Abstract
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.
Keywords: Emergency Department, Healthcare Center, Hajj, Pilgrims, Patients, Saudi Arabia
1. Introduction
Over two million Muslims from more than 140 countries gather each year at Al-Masha'aer, Saudi Arabia's holy areas, to perform Hajj, one of Islam's five pillars. Hajj commences on the eighth to thirteenth day of Dhul Hijjah, the Islamic lunar calendar's 12th month [1]. Since the Islamic lunar calendar is 11 days shorter than the Gregorian calendar, the dates of Hajj vary from year to year. However, Hajj is not limited to these days because pilgrims arrive weeks before Hajj and depart days or even weeks after the end of hajj rituals. In Hajj, there are always a large number of pilgrims gathering in a relatively small space for a short period of time which pose specific health and epidemiological risks [2]. Hajj is a ritual that requires physical fitness as pilgrims may be obligated to walk for several kilometers in a crowd. In addition, there is always a change in their normal sleeping patterns which can be physically exhausting. The climate is very hot. Sometimes, temperature exceeds 40 degrees Celsius which may result in heat exhaustion among pilgrims. Outdoor Hajj rituals have been related to an increased risk of heatstroke, heat exhaustion, dehydration, and sunburn among pilgrims during the hot summer months. The Kingdom of Saudi Arabia's government, in collaboration with the Ministry of Hajj, the Ministry of Health (MOH), and others, seek to prevent health problems through a variety of measures, services, and interventions. Previous studies have shown that pilgrims who visit primary and secondary medical centers during hajj suffer from a variety of communicable and non-communicable diseases including cardiovascular disease, respiratory disease, and heat stroke [3,4]. Despite the massive crowd during Hajj, trauma accounted for less than one-tenth of hospital admissions. More than one-third (39%) of pilgrims had co-morbid conditions requiring medical care. More than one-fifth (22.2%) suffered from cardiovascular diseases (hypertension, ischemic heart disease, congestive heart failure, valvular heart disease, and previous cerebrovascular accidents) and one-fifth (19.4%) suffered from diabetes mellitus [5].
In previous studies, the most common admission diagnoses were infections (36.4%) and cardiovascular diseases (24.9%). Pneumonia was the most common admission diagnosis (19.7%), followed by various clinical manifestations of ischemic heart disease (12.3%) [6].
The Saudi Ministry of Health provides free health services to pilgrims. For this purpose, the authorities have qualified 25,000 healthcare workers and set aside 25 hospitals with 155 permanent and seasonal health centers to ensure that pilgrims have access to various types of medical care during Hajj season. The services are available at Mina, Arafat, and the Two Holy Mosques. Around 60% of patients admitted in hospitals at these four locations are then transferred to advanced care facilities. Critical cases are referred to King Abdullah Medical City-Holy Capital (KAMC-HC) Hospital which is considered the region's most developed and new healthcare facility. It offers 24-hour emergency services to all pilgrims [7].
King Abdul Aziz International Airport Health Care Center (KAIA-HC) is a health care facility located at Jeddah's King Abdul Aziz International Airport. It serves as a flight destination for many pilgrims. It is open 24 hours a day, seven days a week. The staff provides full health care services to pilgrims coming for Hajj, ensuring their safety and lack of infectious diseases. Through the therapeutic, preventive, and ambulatory programs as well as well-equipped health facilities and highly trained medical staff, the KAIA-HC implements comprehensive health plans to provide the highest quality health services. The center provides treatment and health care to sick pilgrims. The critical cases are transferred to the Ministry of Health hospitals in Jeddah. KAIA-HC is considered the front defense line for the prevention of inbound infectious diseases to ensure substantive control and application of quarantine rules to protect the Kingdom against infiltration and spread of infections by taking precautionary measures towards pilgrims. Furthermore, KAIA-HC ensures compliance with health requirements by all incoming pilgrims, mainly those coming from countries with high epidemic rates of certain diseases, to prevent inbound infections. For this purpose, the Ministry of Health checks pilgrim’s travel documents that ensure that they have got the necessary vaccines in their respective countries (international certificate of vaccination). KAIA-HC has qualified more than 600 employees including physicians, nurses, technicians, and administrators for this year's Hajj season. Also, KAIA-HC services are enhanced with five well-equipped ambulances and the latest appliances. In addition, cardiopulmonary resuscitation (CPR) rooms, isolation rooms, medical clinics, and inpatient rooms have been prepared. As a part of the preparation for this year's Hajj (1440 H – 2019), the Ministry of Health (MOH) has equipped KAIA-HC from the 1st of Dhul Qi’dah. With regard to the objectives and purpose of the KAIA-HC, it provides the pilgrims with both preventive and curative services. In the curative services, the pilgrims receive a medically examination and treatment in cases of acute, chronic, or emergency diseases. The pilgrims get all that they need whether medication, admission or isolation. In case of health condition instability, the specialized team refers the issue to the nearest MOH’s hospital to complete the therapeutic plan. KAIA-HC has a triage room, two clinics for men and women, eight admission beds, a dressing room for wounds and fractures, an X-Ray room, a laboratory, and a pharmacy equipped with all medications needed whether for acute, chronic or urgent cases as well as a room for cardiopulmonary resuscitation (CPR) with a team specialized in dealing with critical cases. Also, KAIA-HC has four well-equipped ambulances to transport pilgrims suspected with contagious diseases to a specific hospital dedicated to this service. Preventive services are provided by checking the validity of health certificates which include the necessary vaccination of pilgrims from endemic countries such as polio, meningococcal, and yellow fever vaccinations. In addition, the pilgrims are educated on personal protective measures such as frequent hand washing and using a face mask. Current studies conducted during Hajj have examined the admissions pattern of pilgrims and the range of diagnoses [[8], [9], [10]]. Still, to date, no studies have investigated the acute cases that are treated at the King Abdul Aziz International Airport Health Centre (KAIAHC), before and after Hajj. Also, no research studies have assessed the degree to which these admissions are urgent during this crucial time. As a result of this knowledge gap, we set out to investigate the prevalence of emergency health problems among pilgrims presenting at KAIA-HC, their pattern, types and urgency, chronic disease pattern, and findings during the hajj season of 2019. It is hoped that the findings will help ensure that healthcare facilities at the airport are prepared for any possible problems which could occur during Hajj and that they are used to the best effect.
