Determining the Types of Diseases and Emergency Issues in Pilgrims During Hajj : A Literature Review

Introduction: Every year 2-3 million pilgrims with different background and most of them are elderly from 184 countries in the world congregate in the holy place ‘Haram’ at Makkah in Saudi Arabia to perform Hajj. During the pilgrimage, they come across a great deal of rough and tough environment, physical hassle and mental stress. Due to the hardship of travel, fluctuation of weather, continuous walking during religious rites at specific time and sites, many pilgrims injury, feel tired, sick, and exhausted. These may also create complications and overburden the physiological functions including heart, chest, abdominal, and kidney of those who suffer from chronic diseases. Besides the problem of diseases, crowds could cause some other significant problems including missing and lost pilgrims, injuries, and even death. Objective: To determine the common health problems e.g. diseases and emergency incidents encountered by pilgrims during Hajj was the main objective of this study. Methods: An extensive literature review to determine the common health problems and emergency incidents during Hajj was conducted through a systematic literature review. Numerous scholarly databases were used to search for articles published related to health problems and emergency incidents during Hajj from 2008 to 2016. Eligible articles included case reports, experimental and nonexperimental studies. Only thirty articles out of two hundred and sixty articles had met the specific inclusion criteria. Results: The analysis revealed that respiratory diseases include pneumonia, influenza, and asthma (73.33%) were the main health problems encountered by the pilgrims during Hajj followed by heat stroke or heat attack, sunlight effects (16.67%), cardiovascular disease, heart disease (10%). The analysis also revealed that emergency incidents include traffic accidents, and trauma was 3.33%. Notwithstanding the information given above, according to the analysis, the common health problems during Hajj are mainly divided into two categories: non-communicable diseases (62.5%) and communicable diseases (37.5%). IBM’s statistical package for the social sciences (SPSS) version 22 was used to analysis the result. Conclusion: Both communicable and non-communicable health issues are the most common health problems encountered by pilgrims during Hajj. But, due to lack of existing studies associated with this research area, a definite conclusion could not be made. However, our findings demonstrated the necessity of new research to find solutions to pilgrims’ health problems


INTRODUCTION
The largest yearly religious mass gathering worldwide is the Hajj, one of the obligatory five pillars of Islam.Every year during Hajj event an amount of 2-3 million pilgrims and a total of 10 million pilgrims for Hajj and Umrah from 184 countries congregate in Makkah, Saudi Arabia [1,2,3,4].The number of Hajj pilgrims has increased rapidly from 58, 584 in 1920 to 20, 00,000 (approx) in 2015 where 13, 84, 931 attended from outside Saudi Arabia.During the last 95 years, the increase rate of foreign pilgrims is 3.5, and the reason is a nonstop expansion of the Grand Mosque at Ka'aba in Makkah [5].The following Fig. 1 shows the number of pilgrims attending the Hajj during the year 2006-2015.Data were retrieved from the official portal of the royal embassy of Saudi Arabia, Saudi Ministry of Hajj, and central department of statistics and information [5,6,7].Hajj is a dynamic system to appreciate fully the physical dimensions of it which imply movement and travel.Walking Hajj distance: from Kaaba to Mina: 8 km, from Mina to Arafat: 13 km, Arafat to Muzdalifah: 13 km, Muzdalifah to www.ijacsa.thesai.orgMina: 2 km, Mina to Jamarat Akabah: 3.8 km.Makkah to Madina 450 km.On arrival, the pilgrims must don the Ihram and circumambulate the Ka'ba seven times and then perform the Saa'y seven times between the hills Safa and Marwah, a total distance 3.5 km.Crowd densities can increase to seven individuals per m² during Hajj.Overcrowding is one of the major problems since the area is limited and the numbers are increasing annually.The area of pilgrimage rites is a sandy valley embraced by rugged sun-baked mountains.In Makkah, especially during the hot months of May to September the temperature ranges between 38°C and 50°C with a relative humidity of 25% to 50% [8].This kind of hot environment with high radiant heat favors the development of heat illnesses e.g.heat exhaustion, heat stroke, unintentional physical injuries, and respiratory illnesses, dehydration called as noncommunicable diseases or problems [9].
The imminence between pilgrims due to the packed and crowded accommodation, congregation, and prayers creates an ideal atmosphere for spread and transmission of infectious diseases.Influenza, influenza-like illness, meningococcal disease, viral hemorrhagic fevers, yellow fever, cholera, polio, plague, tuberculosis and gastrointestinal infections, foodborne diseases e.g.diarrhea, food poisoning, etc. are examples of communicable diseases [10,11,12,13].Due to the physical exertion and overcrowding situation, some pre-existing chronic diseases such as asthma, heart disease, chronic chest conditions, diabetes, renal and liver disease may become harmful for pilgrims especially elderly which eventually favors the spread of communicable namely non-chronic diseases or infectious disease [14].
According to the findings, respiratory diseases includes pneumonia, influenza, and asthma 73.33% were the main health problems encountered by the pilgrims during Hajj followed by heat stroke/ attack, sunlight effects 16.67%, diabetic/ diabetes mellitus 13.33%.Cardiovascular disease, heart disease 10%, hypertension 6.67%, dehydration 6.67%, musculoskeletal 6.67%, urinary tract problems 3.33%, meningococcal disease 3.33%, diarrhea and jaundice 3.33%, finally, traffic accidents and trauma 3.33%.According to the studies, the pilgrims encountered 62.5% non-communicable diseases and problems along with 37.5% communicable diseases during Hajj.To determine the common health problems e.g.diseases and emergency incidents encountered by pilgrims during Hajj was the primary objective of this study.Hence, the result from this study could be beneficial in initiating, planning and design the appropriate healthcare system to prevent diseases and emergency situations encountered by Hajj pilgrims.

