International Journal of Travel Medicine and Global Health

International Journal of Travel Medicine and Global Health

Emergency Response of Indian Hajj Medical Mission to Heat Illness Among Indian Pilgrims in Tent-Clinics at Mina and Arafat During Hajj, 2016

Document Type : Original Article

Authors
Inam Danish Khan 1
Syed Bahavuddin Hussaini 2
Shazia Khan 3
Faiz MH Ahmad 1
Faisal Ahmad Faisal 4
Muhammad Arif Salim 5
Razzakur Rehman 6
Syed Asif Hashmi 1
Bushra Asima 7
Muhammad Shaikhoo Mustafa 8
1 Army College of Medical Sciences and Base Hospital, New Delhi, India
2 Madurai Medical College, Government Rajaji Hospital, Madurai, India
3 Specialist Obstetrics and Gynaecology, INHS Kalyani, Vishakhapatnam, India
4 Specialist Paediatrics, MH Roorkee, India
5 Hospital Administrator, Assam, India
6 Specialist Physiology, Guwahati, India
7 Army Hospital Research and Referral, New Delhi, India
8 Public Health Consultant, Chennai, India
10.15171/ijtmgh.2017.26
Abstract
Introduction: Extreme heat claims more lives than all other weather-related exposures combined. Hajj rituals at Mina, Arafat, and Muzdalifah involve a minimally-clothed, moving assemblage of 3.5 million pilgrims who are exposed to a harsh, hot, desert climate during physically challenging outdoor rituals and unsheltered night stays, rendering them prone to heat illness, dehydration, and sunburn. This cross-sectional study assessed the emergency response of the Indian Hajj Medical Mission to overwhelming heat illnesses in Mina and Arafat among Indian pilgrims during Hajj, 2016.
Methods: In 2016, 88 patients affected by the heat were brought to central tent-clinics at 36 maktabs in Mina and Arafat that were established by the Indian Hajj Medical Mission. Patients were offered rapid external evaporative cooling (wet towels) and cold intravenous saline infusion on patient couches and wheelchairs.
Results: The incidence of heat illness among Indian pilgrims in 2016 was 0.62/1000. The ratio of males to females was 1.8:1. Mean ages of males and females were 62.2 ± 7.43 and 52.6 ± 9.3, respectively. Pre-existing conditions, such as diabetes mellitus and hypertension, were present in 93.2% of the patients. The most common presentations included hyperthermia, fatigue, and restlessness. Heatstroke presented in five patients and resulted in one fatality. Twenty-eight patients were referred to Saudi hospitals, and 12 of them were institutionalized. Exertion related to the stoning of Satan ritual during late morning and afternoon hours was the leading cause of heat illness.
Conclusion: The overwhelming incidence of heat illness among Indian pilgrims in the critical five-day period of the Hajj represents the tip of the iceberg as the Hajj attracts over 3.5 million pilgrims from 200 countries annually. Heat illness is difficult to manage in the presence of pre-existing comorbidities and mandates clientele education and outreach warning systems to enhance resilience capital amongst Hajj pilgrims, sportspersons, outdoor enthusiasts, and military personnel.
Keywords
Hajj
Heat Illness
Heat Exhaustion
Heat Stroke
Mass Gathering Medicine
  1. Centres or Disease Control and Prevention. Climate effects on Health. http://www.cdc.gov/climateandhealth/effects/default.htm. Accessed March 30, 2017. Published April 18, 2016.
  2. Intergovernmental Panel on Climate Change (IPCC) Climate Change 2007: Working Group II: Impacts, Adaption and Vulnerability. Cambridge, UK: Cambridge University Press; 2007. http://www.ipcc.ch/publications_and_data/ar4/wg2/en/contents. html. Accessed February 10, 2017.