1.1. Study objectives
1. To estimate the prevalence of emergency health problems among pilgrims travelling through KAIA-HC during Hajj season 2019 (1440 H).
2. To determine the types of emergency health problems.
3. To determine the prevalence of comorbid conditions among pilgrims.
4. To investigate the findings of concerned pilgrims.
2. Methods
This study was carried out at King Abdul Aziz International Airport Health Care Center (KAIA-HC), with the approval of the Institutional Review Board. The study investigated sick pilgrims who had been seen at the clinic before or after Hajj, during the period between 1st Dhul Qi’dah to 29th Dhul Hijjah 1440 H (Corresponding to 4th July to 31st August 2019), mainly focusing on those patients who were categorized as emergency cases.
2.1. Study design
The study is a descriptive cross-sectional study that depends upon chart review.
Study Setting:
KAIA-HC - Hajj terminal, Jeddah, Saudi Arabia.
2.2. Target population
All pilgrims who presented at the KAIA-HC in, Hajj terminal before and after completing the Hajj rituals. Since Saudi pilgrims do not come through Hajj terminal, the selection of participants in this study is limited to non-Saudi pilgrims coming through KAIA-HC at Hajj terminal diagnosed as an emergency case and who had complete data records. The definition of Emergency cases used for this study refers to those sick pilgrims coming through KAIA-HC (before or after performing Hajj) who suffer from health problems that required staying for more than two hours under supervision or isolation rooms at the center. They may require continuous and close medical care. It can refer to those who need CPR, ventilation or hospitalization as well as the accidents, fractures and heat exhaustion.
2.3. Data collection
The medical records of Emergency Hajj patients who had been treated at the KAIA-HC during that time were selected and reviewed retrospectively. Data were extracted from their records and collected on a predesigned data collection instrument (Appendix A). The collected data included demographic information, nationality, clinical diagnosis, comorbid conditions, and the findings.
2.4. Data analysis
Data were analyzed using Epi Info 7, Version 21.0. Descriptive data analysis was undertaken. Continuous variables were represented as means and standard deviations. Categorical variables were described as numbers & percentages.
2.5. Ethical considerations
Approval was obtained from the Ethical Committee of the Research Center at King Fahd Medical City (KFMC). The number of ethical approval is (19-414E). The approval of the institutional review board is attached below (Appendix A). The data obtained is wholly confidential and was used only for the study purposes.
