most frequent pathogen, followed by S. aureus (35.8%) and H. influenzae (30.4%). Virus and bacteria co-infections were identified in 28.5% of participants. 25.1% pilgrims who were positive for respiratory bacteria did not receive antibiotic treatment. In the context of the Hajj pilgrimage, it is important to detect infections that can be easily managed with appropriate treatment, and those that can affect prognosis, requiring hospitalisation. POC rapid molecular diagnostic tools could be used for patient management at small Hajj medical missions and to rationalise antibiotic consumption among Hajj pilgrims.

Evaluation of trauma cases in different types of mass gathering events

BACKGROUND

There are several factors affecting trauma cases in mass gatherings (MG). Event type, mood of the crowd, age, gender and educational background are among these factors. It is to identify the relationship between the event types of trauma cases and temperature variables observed in MG.

METHODS

It is a descriptive epidemiological study. The universe of the research consists of 112 emergency medical service records (ambulance) in organizations such as Çanakkale Victory and Martyrs' Memorial Day (ÇVMMD), Zeytinli Rock Fest, Deaflympics, and European Youth Olympic Winter Festival (EYOF). For the statistical evaluations of the study, frequency analysis, Chi-square test, and logistic regression were used.

RESULTS

Within the scope of the research, 474 emergency medical service cases were examined. About 49.5% (n=235) of the cases took place at the DEAFOLIMPICS. About 57.6% (n=273) of the cases are male. The age average of the cases is 30.3±16.5 (Min: 0, Max: 92). When the pre-diagnosis range at the ÇVMMD is examined, it is seen that 27.7% (n=20) of the cases are trauma cases while 72.2% (n=52) are non-trauma cases. Among the trauma cases, the most frequently observed ones are soft-tissue trauma, multi-trauma, lower limb injury, and head trauma. When the other cases are examined, the most common ones are angina pectoris, nausea-vomiting, asthma, and ache. In the research, 38.3% (n=90) of the cases at the DEAFOLIMPICS are trauma cases, while 61.7% (n=145) are non-trauma cases. While the trauma cases mostly consist of soft-tissue injury and lower limb injury, the non-trauma cases include nausea-vomiting and upper respiratory infections. While the trauma cases were caused by multi-trauma, sharp object injury, soft-tissue injury, and head trauma, the pre-diagnosis of the non-trauma cases mainly included mental confusion and behavioral disorder due to use of alcohol; conversion; behavioral changes due to use of substance and drug use; hypotension; and allergic reaction.

CONCLUSION

As a consequence of the logistic regression modeling, the trauma cases were found to be 1.6 times (p<0.05) higher in men than women and 9.5 times more in those who participated in the EYOF event than those who participated in the ÇVMMD event (p<0.05).

Pattern of utilization, disease presentation, and medication prescribing and dispensing at 51 primary healthcare centers during the Hajj mass gathering

Background

The majority of pilgrims seeking healthcare during Hajj are seen at primary healthcare centers (PHCCs). Data on the utilization of these facilities during Hajj can aid in directing optimal health services delivery and allocation of resources during the pilgrimage.

Method

We investigated the pattern of disease presentation, caseload, and medication prescribing and dispensing at 51 PHCCs during the 2019 Hajj. Data on patients’ demographics, diagnoses, and prescribed medications were retrieved from each PHCC’s electronic records and analyzed. Data were also used to calculate six of the World Health Organization (WHO) indicators for drug use at these facilities.

Results

Data were captured for 99,367 patients who were mostly Hajj pilgrims (95.4%), male (69.1%) from the Eastern Mediterranean (60.8%) and had a mean age of 46.6 years (SD = 14.9). Most patients (85.2%) were seen in Mina and towards the end of Hajj. The majority of patients (96.0%) had a single diagnosis; most commonly, respiratory (45.0%), musculoskeletal (17.2%), and skin (10.5%) diseases. Patients were prescribed 223,964 medications, mostly analgesics (25.1%), antibacterials for systemic use (16.5%), anti-inflammatory and antirheumatic products (16.4%), and cough and cold preparations (11.9%). On average, 2.25 (SD = 0.94) medications were prescribed per consultation, with low (1.3%) prevalence of polypharmacy. An antibiotic and an injectable were prescribed in 43.6 and 2.67% of patient encounters, respectively. Most (92.7%) of the prescribed drugs were actually dispensed, in an average time of 8.06 min (SD = 41.4). All PHCCs had a copy of the essential drugs list available, on which all the prescribed drugs appeared.

Conclusion

Respiratory illnesses are the main reason for PHCCs visits during Hajj, and analgesics and antibiotics are the most common medications prescribed to pilgrims. Our results, including the calculated WHO drug use indicators, contribute to evidence-based optimization of primary healthcare services during Hajj.