  3. Manoochehry S, Rasouli HR. Recurrent Human Tragedy During Hajj. Int J Travel Med Glob Health. 2017;5(1):36-37. doi:10.15171/IJTMGH.2017.07.
  4. Khan ID, Khan SA, Asima B, Hussaini SB, Zakiuddin M, Faisal FA. Morbidity and mortality amongst Indian Hajj pilgrims: a 3-year experience of Indian Hajj Medical Mission in Mass- Gathering Medicine. J Infect Public Health. 2017. doi:10.1016/j.jiph.2017.06.004.
  5. Khan ID, Khan S, Khan MA, et al. Indian Medical Mission at Hajj- 2016: Mass-Gathering Medicine Perspectives, Challenges, and Opportunities in a Mission Posture. Int J Travel Med Glob Health. 2017;5(3):94-101. doi:10.15171/ijtmgh.2017.20.
  6. Memish ZA, Stephens GM, Steffen R, Ahmed QA. Emergence of medicine for mass gatherings: lessons from the Hajj. Lancet Infect Dis. 2012;12(1):56-65. doi:10.1016/S1473-3099(11)70337-1.
  7. Khan ID, Sahni AK, Sen S, Gupta RM, Basu A. Outbreak of Prototheca wickerhamii algaemia and sepsis in a tertiary care chemotherapy oncology unit. Med J Armed Forces India. 2017. doi:10.1016/j.mjafi.2017.07.012.
  8. Khan ID, Sahni AK. Rapid Diagnosis of Dengue Outbreaks in Resource Limited Facilities. West Indian Med J. 2017;66(1):4-9. doi:10.7727/wimj.2016.095.
  9. Shujaa A, Alhamid S. Health response to Hajj mass gathering from emergency perspective, narrative review. Turk J Emerg Med. 2015;15(4):172-176. doi:10.1016/j.tjem.2015.02.001.
  10. Alberini A, Gans W, Alhassan M. Individual and public-program adaptation: coping with heat waves in five cities in Canada. Int J Environ Res Public Health. 2011;8(12):4679-4701. doi:10.3390/ijerph8124679.
  11. Al-Ghamdi SM, Akbar HO, Qari YA, Fathaldin OA, Al-Rashed RS. Pattern of admission to hospitals during muslim pilgrimage (Hajj). Saudi Med J. 2003;24(10):1073-1076.
  12. Noweir MH, Bafail AO, Jomoah IM. Study of heat exposure during Hajj (pilgrimage). Environ Monit Assess. 2008;147(1-3):279-295. doi:10.1007/s10661-007-0120-6.
  13. Excessive Heat Events Guidebook. Washington, DC: US Environmental Protection Agency; 2006.
  14. al-Mashhadani SA, Gader AG, al Harthi SS, Kangav D, Shaheen FA, Bogus F. The coagulopathy of heat stroke: alterations in coagulation and fibrinolysis in heat stroke patients during the pilgrimage (Haj) to Makkah. Blood Coagul Fibrinolysis. 1994;5(5):731-736. doi:10.1097/00001721-199410000-00009.
  15. al-Harthi SS, Karrar O, al-Mashhadani SA, Saddique AA. Metabolite and hormonal profiles in heat stroke patients at Mecca pilgrimage. J Intern Med. 1990;228(4):343-346. doi:10.1111/j.1365-2796.1990.tb00243.x.
  16. Donoghue AM, Sinclair MJ, Bates GP. Heat exhaustion in a deep underground metalliferous mine. Occup Environ Med. 2000;57(3):165-174. doi:10.1136/oem.57.3.165.
  17. Yaqub BA, Al-Harthi SS, Al-Orainey IO, Laajam MA, Obeid MT. Heat stroke at the Mekkah pilgrimage: clinical characteristics and course of 30 patients. Q J Med. 1986;59(229):523-530.
  18. Kashmeery A. Physiological studies on heat exhaustion victims among Mecca pilgrims. Acta Med Austriaca. 1995;22(1-2):16-22.
  19. Khan ID. Extreme altitude pulmonary oedema (EAPO) in acclimatized soldiers. Med J Armed Forces India. 2012;68(4):339- 345. doi:10.1016/j.mjafi.2012.04.018.
  20. Khan ID. Comorbid Cerebral and Pulmonary Edema at 7010 M/23000 Ft: An Extreme Altitude Perspective J Med. 2013;14(2):153-155. doi:10.3329/jom.v14i2.19668.
  21. Simister J, Cooper C. Thermal stress in the U.S.A.: effects on violence and on employee behaviour. Stress Health. 2005;21(1):3- 15. doi:10.1002/smi.1029.