3. Results
Among a total number of 7,643 pilgrims who presented to KAIA-HC during Hajj 1440 AH (2019 AD), only 296 (3.87%) were considered as emergency cases. The average age of the 296 emergency cases whose records were reviewed was 43 years (Standard Deviation (SD) ±7.5), with ages ranging from 5 to 92 years. The largest age group was 30 to 59 years of age group with a number of 134 (45.3%). Among participants, 70 (48.6%) cases of male pilgrims were in 30 to 59 age group, and 64 (42.1%) cases of female pilgrims were in 30 – 59 age group. In this study, the female to male ratio was nearly equal; female (51.35%) and male (48.64%). The participants came from 31 nationalities. The largest group came from Indonesia 42 (14.2%), 37 (12.5%) were from Egypt, 31 (10.5%) from Pakistan, 25 (8.5%) from India, 22 (7.4%) from Iraq and 15 (5.1%) from Ethiopia (Table 1). Tables 1 & 2 demonstrate the clinical diagnoses of emergency cases presented to KAIA-HC by system with cardiovascular diseases were the most common provisional diagnoses (n = 111, 37.5%), followed by respiratory diseases (n = 73, 24.7%), diabetes-linked complications (n = 28, 9.5%), and surgical causes (n = 28, 9.5%). As shown in table 2, Cardiovascular (CVS) problems accounted for more than one-third of all primary diagnoses, with the majority of (CVS) cases 82(24.4%) showing low and high blood pressure, with 59(19.9%) presenting with hypertension and 23(7.8%) presenting with hypotension. 16 (5.4%) of the patients seen at KAIA-HC had a myocardial infarction, 10 (3.4%) had a cerebrovascular accident, and 1 (0.3%) had heart failure. The most common respiratory diagnosis was the acute exacerbations of bronchial asthma (n = 53, 17.9%), followed by chest infections involving some pulmonary TB cases (n = 13, 4.4%). Moreover, 4 patients (1.4%) were diagnosed with pulmonary embolism. 28 (9.5%) patients had diabetes-related complications: 10 (3.4%) had hypoglycemia, 11 (3.7%) had hyperglycemia and 7 had diabetic ketoacidosis (DKA). There were 28 surgical diagnoses (9.5%), 13 (4.4%) were cut wounds, 11 (3.7%) were bone fracture and dislocation, and 4 (1.4%) were head trauma. 9 (3%) of the cases had renal problems, the majority of which were chronic renal failure for dialyzes (n = 4), renal colic (n = 3), and urinary retention (n = 2). Table 3 illustrates a univariate analysis of the relationship between the main clinical diagnosis of emergency cases in terms of their findings and demographic characteristics. Table 3 points out a significant association (P < 0.001) and (P=0.004) between the main clinical diagnosis, age category, and mode of hospital arrival, respectively; with (cardiovascular diseases, respiratory diseases, and diabetes-related complications) significantly higher in the age group (30 to less than 60 years). In terms of the findings of the participant emergency cases, the majority of patients; 151 (51%) were discharged after management, followed by 82 (27.7%) who were referred to another hospitals, 50 (16.9%) remained under medical advice and 13 (4.4%) died. The findings do not show a significant association with the main clinical diagnosis (cardiovascular diseases, respiratory diseases, and diabetes-related complications, surgical and gastrointestinal diseases), table 3.
Table 1.
Demographic characteristics and gender distribution of Emergency Cases presenting to King Abdul Aziz International Airport Health Care Center (KAIA-HC) during Hajj 1440 H.
| Variable | Total (296) |
Male (144) |
Female (152) |
|||
|---|---|---|---|---|---|---|
| Frequency | Percentage | Frequency | Percentage | Frequency | Percentage | |
| Nationality | ||||||
| Indonesia | 42 | 14.2% | 19 | 13.2% | 23 | 15.1% |
| Egypt | 37 | 12.5% | 15 | 10.4% | 22 | 14.5% |
| Pakistan | 31 | 10.5% | 16 | 11.1% | 15 | 9.9% |
| Indian | 25 | 8.4% | 16 | 11.1% | 9 | 5.9% |
| Iraq | 22 | 7.4% | 10 | 6.9% | 12 | 7.9% |
| Ethiopia | 15 | 5.1% | 5 | 3.5% | 10 | 6.6% |
| Algeria | 13 | 4.4% | 6 | 4.2% | 7 | 4.6% |
| Bangladesh | 13 | 4.4% | 6 | 4.2% | 7 | 4.6% |
| Iran | 12 | 4.1% | 4 | 2.8% | 8 | 5.3% |
| Morocco | 9 | 3.0% | 5 | 3.5% | 4 | 2.6% |
| Nigeria | 10 | 3.4% | 6 | 4.2% | 4 | 2.6% |
| Turkey | 10 | 3.4% | 7 | 4.9% | 3 | 2.0% |
| Others⁎ | 57 | 19.3% | 29 | 20.1% | 28 | 18.4% |
| Age | ||||||
| <30 Years | 60 | 20.3% | 22 | 15.3% | 38 | 25.0% |
| 30--59 Years | 134 | 45.3% | 70 | 48.6% | 64 | 42.1% |
| 60 & above | 102 | 34.5% | 52 | 36.1% | 50 | 32.9% |
| Clinical diagnosis | ||||||
| Cardiovascular | 111 | 37.5% | 62 | 43.1% | 49 | 32.2% |
| Respiratory | 73 | 24.7% | 26 | 18.1% | 47 | 30.9% |
| Endocrine | 28 | 9.5% | 11 | 7.6% | 17 | 11.2% |
| Surgical | 28 | 9.5% | 13 | 9.0% | 15 | 9.9% |
| CNS | 6 | 2.0% | 4 | 2.8% | 2 | 1.3% |
| Renal | 9 | 3.0% | 8 | 5.6% | 1 | .7% |
| Gastrointestinal | 22 | 7.4% | 10 | 6.9% | 12 | 7.9% |
| Others⁎⁎ | 19 | 6.4% | 10 | 6.9% | 9 | 5.9% |
| Finding | ||||||
| Discharged | 151 | 51.0% | 69 | 47.9% | 82 | 53.9% |
| Left against medical advice (LAMA) | 50 | 16.9% | 24 | 16.7% | 26 | 17.1% |
| Referred | 82 | 27.7% | 43 | 29.9% | 39 | 25.7% |
| Death | 13 | 4.4% | 8 | 5.6% | 5 | 3.3% |
| Mode of Arrival | ||||||
| Red Crescent | 75 | 25.3% | 35 | 24.3% | 40 | 26.3% |
| Wheelchair | 82 | 27.7% | 37 | 25.7% | 45 | 29.6% |
| Stretcher | 11 | 3.7% | 7 | 4.9% | 4 | 2.6% |
| Ambulance | 47 | 15.9% | 20 | 13.9% | 27 | 17.8% |
| Walk In | 81 | 27.4% | 45 | 31.3% | 36 | 23.7% |
Others: Niger, Afghanistan, Mali, Guinea, Tunisia, Syria, Malaysia, Sudan, Uzbekistan, Libya, America, Belgium, China, Emirates, Kenya, Oman, Russia, Somalia, Sri Lanka.