A Saudi Arabian Public Health Perspective of Tuberculosis

Tuberculosis is a global health challenge due to its spreading potential. The Kingdom of Saudi Arabia (KSA) faces a challenge in the spread of tuberculosis from migrant workers, but the foremost threat is the huge number of pilgrims who travel to visit sacred sites of the Islamic world located in the holy cities of Makkah and Al Madina. Pilgrims visit throughout the year but especially in the months of Ramadan and Zul-Hijah. The rise of resistance in Mycobacterium tuberculosis is an established global phenomenon that makes such large congregations likely hotspots in the dissemination and spread of disease at a global level. Although very stringent and effective measures exist, the threat remains due to the ever-changing dynamics of this highly pathogenic disease. This overview primarily highlights the current public health challenges posed by this disease to the Saudi health system, which needs to be highlighted not only to the concerned authorities of KSA, but also to the concerned global quarters since the pilgrims and migrants come from all parts of the world with a majority coming from high tuberculosis-burdened countries.

A Longitudinal Study Regarding the Health Profile of the 2017 South African Hajj Pilgrims

The Hajj mass gathering annually attracts over two million Muslim pilgrims worldwide to the Kingdom of Saudi Arabia (KSA). We aimed to establish demographics and health profiles for the South African pilgrims performing the 2017 Hajj. Methods: This is a longitudinal survey-based study conducted on 1138 adult South African pilgrims in two phases (during and post-Hajj). Data on demographics, vaccination status, underlying health conditions, pre-Hajj training, health promotion, travel history, and health issues during and post-Hajj were collected using pre-designed questionnaires. Results: Participants had a mean age of 49.2 years (SD = 13.3; range 18–81), with a male: female ratio of 1.2:1. The majority of pilgrims were married (88.2%), of Indian/Asian background (73%), and literate (>99%). Nearly all pilgrims were vaccinated against meningococcal disease and yellow fever, but only 23.7% were vaccinated against Influenza. Hypertension, diabetes, and elevated cholesterol levels were the most common underlying health conditions reported by 22.6%, 13.2%, and 11.5% of pilgrims, respectively. One month after return to South Africa, nearly 65% of pilgrims reported illness during Hajj, while 40% reported falling ill post event upon return to South Africa. Nevertheless, only a few were admitted to hospitals (12 during Hajj and 15 post-Hajj). Among ill pilgrims, respiratory symptoms were the most commonly experienced symptoms during (70.2%) and post-Hajj (82.2%). Other symptoms such as walking-related symptoms include symptoms directly related or mainly caused by walking (e.g., leg pain, sore feet, blisters on the feet), dehydration, and gastrointestinal tract symptoms reported during Hajj. Medication to treat respiratory symptoms and antibiotics were the most commonly used medications during and post-Hajj. Having an underlying health condition was an independent predictor of falling ill during or post Hajj. Conclusion: Our study indicates that a sizable proportion of South African pilgrims are elderly with underlying health conditions and most contract respiratory tract infections during and post Hajj. Our study highlights the need for systematic collection of prospective pilgrims’ demographics and health data and more attention to post-Hajj health follow-ups of pilgrims.

Knowledge, Attitude, and Perception of Health Care Personnel Working in Intensive Care Units of Mass Gatherings Toward the Application of Telemedicine Robotic Remote-Presence Technology: A Cross-Sectional Multicenter Study

Background: The innovative telemedicine robotic remote-presence technology offers a promising solution to confront the challenges faced by health care personnel during events of mass gatherings by consulting expertise from offsite settings. Objective: To assess knowledge, attitude, and perceptions of health care personnel (physicians and nurses) toward telemedicine robotic remote-presence technology, at the intensive care units (ICUs) of hospitals serving mass gathering. Methods: The primary sampling unit included physicians and nurses using the sophisticated technology of telemedicine with robotic presence at the ICUs of Mina hospitals. An electronic invitation containing the survey tool was sent to all the participants from the four selected hospitals. Mean scores for knowledge and attitude questions were based on Likert scale responses. Result: The study received a final sample of 140 valid and complete responses. The findings showed overall positive attitude, but the knowledge was limited. On a maximum score of 5, the mean knowledge and attitude scores obtained were 2.55 and 3.51. The participants expressed strong agreement in using technology to seek expert opinion, increase communication among providers, and improve clinical decisions, which is an essential factor during mass gatherings. However, concerns about patient privacy and confidentiality were raised. Lack of training and insufficient knowledge regarding telemedicine and robotic systems' applications were identified as significant barriers, followed by issues related to equipment malfunction. Conclusion: Reinforcing continuous training programs to the health care staff to maximize the potential benefits of the innovative technology is suggested.