  22. Trang PM, Rocklov J, Giang KB, Kullgren G, Nilsson M. Heatwaves and Hospital Admissions for Mental Disorders in Northern Vietnam. PLoS One. 2016;11(5):e0155609. doi:10.1371/journal.pone.0155609.
  23. Horowitz BZ. The golden hour in heat stroke: use of iced peritoneal lavage. Am J Emerg Med. 1989;7(6):616-619. doi:10.1016/0735-6757(89)90285-4.
  24. Seraj MA, Channa AB, al Harthi SS, Khan FM, Zafrullah A, Samarkandi AH. Are heat stroke patients fluid depleted? Importance of monitoring central venous pressure as a simple guideline for fluid therapy. Resuscitation. 1991;21(1):33-39. doi:10.1016/0300-9572(91)90076-B.
  25. Khan ID, Sahni AK, Bharadwaj R, Lall M, Jindal AK, Sashindran VK. Emerging organisms in a tertiary healthcare set up. Med J Armed Forces India. 2014;70(2):120-128. doi:10.1016/j.mjafi.2013.09.005.
  26. Khan ID, Sahni AK. Bacterial infections and emerging resistance in renal transplant recipients. Bangladesh J Med Sci. 2015;14(1):14- 21. doi:10.3329/bjms.v14i1.16306.
  27. Khan ID, Gupta N, Rangan NM, et al. Evaluation Of Pre and Post Analytical Variables in Clinical Microbiology Services in Multidisciplinary ICU of a Medical College And Tertiary Care Hospital. J Basic Clin Med. 2016,5(1):2-4.
  28. Khan ID, Basu A, Kiran S, Trivedi S, Pandit P, Chattoraj A. Device- Associated Healthcare-Associated Infections (DA-HAI) and the caveat of multiresistance in a multidisciplinary intensive care unit. Med J Armed Forces India. 2017;73(3):222-231. doi:10.1016/j.mjafi.2016.10.008.
  29. Khan ID. On-site Management of Frostbite in the Himalayas. Int J Travel Med Glob Health. 2017;5(1):28-32. doi:10.15171/IJTMGH.2017.05.
  30. Khan ID, Asima B, Khan SA. Operations throughput as a determinant of golden-hour in mass-gathering medicine. Int J Med and Med Res. 2017;3(1):52-58. doi:10.11603/ijmmr.2413-6077.2017.1.7804.
  31. Sankoff J. Heat illnesses: a hot topic in the setting of global climate change. Aust Fam Physician. 2015;44(1-2):22-26.
  32. Mandourah Y, Ocheltree A, Al Radi A, Fowler R. The epidemiology of Hajj-related critical illness: lessons for deployment of temporary critical care services*. Crit Care Med. 2012;40(3):829-834. doi:10.1097/CCM.0b013e318236f49b.
  33. Bowron CS, Salahudin MM. Select Destinations The Middle East and North Africa. Saudi Arabia: Hajj Pilgrimage. In: CDC Health Information for International Travel: The Yellow Book 2016. https://wwwnc.cdc.gov/travel/yellowbook/2018/select-destinations/saudi-arabia-hajj-umrah-pilgrimage.
  34. Ahmed QA, Arabi YM, Memish ZA. Health risks at the Hajj. Lancet. 2006;367(9515):1008-1015. doi:10.1016/S0140-6736(06)68429-8.
  35. Gabal MS, Khadiga AS. Pattern of heat stroke and heat exhaustion among pilgrims over 20 years (1982-2001). J Egypt Public Health Assoc. 2003.
  36. Cleary M. Predisposing risk factors on susceptibility to exertional heat illness: clinical decision-making considerations. J Sport Rehabil. 2007;16(3):204-214. doi:10.1123/jsr.16.3.204.
  37. Turkestani A, Balahmar M, Ibrahem A, Moqbel E, Memish ZA. Using health educators to improve knowledge of healthy behaviour among Hajj 1432 (2011) pilgrims. East Mediterr Health J. 2013;19 Suppl 2:S9-S12.
  38. Inman WJ. Medical drones could be the next wave of emergency response. Fox News. December 14 2016. http://www.foxnews.com/health/2016/12/14/medical-drones-could-be-next-wave-emergency-response.amp.html.
International Journal of Travel Medicine and Global Health
Volume 5, Issue 4 - Serial Number 19
Autumn 2017
Pages 135-139

  • Receive Date 02 October 2017
  • Revise Date 17 November 2017
  • Accept Date 18 November 2017