Others: Derma, Mental, Heat exhaustion, OB/GYN, Hematology
Table 2.
The most common clinical diagnoses of emergency cases presented to King Abdul Aziz International Airport Health Care Center (KAIA-HC) during Hajj 1440 H are distributed by body system affected.
| Disease group | Diagnosis | No. of patients |
|
|---|---|---|---|
| Freq | % | ||
| Cardiovascular Diseases | Hypertension | 59 | 19.9% |
| Hypotension | 23 | 7.8% | |
| Myocardial Infarction | 16 | 5.4% | |
| Cerebrovascular Accident | 10 | 3.4% | |
| Supraventricular tachycardia | 2 | 0.7% | |
| Heart Failure | 1 | 0.3% | |
| Respiratory Diseases | Bronchial Asthma | 53 | 17.9% |
| Pulmonary Embolism | 4 | 1.4% | |
| Chest Infections (pulmonary TB, Pneumonia) | 13 | 4.4% | |
| Respiratory acidosis | 1 | 0.3% | |
| Chronic obstructive pulmonary disease (COPD) | 2 | 0.7% | |
| Diabetes-linked Complications | Hypoglycemia | 10 | 3.4% |
| Hyperglycemia | 11 | 3.7% | |
| DKA, Hypokalemia, Hyperkalemia | 7 | 2.4% | |
| Renal Diseases | Chronic Renal Failure (Dialysis) | 4 | 1.4% |
| Renal Colic | 3 | 1.0% | |
| Urinary Retention | 2 | 0.7% | |
| Gastrointestinal | Gastroenteritis, Lower GI bleeding, Bowel Ischemia | 22 | 7.4% |
| Surgical | Cut Wounds | 13 | 4.4% |
| Bone Fractures & Dislocation | 11 | 3.7% | |
| Head Trauma | 4 | 1.4% | |
| CNS | Epilepsy | 6 | 2.0% |
| Others | Psychosis, Leukemia, Epistaxis, Heat exhaustion, Drug allergy, Dehydration, drug over dosage, spontaneous vaginal delivery | 19 | 6.4% |
Table 3.
Univariate analysis showing comparison of main clinical diagnosis of emergency cases in terms of their finding and demographic characteristics presented to King Abdul Aziz International Airport Health Care Center (KAIA-HC) during Hajj 1440 H.
| Variable | Main clinical diagnosis |
χ2 Test p value |
|||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Cardiovascular n=111 |
Respiratory n=73 |
Endocrine n=28 |
Surgical n=28 |
Gastrointestinal n=22 |
|||||||
| Freq | % | Freq | % | Freq | % | Freq | % | Freq | % | ||
| Nationality | |||||||||||
| Indonesia | 14 | 12.6% | 19 | 26.0% | 1 | 3.6% | 1 | 3.6% | 1 | 4.5% |
χ2⁎=59.98 df=48 P=0.115 |
| Egypt | 16 | 14.4% | 8 | 11.0% | 2 | 7.1% | 4 | 14.3% | 1 | 4.5% | |
| Pakistan | 9 | 8.1% | 6 | 8.2% | 2 | 7.1% | 6 | 21.4% | 3 | 13.6% | |
| Indian | 12 | 10.8% | 1 | 1.4% | 3 | 10.7% | 5 | 17.9% | 3 | 13.6% | |
| Iraq | 9 | 8.1% | 4 | 5.5% | 4 | 14.3% | 3 | 10.7% | 1 | 4.5% | |
| Ethiopia | 6 | 5.4% | 4 | 5.5% | 3 | 10.7% | 2 | 7.1% | 0 | 0.0% | |
| Algeria | 3 | 2.7% | 4 | 5.5% | 2 | 7.1% | 1 | 3.6% | 3 | 13.6% | |
| Bangladesh | 2 | 1.8% | 4 | 5.5% | 2 | 7.1% | 1 | 3.6% | 1 | 4.5% | |
| Iran | 5 | 4.5% | 2 | 2.7% | 0 | 0.0% | 1 | 3.6% | 2 | 9.1% | |
| Morocco | 3 | 2.7% | 2 | 2.7% | 2 | 7.1% | 1 | 3.6% | 1 | 4.5% | |
| Nigeria | 6 | 5.4% | 1 | 1.4% | 0 | 0.0% | 1 | 3.6% | 0 | 0.0% | |
| Turkey | 5 | 4.5% | 0 | 0.0% | 1 | 3.6% | 1 | 3.6% | 2 | 9.1% | |
| Others | 21 | 18.9% | 18 | 24.7% | 6 | 21.4% | 1 | 3.6% | 4 | 18.2% | |
| Age | |||||||||||
| <30 Years | 2 | 1.8% | 26 | 35.6% | 6 | 21.4% | 9 | 32.1% | 11 | 50.0% | χ2=66.86 df=8 P<0.001⁎⁎ |