Prevalence of Diabetes and Hypertension among Hajj Pilgrims: A Systematic Review

The Hajj mass gathering is attended by over two million Muslims each year, many of whom are elderly and have underlying health conditions. Data on the number of pilgrims with health conditions would assist public health planning and improve health services delivery at the event. We carried out a systematic review of literature based on structured search in the MEDLINE/PubMed, SCOPUS and CINAHL databases, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, to estimate the prevalence of diabetes and hypertension among Hajj pilgrims. Twenty-six studies conducted between 1993 and 2018 with a total of 285,467 participants were included in the review. The weighted pooled prevalence rates of hypertension and diabetes among Hajj pilgrims in all included studies were 12.2% (95% CI: 12.0-12.3) and 5.0% (95% CI: 4.9-5.1), respectively. The reported prevalence of other underlying health conditions such as chronic respiratory, kidney or liver disease, cardiovascular disease, cancer and immune deficiency were generally low. Potentially a large number of pilgrims each Hajj have diabetes and/or hypertension and other underlying health conditions. Hajj could be a great opportunity to reduce the burden of these diseases within the over 180 countries participating in the event by identifying undiagnosed cases and optimizing patients' knowledge and management of their conditions. Prospero registration number: CRD42020171082.

Incidence, Characteristics, Laboratory Findings and Outcomes in Acro-Ischemia in COVID-19 Patients

Aim

In addition to its respiratory impact of SARS-CoV2, skin lesions of probable vascular origin have been described. This study intends to quantify the incidence of acro-ischemic lesions in COVID-19 infected adult subjects in our population, describing clinical patterns and associated findings.

Methods

All adult confirmed cases of COVID-19 infection who presented with acro-ischemic lesions and received care in our institution were prospectively enrolled up to May 15th, 2020. The variables included demographics, comorbidities, analytical parameters, clinical presentations and COVID-19 treatment.

Results

We enrolled 24 patients. The overall rate of acro-ischemic findings in COVID-19 patients was 1.2% [0.6% for outpatients and 2.9% for hospitalized (ICU and non-ICU patients)], but the observed incidence for acro-ischemia in ICU patients was remarkably higher (23.0%, p<0.001). We have described four different clinical patterns of acroischemia: atypical Raynaud´s phenomenon (ARP), (4); pseudo-pernio (PP), (5); severe microcirculatory ischemia with preserved pulse (SMI), (6); and dry gangrene with arteriosclerosis obliterans (AO), (9). Kendall´s τ correlation with lung disease severity was 0.877 (95% CI, 0.756 to 0.968); p<0.01). ARP individuals were predominantly female, while SMI appeared lately in elderly hospitalized subjects with better prognosis. AO occurred in patients with more comorbidity and younger than those with SMI. We observed other associated lesions of suggestive ischemic nature in other organs in all groups (15 patients of total sample). Plasma procalcitonin was significantly higher in patients who developed SMI (median and interquartile range: 9.99 (4.2, 12.3) mg/mL vs 0.26 (0.11, 0.89) mg/mL; p<0.001), and D-dimer level at hospital admission was significantly higher in AO patients (median and interquartile range: 1166 (1050, 2111) mg/L vs 502 (448, 777) mg/L; p<0.001).

Conclusion

The observed risk for acroischemia in COVID-19 is high in ICU patients (23%). We have described four different clinical patterns of acroischemia (ARP, PP, SMI and AO) associated with lung disease severity. Authors have communicated various lesions of suggestive ischemic nature in other organs. Raynaud-like pattern is reported as a "novelty".

Disease surveillance during a large religious mass gathering in India: The Prayagraj Kumbh 2019 experience

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At Kumbh Mela 2019, disease surveillance was established for 22 acute diseases and syndromes.

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Among the reported illnesses, 95% were communicable diseases such as acute respiratory illness (35%), acute fever (28%), and skin infections (18%).

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The incident command centre generated 12 early warning signals from indicator-based and event-based surveillance: acute diarrheal diseases (n = 8, 66%), vector-borne diseases (n = 2, 16%), vaccine-preventable disease (n = 1, 8%), and thermal event (n = 1, 8%).

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There were two outbreaks (acute gastroenteritis and chickenpox) that were investigated and controlled.

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Implementation of disease surveillance facilitated early outbreak detection and response.

Background

Mass gathering (MG) events are associated with public health risks. During the period January 14 to March 4, 2019, Kumbh Mela in Prayagraj, India was attended by an estimated 120 million visitors. An onsite disease surveillance was established to identify and respond to disease outbreaks.

Methods

A health coordination committee was established for planning. Disease surveillance was prioritized and risk assessment was done to identify diseases/conditions based on epidemic potential, severity of illness, and reporting requirement under the International Health Regulations (IHR) of 2005. A daily indicator and event-based disease surveillance was planned. The indicator-based surveillance (IBS) manually and electronically recorded data from patient hospital visits and collected MG area water testing data to assess trends. The event-based surveillance (EBS) helped identify outbreak signals based on pre-identified event triggers from the media, private health facilities, and the food safety department. Epidemic intelligence was used to analyse the data and events to detect signals, verify alerts, and initiate the response.

Results

At Kumbh Mela, disease surveillance was established for 22 acute diseases/syndromes. Sixty-five health facilities reported 156 154 illnesses (21% of a total 738 526 hospital encounters). Among the reported illnesses, 95% (n = 148 834) were communicable diseases such as acute respiratory illness (n = 52 504, 5%), acute fever (n = 41 957, 28%), and skin infections (n = 27 094, 18%). The remaining 5% (n = 7300) were non-communicable diseases (injuries n = 6601, 90%; hypothermia n = 224, 3%; burns n = 210, 3%). Water samples tested inadequate for residual chlorine in 20% of samples (102/521). The incident command centre generated 12 early warning signals from IBS and EBS: acute diarrheal disease (n = 8, 66%), vector-borne disease (n = 2, 16%), vaccine-preventable disease (n = 1, 8%), and thermal event (n = 1, 8%). There were two outbreaks (acute gastroenteritis and chickenpox) that were investigated and controlled.

Conclusions

This onsite disease surveillance imparted a public health legacy by successfully implementing an epidemic intelligence enabled system for early disease detection and response to monitor public health risks. Acute respiratory illnesses emerged as a leading cause of morbidity among visitors. Future MG events should include disease surveillance as part of planning and augment capacity for acute respiratory illness diagnosis and management.

Medication utilization pattern among outpatients during the Hajj mass gathering

Background

The Kingdom of Saudi Arabia (KSA) provides free healthcare, including medications, for the over 2 million Muslim pilgrims who attend Hajj every year. Information on drug utilization patterns at the Hajj is important to strengthen the supply chain for medicines, avert stock-outs, identify inappropriate use, and support public health planning for the event.

Method

We investigated drug utilization pattern among outpatients in eight seasonal Holy sites hospitals in Makkah, KSA, during the 2018 Hajj. Data on medication prescribed and dispensed were retrieved from the hospitals' electronic records. Data were also used to calculate six of the WHO indicators for drug use at these facilities.

Results

A total of 99,117 medications were prescribed for 37,367 outpatients during 37,933 encounters. Outpatients were mainly older males and originated from 134 countries. Twenty medications accounted for 72.8% of the 323 different medications prescribed. These were mainly nonsteroidal anti-inflammatory drugs, analgesics and antipyretics, and antibacterial medicines for systemic use. Outpatients were prescribed an average of 2.6 (SD = 1.2) drugs per consultation and polypharmacy (≥5 medications) was observed in 4.8% of the encounters. Antibiotics and an injection were prescribed in 46.9% and 6.5% of encounters, respectively. Nearly 90% of the prescribed drugs were actually dispensed. On average, medications were dispensed 16.4 (SD = 119.8) minutes from the time they were prescribed for the patient. All hospitals had a copy of the essential drugs list available and all of the prescribed drugs appeared on that list.

Conclusion

Nonsteroidal anti-inflammatory drugs, analgesics and antibiotics are the most common medications prescribed to outpatient during Hajj. Our results, including the calculated WHO drug use indicators, can form a basis for further investigations into appropriate drug use at the Hajj and for planning purposes. These results could also guide the development of reference values for medications prescribing and use indicators at mass gatherings.

Public Health Threats in Mass Gatherings: A Systematic Review

Mass gatherings (MGs) are held throughout the world. The aim of this review was to assess and identify the health threats based on the type of the MG, type of diseases, and injuries. Research platforms such as Web of Science, Medline, and Scopus were searched through June 2017. All epidemiologic studies that investigated the health threats during the MGs, such as communicable diseases, injuries, high-risk behaviors, and environmental health problems, were included in this review. Out of 1264 references, 45 articles were included in the review.Three main types of MGs include religious, festival, and sporting event; and fairs such as trade, book, and agricultural types were also reported in the selected studies. In the religious MGs, infectious diseases were the most common health threat. Road traffic accidents and environmental health problems were additional health threats. At MG sporting events, injuries were the most common health problems. Infectious diseases and alcohol and drug-related disorders were other reported public health concerns. In the festival MGs, alcohol and drug-related problems were commonly reported. This review showed that health threats vary, based on the type of mass gathering. The health organizers of MGs should consider the type of the MG and the health needs and safety of the participants to help them plan their action and provide the needed health care services.