| 30--59 Years | 74 | 66.7% | 23 | 31.5% | 14 | 50.0% | 3 | 10.7% | 7 | 31.8% | |
| 60 & above | 35 | 31.5% | 24 | 32.9% | 8 | 28.6% | 16 | 57.1% | 4 | 18.2% | |
| Gender | |||||||||||
| Male | 62 | 55.9% | 26 | 35.6% | 11 | 39.3% | 13 | 46.4% | 10 | 45.5% | χ2=7.98 df=4 P=0.09 |
| Female | 49 | 44.1% | 47 | 64.4% | 17 | 60.7% | 15 | 53.6% | 12 | 54.5% | |
| Findings | |||||||||||
| Discharged | 55 | 49.5% | 39 | 53.4% | 16 | 57.1% | 14 | 50.0% | 20 | 90.9% | χ2⁎=18.62 df=122 P=0.098 |
| LAMA | 17 | 15.3% | 9 | 12.3% | 3 | 10.7% | 7 | 25.0% | 0 | 0.0% | |
| Referred | 32 | 28.8% | 22 | 30.1% | 7 | 25.0% | 7 | 25.0% | 2 | 9.1% | |
| Death | 7 | 6.3% | 3 | 4.1% | 2 | 7.1% | 0 | 0.0% | 0 | 0.0% | |
| Mode of Arrival | |||||||||||
| Red Crescent | 25 | 22.5% | 18 | 24.7% | 6 | 21.4% | 11 | 39.3% | 3 | 13.6% | χ2⁎=34.92 df=16 P=0.004⁎⁎ |
| Wheelchair | 32 | 28.8% | 14 | 19.2% | 15 | 53.6% | 2 | 7.1% | 10 | 45.5% | |
| Stretcher | 5 | 4.5% | 2 | 2.7% | 2 | 7.1% | 0 | 0.0% | 0 | 0.0% | |
| Ambulance | 14 | 12.6% | 15 | 20.5% | 2 | 7.1% | 8 | 28.6% | 1 | 4.5% | |
| Walk in | 35 | 31.5% | 24 | 32.9% | 3 | 10.7% | 7 | 25.0% | 8 | 36.4% | |
More than 20% of cells in this variable have expected cell counts less than 5. Chi-square results may be invalid.
significant p-value
As shown in table 4, the most common referral causes were myocardial Infarction numbered 12(4.05%), followed by cerebrovascular accident 10(3.3%) and chest infection in 8 (2.7%). The overall mortality rate was (4.3%). The total number of deaths was 13. The most common causes of death were myocardial infarction (n = 4), asthma (n = 3), hypertension (n = 2) and hyperglycemia (n = 2). The proportionate mortality rates were 30.79%, 23.07%, 15.38% and 15.38% for myocardial infarction, asthma, hypertension and hyperglycemia, respectively. Out of 296 patients presented to KAIA-HC, 10 (3.4%) required cardiopulmonary resuscitation (CPR); three (1.01%) of these cases resulted in unsuccessful CPR and death.
Table 4.
Body system affected by finding of emergency cases presented to King Abdul Aziz International Airport Health Care Center (KAIA-HC) during Hajj 1440 H.
| Diseases body system | Discharged |
LAMA |
Referred |
Death |
Total |
|||||
|---|---|---|---|---|---|---|---|---|---|---|
| No | % | No | % | No | % | No | % | No | % | |
| Cardiovascular | 55 | 36.4% | 17 | 34.0% | 32 | 39.0% | 7 | 53.8% | 111 | 37.5% |
| Respiratory | 39 | 25.8% | 9 | 18.0% | 22 | 26.8% | 3 | 23.1% | 73 | 24.7% |
| Endocrine | 16 | 10.6% | 3 | 6.0% | 7 | 8.5% | 2 | 15.4% | 28 | 9.5% |
| Surgical | 14 | 9.3% | 7 | 14.0% | 7 | 8.5% | 0 | 0.0% | 28 | 9.5% |
| CNS | 1 | 0.7% | 4 | 8.0% | 1 | 1.2% | 0 | 0.0% | 6 | 2.0% |
| Renal | 0 | 0.0% | 5 | 10.0% | 4 | 4.9% | 0 | 0.0% | 9 | 3.0% |
| Gastrointestinal | 20 | 13.2% | 0 | 0.0% | 2 | 2.4% | 0 | 0.0% | 22 | 7.4% |
| Others | 6 | 4.0% | 5 | 10.0% | 7 | 8.5% | 1 | 7.7% | 19 | 6.4% |
| Total | 151 | 100.0% | 50 | 100.0% | 82 | 100.0% | 13 | 100.0% | 296 | 100.0% |
* LAMA: Left against medical advice.