HANSEN’S DISEASE DIAGNOSED AFTER ANTI-CANCER CHEMOTHERAPY

Background. Leprosy or Hansen’s disease is a chronic granulomatous disease involving predominantly skin, peripheral nerves and nasal mucosa but capable of affecting any tissue or organ. Histoid leprosy is a very rare well-defined clinicopathological variant of multibacillary lepromatous leprosy, which is very difficult to diagnose due to different specific clinical and histopathological findings that mimic a fibromatous disorder. Histoid leprosy occurs generally after treatment failure and sometimes de novo. Objective. The aim of the study was to explore histoid leprosy throughout a case report. Methods. A case report of histoid leprosy diagnosed after cancer chemotherapy is presented. Results. A 25-year-old healthy male presented with multiple skin coloured, discrete, well defined, painless papules and nodules scattered over nape of neck, right side of the trunk and both arms along with numbness as well as tingling sensation over both the arms and trunk. It was a case of non-seminomatous germ cell tumour (NSGCT), left testis, diagnosed and treated with a high inguinal orchidectomy with adjuvant chemotherapy in 2016. Ziehl Neelsen (ZN) stain for Acid Fast Bacilli (Mycobacterium leprae) – a modified Fite stain method showed numerous acid-fast bacilli. Histopathological diagnosis of Hansen’s disease (Histoid) was conducted. The patient was admitted and started on triple drug multi-bacillary multi-drug therapy (MB-MDT). A remarkable improvement was noticed in the lesion status within one month of institution of the therapy. Conclusions. Histoid leprosy is a discrete infrequent form of multibacillary leprosy with distinctive clinical, bacteriological and histomorphological features. Histopathologic examination with modified Fite stain is still the mainstay of diagnosis.

The dynamics and interactions of respiratory pathogen carriage among French pilgrims during the 2018 Hajj

We conducted this study to describe the dynamics of the acquisition of respiratory pathogens, their potential interactions and risk factors for possible lower respiratory tract infection symptoms (LRTI) among French pilgrims during the 2018 Hajj. Each participant underwent four successive systematic nasopharyngeal swabs before and during their stay in Saudi Arabia. Carriage of the main respiratory pathogens was assessed by PCR. 121 pilgrims were included and 93.4% reported respiratory symptoms during the study period. The acquisition of rhinovirus, coronaviruses and Staphylococcus aureus occurred soon after arrival in Saudi Arabia and rates decreased gradually after days 5 and 6. In contrast, Streptococcus pneumoniae and Klebsiella pneumoniae carriage increased progressively until the end of the stay in Saudi Arabia. Haemophilus influenzae and Moraxella catarrhalis carriage increased starting around days 12 and 13, following an initial clearance. Influenza viruses were rarely isolated. We observed an independent positive mutual association between S. aureus and rhinovirus carriage and between H. influenzae and M. catarrhalis carriage. Dual carriage of H. influenzae and M. catarrhalis was strongly associated with S. pneumoniae carriage (OR = 6.22). Finally, our model showed that M. catarrhalis carriage was negatively associated with K. pneumoniae carriage. Chronic respiratory disease was associated with symptoms of LRTI. K. pneumoniae, M. catarrhalis-S. aureus and H. influenzae-rhinovirus dual carriage was associated with LRTI symptoms. Our data suggest that RTIs at the Hajj are a result of complex interactions between a number of respiratory viruses and bacteria.

International mass gatherings and travel-associated illness: A GeoSentinel cross-sectional, observational study

BACKGROUND

Travelers to international mass gatherings may be exposed to conditions which increase their risk of acquiring infectious diseases. Most existing data come from single clinical sites seeing returning travelers, or relate to single events.

METHODS

Investigators evaluated ill travelers returning from a mass gathering, and presenting to a GeoSentinel site between August 2015 and April 2019, and collected data on the nature of the event and the relation between final diagnoses and the mass gathering.

RESULTS

Of 296 ill travelers, 51% were female and the median age was 54 years (range: 1-88). Over 82% returned from a religious mass gathering, most frequently Umrah or Hajj. Only 3% returned from the Olympics in Brazil or South Korea. Other mass gatherings included other sporting events, cultural or entertainment events, and conferences. Respiratory diseases accounted for almost 80% of all diagnoses, with vaccine preventable illnesses such as influenza and pneumonia accounting for 26% and 20% of all diagnoses respectively. This was followed by gastrointestinal illnesses, accounting for 4.5%. Sixty-three percent of travelers reported having a pre-travel encounter with a healthcare provider.

CONCLUSIONS

Despite this surveillance being limited to patients presenting to GeoSentinel sites, our findings highlight the importance of respiratory diseases at mass gatherings, the need for pre-travel consultations before mass gatherings, and consideration of vaccination against influenza and pneumococcal disease.

Risks threatening the health of people participating in mass gatherings: A systematic review

CONTEXT

Mass gatherings (MGs) are established for different religious, social, political, cultural, and sport motivations. Many risks threaten the participants' health in MGs for different reasons. One duty of health-care system is to identify the risks and manage them to reduce the participants' injuries in MGs. This study aimed to identify and classify the risks threatening the health of participants in MGs and review related articles systematically.

SUBJECTS AND METHODS

In this study, we investigated electronic databases including Science Direct, PubMed, Ovid, ProQuest, Web of Science, Scopus, and Google Scholar. This systematic review investigated those health articles which studied MGs published after 2000. Keywords that were searched included (Mass gathering OR Crowd) AND (Assessment OR Evaluation) AND (Disaster OR Emergencies) AND (Injuries OR Stamped). The final full text articles were assessed qualitatively by STROBE article assessment checklist, and then the data extracted from the results of the articles were analyzed and reported.