As shown in table 5, hypertension was the most frequent comorbid condition (n = 198), followed by diabetes mellitus (n = 159), bronchial asthma (n = 80), ischemic heart disease (n = 64), and renal failure (n = 50). In terms of gender distribution, hypertension was the most common comorbid condition among male patients (n = 106), followed by diabetes mellitus (n = 87), ischemic heart disease (n = 37), and bronchial asthma (n = 26). In female patients, the most common comorbid condition was hypertension (n = 92), followed by diabetes mellitus (n = 72), bronchial asthma (n = 54), and ischemic heart disease (n = 27).
Table 5.
Reported comorbidities of emergency cases and gender distribution presented to King Abdul Aziz International Airport Health Care Center (KAIA-HC) during Hajj 1440 H.
| Co morbidities | Male (144) |
Female (152) |
Total (296) |
|||
|---|---|---|---|---|---|---|
| No. | % | No. | % | No. | % | |
| Hypertension | 106 | 73.6% | 92 | 60.5% | 198 | 66.9% |
| DM | 87 | 60.4% | 72 | 47.4% | 159 | 53.7% |
| Bronchial Asthma | 26 | 18.1% | 54 | 35.5% | 80 | 27.0% |
| Ischemic Heart Disease | 37 | 25.7% | 27 | 17.8% | 64 | 21.6% |
| Renal Failure | 24 | 16.7% | 26 | 17.1% | 50 | 16.9% |
| Seizure | 4 | 2.8% | 4 | 2.6% | 8 | 2.7% |
| Others⁎ | 2 | 1.4% | 2 | 1.3% | 4 | 1.4% |
| No Comorbidity | 11 | 7.6% | 17 | 11.2% | 28 | 9.5% |
Psychiatric Problems, Hepatitis C, Anemia, cancer.
As revealed in Table 6, Table 7, the number of discharged pilgrims and death findings were inversely related to the number of co-morbid conditions (i.e., the fewer comorbid condition a pilgrim has, the more likely he or she was discharged 107(70.9%). Death was the finding of pilgrims who had the highest number co-morbid condition (13(100%)). Having more comorbidities is associated with a worse findings as death (n = 13) occurs in patients who have four or more comorbid condition. Moreover, there is significant association between the findings and the number of comorbid condition (p < 0.001). Furthermore, there is a moderately significant positive correlation between the findings and the number of comorbid conditions (r = 0.638, p < 0.001).
Table 6.
Number of Co Morbidities by findings of emergency cases presented to King Abdul Aziz International Airport Health Care Center (KAIA-HC) during Hajj 1440 H.
| Number of Co-Morbidities | Discharged |
LAMA |
Referred |
Death |
Total |
|||||
|---|---|---|---|---|---|---|---|---|---|---|
| No | % | No | % | No | % | No | % | No | % | |
| 0 | 23 | 15.2% | 3 | 6.0% | 1 | 1.2% | 0 | 0.0% | 27 | 9.1% |
| 1 | 84 | 55.6% | 12 | 24.0% | 13 | 15.9% | 0 | 0.0% | 109 | 36.8% |
| 2 | 36 | 23.8% | 15 | 30.0% | 17 | 20.7% | 0 | 0.0% | 68 | 23.0% |
| 3 | 8 | 5.3% | 17 | 34.0% | 33 | 40.2% | 0 | 0.0% | 58 | 19.6% |
| 4 | 0 | 0.0% | 3 | 6.0% | 14 | 17.1% | 9 | 69.2% | 26 | 8.8% |
| 5 | 0 | 0.0% | 0 | 0.0% | 4 | 4.9% | 4 | 30.8% | 8 | 2.7% |
| Total | 151 | 100.0% | 50 | 100.0% | 82 | 100.0% | 13 | 100.0% | 296 | 100.0% |
Table 7.
Comparing the number of Co-Morbidities by the finding of emergency cases presented to King Abdul Aziz International Airport Health Care Center (KAIA-HC) during Hajj 1440 H.
| Variable | Number of comorbidities |
|||
|---|---|---|---|---|
| 0-1 comorbidities No (%) |
2 or more comorbidities No (%) |
Chi-square (χ2 Test) |
P-value | |
| Findings | ||||
| Discharged | 107 (70.9%) | 44 (29.1%) | χ2 =81.43 df=3 |
<0.0001* |
| DAMA | 15 (30.0%) | 35 (70.0%) | ||
| Referred | 14 (17.1%) | 68 (82.9%) | ||
| Death | 0 | 13 (100.0%) | ||
Highly significant p-value.