RESULTS

Initially, a total of 1874 articles were found, qualitative exclusion and inclusion criteria were applied, and finally 29 full-text articles were selected for the analysis. More than forty health-related risks were recognized. In order to better understand the risks and use of the results more efficiently, the risks were classified and reported into the following five domains: environmental risks, individual risks, psychological risks, public health risks, and management risks.

CONCLUSION

Many risks threaten the health of participants in MGs. Recognizing and managing the risks are considered the primary and basic essentials of health sector for the better management of MGs.

Disease Burden on Health Facilities in Governorates South of Karbala During the Arbaeenia Mass Gathering in Iraq in 2014: Cross-Sectional Study

BACKGROUND

Millions of Iraqi pilgrims travel annually from the southern governorates to Karbala and pass through Thiqar, Muthana, and Diwania Governorates to join the Arbaeenia mass gathering event. During this event, participants are at high risk for diseases and death and stifle local health care resources. In addition, the mass gathering causes considerable burden on health facilities in the hosting localities.

OBJECTIVE

This study aims to estimate the disease burden on health facilities caused by the pilgrims passing through Thiqar, Muthana, and Diwania Governorates en route to Karbala in Iraq.

METHODS

This cross-sectional study was conducted on all health facilities in three governorates (Thiqar, Muthana, and Diwania) situated along the southern way to Karbala from Basra. The study started on December 11, 2014, and ended on December 24, 2014. The morbidity and mortality were collected from surveillance logbooks and death registers. Drug purchase data were obtained from the personnel in charge of the pharmacies. The study period was divided into three phases on the basis of the timing of the mass gathering event: pre-event, the event, and postevent.

RESULTS

There were 884,834 incidents reported during the study. The majority of incidents were reported during the event phase (95%) and were attended mostly at mobile clinics (77%). The average daily incidents during the pre-event, event, and postevent phases were 4300, 56,040, and 4548 incidents, respectively. Musculoskeletal disorders were the most common illness reported (55%). The average number of daily deaths was 43, 36, and 45 during the pre-event, event, and postevent, respectively, and these values did not differ significantly. Cardiovascular diseases (43.5%), injuries (29.8%), and respiratory illnesses (12%) were the leading causes of deaths. Approximately US $1.3 million was spent on drug purchases during this mass gathering in the three governorates.

CONCLUSIONS

The Arbaeenia mass gathering causes a tremendous disease and economic burden on governorates that pilgrims pass through to attend this mass gathering in Karbala. Although Iraq's Ministry of Health is aware of the high burden of this mass gathering on the health facilities in these governorates, more work is needed to ensure quality services during the event.

Uptake of Recommended Vaccines and Its Associated Factors Among Malaysian Pilgrims During Hajj and Umrah 2018

This study aimed to assess the uptake of recommended vaccines and to identify the factors associated with the vaccines' uptake among Malaysian Hajj and Umrah pilgrims. A cross-sectional survey among Malaysian Hajj and Umrah pilgrims in 2018. The uptake of the recommended vaccines was surveyed through an anonymous self-administered questionnaire to pilgrims attending a pre-departure Hajj/Umrah orientation course. Descriptive statistics were used for elaborating the demographic characteristics and vaccines uptake of the respondents. Multiple logistic regression was used for predicting the factors associated with the vaccines' uptake. A total of 1,274 pilgrims participated in the study with a mean age (standard deviation) of 42.42 (15.6). A total of 833 (65.4%) participants were females and 232 of the participants (18.2%) had at least more than one chronic disease. The uptake of influenza and pneumococcal vaccines were 28.6% (364/1,274) and 25.4% (324/1,274), respectively. Among the 527 pilgrims who were "at increased risk" of infections, 168 (31.9%) and 184 (34.9%) received influenza and pneumococcal vaccines, respectively. Gender, marital status and occupation were the common predictors associated with vaccines uptake. The vaccination uptake among Malaysian Hajj and Umrah pilgrims is low and declining from previous years. Educating the pilgrims toward vaccine uptake is essential and exploring the barriers for vaccination.

Exploring Australian Hajj Tour Operators' Knowledge and Practices Regarding Pilgrims' Health Risks: A Qualitative Study

Background

Travel agents are known to be one of the main sources of health information for pilgrims, and their advice is associated with positive health behaviors.

Objective

This study aimed to investigate travel agents’ health knowledge, what health advice they provide to the pilgrims, and their sources of health information.

Methods

In-depth interviews were conducted among specialist Hajj travel agents in Sydney, Australia. Thematic analysis was undertaken.