4. Discussion
This study sets out to estimate the prevalence of emergency health problems among pilgrims who presented to KAIA-HC health center during Hajj 1440 H, in addition to determining the types of emergency health problems and their findings. The findings of this study point out that among the total number of 7,643 of pilgrims who presented to KAIA-HC during Hajj 1440 H, only 296 (3.9%) were considered as emergency cases. The majority of patients had a combination of old age and numerous underlying chronic medical diseases. The demographic data shows that the age and sex distribution mirrored other studies conducted during Hajj [8,11]. In our study, the average age of the 296 emergency cases was 43 years (Standard Deviation SD ±7.5), with an age range of 5 to 92 years. 45.3% were in the 30 to 59 years age group in both genders; 70 (48.6%) of males and 64 (42.1%) of females. In a previous study [6], the majority (79%) of hospitalized patients were older than 40 years and more than one third (38.3%) were more than 60 years [5], which is almost like our study findings. Hospital admissions during Hajj are related to older age and it occurs mostly among patients with associated co-morbid conditions. Our study showed that cardiovascular-related diseases were the most frequent provisional diagnoses among emergency cases, followed by respiratory diseases. Hypertension, diabetes mellitus, bronchial asthma and ischemic heart diseases were the most common comorbid conditions. Our study agrees with the findings of earlier studies focusing on disease patterns during Hajj period, which found a preponderance of non- communicable diseases, particularly among elderly pilgrims. The majority of studies conducted during Hajj pointed out that respiratory, cardiac, neurological, and gastrointestinal infections were the most common complaints of pilgrims admitted into hospital [2,12,13]. A previous study reported that Infections (36.4%) and cardiovascular diseases (24.9%) were the most common admitting diagnoses. More specifically, pneumonia (19.7%) was the most common admitting diagnosis followed by (12.3%) the various clinical presentations of ischemic heart disease [5]. In our study, the most common provisional diagnoses were cardiovascular diseases (n = 111, 37.5%), respiratory diseases (n = 73, 24.7%), diabetes-related complications (n = 28, 9.5%), and surgical causes (n = 28, 9.5%). The most common causes of referral emergency cases were myocardial infarction (n = 12, 4.5%), cerebrovascular accident (n = 10, 3.3%), and chest infection (n = 8, 2.7%). In another study, cardiovascular diseases and diabetes mellitus were the main causes of both morbidity and mortality. This is an expected finding taking into account the age of the pilgrims and the large number of cardiovascular risk factors [14]. It has already been demonstrated that if pilgrims above the age of 50 are examined for cardiovascular risk factors and diseases and provided with the right treatment before leaving for Hajj, there will be a sharp decline in the number of people hospitalized during Hajj in addition to the decreased mortality figures [15]. Khan and Ishag [13] found that cardiovascular disease was responsible for 34% of visits. The findings from the Al-Masha’aer centers showed that asthma and chronic obstructive pulmonary disease (22.5 %), hypertension (17.5%), and diabetes mellitus (15%) were frequently reported comorbid conditions in admitted patients during Hajj. This finding is consistent with our research. Many of the patients who presented at KAIA-HC had hypertension, diabetes, bronchial asthma, ischemic heart disease, and renal failure, all of which have serious health consequences. Previous studies have reported that many pilgrims with chronic illnesses who perform Hajj fail to follow their treatment regularly or correctly. This suggests that the complications that may arise could have been precipitated by a lack of treatment compliance [16]. It is therefore essential to ensure that, in the future, prospective pilgrims will be educated about the type of underlying disease they have and the importance of regular treatment so that complication is not exacerbated. Our study showed that myocardial Infarction, followed by cerebrovascular accident and chest infection were the most common referral causes among patients presenting to KAIA-HC. Many patients in our study were older adults who also suffered from co-morbid conditions such as diabetes mellitus and chronic obstructive pulmonary diseases which is similar to previous studies [17,18].
In our study we had 13 cases (4.4%) suffering from chest infection. Since pilgrims are in close contact with one another during Hajj, this makes it easier for aerosolized and airborne infections as well as foodborne diseases to spread quickly which may point out the high rates of upper respiratory tract infections (URTI) previously reported among pilgrims during Hajj [19,20]. Upper respiratory tract infections can allow airborne infections to spread and play a part in exacerbating obstructive airway diseases and bronchial asthma. Only one patient in our study was found to have TB. Many pilgrims come from areas where the TB rate is high [20]. Other researchers have argued that tuberculosis is the most important cause of pneumonia in pilgrims’ hospitalization [21]. However, we did not find any evidence to back up this assumption. The cases of pneumonia and the transmission of airborne diseases can be tackled by implementing an educational program for the pilgrims and teaching them about the dangers of coughing and spitting up sputum in public. Face masks can also be promoted for personal use and influenza vaccinations can be offered to reduce upper respiratory tract infections [22,23]. In our study, traumatic injuries range from minor wounds related to performing rituals to more severe head injuries. Similar to previous studies, trauma during hajj is limited. Most literature that discusses health problems during Hajj focuses on medical diseases since medical conditions are more prevalent than surgical ones. Unfortunately, surgical cases are much more severe [5]. In the past, the summer months witnesses an increase in morbidity rates due to gastroenteritis and heat-related illnesses with 615 deaths