Results

Of the 13 accredited Hajj travel agents, 9 (69%) were interviewed. A high level of awareness regarding gastrointestinal infections, standard hygiene methods, and the risk of injury was noted among the participants and was included in advice provided to pilgrims. However, very limited knowledge and provision of advice about the risk of respiratory infections was identified. Knowledge of the compulsory meningococcal vaccine was high, and all participated travel agents reported influenza vaccine (a recommended vaccine) as a second “compulsory” vaccine for Hajj visas. Conversely, participants reported very limited knowledge about other recommended vaccines for Hajj. The Ministry of Hajj website and personal Hajj experience were the main sources of information.

Conclusions

This study identifies a potential path for novel health promotion strategies to improve health knowledge among Hajj travel agents and subsequently among Hajj pilgrims.

Mass gatherings medicine: public health issues arising from mass gathering religious and sporting events

Mass gathering events are associated with major public health challenges. The 2014 Lancet Series on the new discipline of mass gatherings medicine was launched at the World Health Assembly of Ministers of Health in Geneva in May, 2014. The Series covered the planning and surveillance systems used to monitor public health risks, public health threats, and experiences of health-care providers from mass gathering events in 2012 and 2013. This follow-up Review focuses on the main public health issues arising from planned mass gathering events held between 2013 and 2018. We highlight public health and research data on transmission of infectious diseases and antibiotic-resistant bacteria, mass casualty incidents, and non-communicable diseases, including thermal disorders. In the events discussed in this Review, the combination of a large influx of people, many from countries with outbreak-prone infectious diseases, with a high degree of crowd interactions imposed substantial burdens on host countries' health systems. The detection and transmission of antibiotic-resistant bacteria in pilgrims attending the Kumbh Mela and the Hajj raise concern of possible globalisation from mass-gathering religious events. Priorities for further investments and opportunities for research into prevention, surveillance, and management of these public health issues are discussed.

Respiratory and gastrointestinal infections at the 2017 Grand Magal de Touba, Senegal: A prospective cohort survey

Background

The Grand Magal of Touba is the largest Muslim pilgrimage in Senegal with a potential for infectious disease transmission.

Methods

Clinical follow-up, adherence to preventive measures and qPCR-based respiratory and gastrointestinal pathogens carriage pre- and post-Magal, were assessed.

Results

110 pilgrims from South Senegal were included. The duration of stay in Touba was 3 days. 41.8% and 14.5% pilgrims reported respiratory and gastrointestinal symptoms. Most individuals having the onset of symptoms during their stay in Touba, or soon after returning. The acquisition of rhinoviruses, coronaviruses and adenovirus was 13.0, 16.7 and 4.6% respectively and that of Streptococcus pneumoniae and Haemophilus influenzae was 3.7% and 26.9%.

Acquisition of gastrointestinal viruses and parasites was low, while bacterial acquisition ranged from 2.2% for Campylobacter jejuni to 33.0% for enteropathogenic Escherichia coli.

Conclusion

This preliminary study confirms that Grand Magal pilgrims are likely to be exposed to communicable disease risk as observed in other pilgrimage settings. Further study including larger numbers of pilgrims are needed to investigate potential risk factors for respiratory and gastrointestinal infections at the Grand Magal.

Obstetric and Neonatal Outcomes of Pregnant Indian Pilgrims: A three-year experience at the Indian Hajj Medical Mission

Objectives

The Hajj, an annual mass gathering of Muslim pilgrims, is known for its high morbidity and mortality rates. However, pregnant women sometimes participate in this pilgrimage, despite guidelines that discourage such an undertaking due to potential fetomaternal complications. This study aimed to evaluate fetomaternal outcomes among pregnant Indian Hajj pilgrims.

Methods

This prospective cross-sectional study was conducted at two Indian Hajj Medical Mission (IHMM)-affiliated secondary care hospitals in Saudi Arabia during the Hajj periods of August-October 2015 and 2016 and July-September 2017. All female Indian pilgrims of reproductive age who underwent pregnancy screening at secondary care IHMM hospitals during this period were included in the study. Definitive obstetric care was provided at the Makkah Maternity & Child Hospital. Data regarding the pilgrims' obstetric characteristics, antenatal complications, management and fetomaternal outcomes were evaluated.

Results

A total of 114 pregnant Indian pilgrims were identified during the study period. The most common antenatal complications were respiratory tract infections (51.75%), followed by iron deficiency anaemia (17.54%), hyperemesis gravidarum (14.04%), hypothyroidism (9.65%) and gestational diabetes mellitus (5.26%). There were 20 vaginal deliveries (17.54%), two Caesarean sections (1.75%) and 32 abortions (28.07%). The cumulative three-year birth rate was 24.60 per 1,000 females.

Conclusion

During Hajj, pregnant pilgrims have a high risk of abortion, respiratory tract infections and various antenatal, perinatal and neonatal complications which may go unreported or untreated. Women should therefore be educated regarding the risk of adverse fetomaternal outcomes which may occur while undertaking a Hajj pilgrimage during pregnancy.