from heatstroke reported during the 1985 Hajj [24]. The number of deaths due to heart-related diseases declined in recent years thanks to the authorities' educational campaigns, the construction of heatstroke units and the provision of cooling beds [25]. In our study, there are only two cases who suffered from heat exhaustion thanks to the Saudi government's efforts to introduce prevention and protection strategies [26]. In the past, pilgrims have been exposed to meningococcal meningitis, which poses a threat not only to those involved but also to their communities [27,28]. In 2001, the Saudi Ministry of Health made obligated all pilgrims to be vaccinated with the Quadrivalent meningococcal vaccine. Subsequently, the number of reported cases decreased significantly [27,29]. Fortunately, our study did not detect any patient with meningococcal meningitis. Among the patients who received treatment in KAIA-HC, more than half (51%) were discharged without additional treatment and without being referred to another hospital. It is worth bearing in mind that the Saudi government provides all pilgrims with excellent quality healthcare and access to hospitals which is not confined to patients with severe conditions [30]. The reported number of deaths in our study was 13 patients with an overall mortality rate of 4.3 %. Ghaznawi and Ibrahim reported 1,784 deaths in Hajj season of 1405 AH (1985 AD) [25] which were ascribed to the too high temperatures in that year and the large number of heatstroke cases. Hajj season of 1422 AH (2002 AD) also witnessed high rates of deaths due to trauma and meningitis [5]. This was not the case in Hajj season IN (1440 AH – 2019 AD). It is possible that our study underestimated the actual number of deaths because we focused on short-term findings and limited our research to one center (KAIA-HC) and did not follow-up the referred patients who were still alive. Some of our study participants (n = 82, 27.7%) were finally transferred to other facilities. Since many of these pilgrims were very ill, it is possible that the final mortality rate could have been much higher. It is equally possible that there was a positive outcome of those pilgrims as a result of the advanced healthcare services provided along with the advanced technology, skills, and resources. If we consider the majority of the emergency cases studied were older adults with chronic medical health issues, it would be beneficial to educate potential Hajj pilgrims to undergo an official medical evaluation in their home countries before departing for the hajj. This initiative will help to identify their diseases and make it easier to provide them with appropriate medical care both in terms of quality and quantity. If Hajj pilgrims arrive in KSA with a formal medical report outlining their underlying medical issues, it will be easier to provide them with the appropriate care during the hajj if required.
Future researches are needed to determine which measures can be taken to reduce cardiovascular and stroke morbidity as well as overall mortality during Hajj to determine the classes of patients who can travel safely. The functional status and mobility capacity must be assessed as part of clinical evaluations prior to Hajj. Furthermore, a study must be conducted to compare different types of interventions in order to determine how mortality rates can be reduced most effectively as well as determining which interventions are more effective and beneficial than others. Our study did not compare Hajj with non-Hajj patients during the same period which can be viewed as a limitation since evaluating both groups' behavior in terms of the pattern of emergency illnesses and their findings could shed light on differences between the two groups. We would endorse replicating this research idea longitudinally (e.g., over five years) for better findings assessment and recommendations.
5. Conclusion
The majority of KAIA-HC emergency visitors were middle-aged and older adults who suffer from chronic medical conditions. Cardiovascular diseases (hypertension, hypotension, myocardial infarction and cerebrovascular diseases) were the most frequent diagnoses among emergency cases followed by respiratory diseases (bronchial asthma, chest infections, and pulmonary embolism) and diabetes-related complications (hyperglycemia, hypoglycemia and DKA). 51% of patients were discharged without the need for a higher level of medical care. The mortality rate was low (4.3%). The most common comorbidity was hypertension followed by diabetes, bronchial asthma, ischemic heart disease and renal failure.
6. Recommendations
-
1.
Before leaving for Hajj, potential Hajj pilgrims should undergo an official medical evaluation in their home countries. Hajj pilgrims arriving in Saudi Arabia should have a formal medical report detailing any underlying medical issues. This initiative will help to identify their diseases and make it easier for them to receive appropriate treatment in Saudi Arabia if necessary.
-
2.
It is essential to educate prospective pilgrims on the importance of adhering to treatment procedures in order to avoid complications.
-
3.
Medical (particularly cardiac) and surgical departments in hospitals receiving referrals from KAIA-HC should be supported and well-equipped during hajj.
-
4.
Future research is needed to determine which interventions can be implemented to reduce cardiovascular and stroke morbidity as well as overall mortality during Hajj.
-
5.
Future multicenter studies for determining the prevalence, pattern, and findings of emergency health problems among pilgrims as well as comorbidities and their relationship with sociodemographic characteristics are recommended.
Funding statement
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Declaration of Competing Interest
No conflict of interest.
Contributor Information
Khaled Masoud Alrufaidi, Email: kalghamdi21@moh.gov.sa.
Nawaf Mufarreh AlGhamdi, Email: namualghamdi@moh.gov.sa.
Hashim Mohammed Makhrashi, Email: Hmakhrashi@moh.gov.sa.
Saeed Abdulaziz AlGhamdi, Email: Salghamdi242@moh.gov.sa.
Ahmed Ghormallah AlZahrani, Email: ahgalzahrani@moh.gov.sa.
Eman Elsayed Abd-Ellatif, Email: eman_saleh@mans.edu.eg.
Appendix A (IRB approval)
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