Infectious Diseases and Mass Gatherings

Purpose of Review

Mass gatherings (MGs) are characterized by a high concentration of people at a specific time and location. Infectious diseases are of particular concern at MGs. The aim of this review was to summarize findings in the field of infectious diseases with a variety of pathogens associated with international MGs in the last 5 years.

Recent Findings

In the context of Hajj, one of the largest religious MGs at Mecca, Saudi Arabia, respiratory tract infections are the leading cause of infectious diseases in pilgrims with a prevalence of 50–93%. The most commonly acquired respiratory viruses were human rhinovirus, followed by human coronaviruses and influenza A virus, in decreasing order. Haemophilus influenzae, Staphylococcus aureus, and Streptococcus pneumoniae were the predominant bacteria. The prevalence of Hajj-related diarrhea ranged from 1.1 to 23.3% and etiologies included Salmonella spp., and Escherichia coli, with evidence of acquisition of antimicrobial-resistant bacteria. In other MGs such as Muslim, Christian, and Hindu religious events, sports events, and large-scale open-air festivals, outbreaks have been reported less frequently. The most common outbreaks at these events involved diseases preventable by vaccination, notably measles and influenza. Gastrointestinal infections caused by a variety of pathogens were also recorded.

Summary

Because social distancing and contact avoidance are difficult measures to implement in the context of many MGs, individual preventive measures including vaccination, use of face mask, disposable handkerchief and hand hygiene may be recommended. Nevertheless, the effectiveness of these measures has been poorly investigated in the context of MGs.

High frequency of Haemophilus influenzae associated with respiratory tract infections among Malaysian Hajj pilgrims

BACKGROUND

Overcrowding during the annual Hajj pilgrimage has been known to increase the risk of infectious diseases transmission. Despite the high prevalence of respiratory illness among Malaysian Hajj pilgrims, knowledge about the etiologic pathogens is yet very limited. Thus, this study aimed to determine the spectrum of bacterial respiratory pathogens among the Hajj pilgrims returning to Malaysia in year 2016.

METHODS

Expectorated sputum specimens were collected from the Hajj pilgrims with symptomatic respiratory tract infections (RTIs). Subsequently, the bacterial pathogens were identified using the standard bacteriological culture method and Vitek II system.

RESULTS

This study indicated that 255 (87.33%) out of 292 cultured sputa were positive with at least one potential pathogenic bacteria. Out of 345 total bacterial isolates, 60% (n=207) were Haemophilus influenzae, which was associated with both single bacterium infection (132/173, 76.3%) and multiple bacterial infections (75/82, 91.5%). The other bacterial isolates included; Klebsiella pneumoniae (n=37, 10.7%), Moraxella catarrhalis (n=27, 7.8%), Haemophilus parainfluenzae (n=25, 7.2%), Streptococcus group G (n=18, 5.2%), Klebsiella spesies (n=16, 4.6%), Streptococcus pneumoniae (n=11, 3.2%) and few other organisms.

CONCLUSION

High frequency of H. influenzae was isolated from Malaysian Hajj pilgrims, especially those with respiratory symptoms. Further study should evaluate the actual pathogenicity of the organism and the interactions between the respiratory microbiota towards developing effective prevention strategies of RTIs among the local pilgrims.

Evaluation of the diabetes in pregnancy study group of India criteria and Carpenter-Coustan criteria in the diagnosis of gestational diabetes mellitus

OBJECTIVE

Gestational diabetes mellitus (GDM) is defined as any degree of glucose intolerance that is diagnosed for the first time during pregnancy. This prospective study was undertaken to validate the single-step non-fasting 75 gm Diabetes in Pregnancy Study Group of India (DIPSI) criteria of GDM in Indian patients in comparison with the two-step fasting 100 gm glucose challenge through the Carpenter Coustan criteria (CCC).

MATERIALS AND METHODS

Two hundred patients underwent comparative testing using the DIPSI criteria and CCC. Plasma venous blood glucose levels were estimated using the hexokinase method; values ≥140 mg/dL at 2 hours were considered positive according to the DIPSI criteria. Any two values from ≥95 mg/dL for fasting, ≥180 mg/dL at 1 hour, ≥155 mg/dL at 2 hours, and ≥140 mg/dL at 3 hours were considered positive with the CCC.

RESULTS

The mean age and body mass index were 24.26±3.75 years and 20.7±3.07 kg/m2. The sensitivity, specificity, and positive and negative predictive values of the DIPSI guidelines were found as 100%, 97.14%, 83.87%, and 100%, respectively. The positive and negative likelihood ratios were 35.8 and zero. Diagnostic accuracy was found as 97.56%.

CONCLUSION

DIPSI having high sensitivity, specificity, negative predictive value and diagnostic accuracy. DIPSI offers simplicity, feasibility, convenience, and repeatability while economizing universal screening and diagnosis of GDM on a mass-scale. The DIPSI procedure has the potential to be applied to the entire obstetric population, in the implementation of public health programs to diagnose GDM in the community, thus reaching the needs of the developing world.