II. SEARCH STRATEGY AND SELECTION CRITERIA
The Lancet, IEEE Explore, MedLine, EBSCO Host, PubMed, Google Scholar, Science Direct, the Elsevier (Scopus), Academic search complete, Springer Link, ACM digital library, Emerald Insight, Taylors and Francis and Wiley database were used to search for articles published related to health problems and emergency incidents during Hajj from 2008 to 2016.The majority of related articles were published in various prominent journals around the world where most of the studies were carried in Saudi Arabia, Iran, France, United Kingdom, Malaysia, and Pakistan.Finally, we accessed official Saudi governmental statistics, with a particular emphasis on data from the Saudi Ministry of Health and Saudi Ministry of Hajj and Umrah.The combinations of specific keywords were utilized to retrieve the articles including pilgrims, Hajj, Diseases, healthcare, health problem, medical, medicine, overcrowd, emergency incidents, health pattern.Only thirty studies had met the specific inclusion criteria: the subjects were Hajj, pilgrims, health, crowd, emergency; the type of study was experimental or nonexperimental study; available full article in English.The research was conducted to find the answers to these questions e.g.What are the major diseases do the pilgrims carry and suffering?What are the reasons behind emergency incidents during Hajj?What are the emergency incidents occur during Hajj?Fig. 2 illustrates the search strategy as depicted.This paper is organized as, Section II: Search strategy and selection criteria; Section III: Data collection and analysis; Section IV: Analyzing the result; Section V: Discussion of the research; and Section VI: Conclusion.

III. DATA COLLECTION AND ANALYSIS
Items and their distributions of all respondents in the studies chosen were well briefed and summarized according to the author, and year.Meanwhile, the subsequent information gathered were objective, study design, the pattern of health problems and emergency situations, analyzing of the result and discussion of research shown in Table I.Table I tabulated all the information from selected articles.

IV. ANALYSING THE RESULT
Universally, elderly pilgrims were vulnerable to get the infection due to decreased rate of immune responses which is actively provoked by other factors such as hard work, lack of sleep and disturbances in the dietary schedule, and mental stress.Main reasons for infectious disease transmission due to airborne agents and pilgrims health hazards; especially injuries, trauma, etc. are extended stays at Hajj sites, and physical exhaustion, extreme heat, and crowded accommodation [15].The most feared trauma hazard during Hajj is stampede causing huge casualties.Chronicle of Hajj disasters as depicted in Table II, where data retrieved from the official portal of the embassy of Saudi Arabia, Saudi Ministry of Hajj, and central department of statistics and information [5, 6, and 7].Hajjis face multiple health issues like extreme temperatures, intravascular volume and electrolytes disturbances which also increases the risk of communicable and non-communicable diseases, where Hajj pilgrims encounter a great deal of tough physical and mental stress [16].Some studies related to the current health and diseases situation during Hajj spotted that, one in three pilgrims experiences such respiratory symptoms [17].Congestion and close contact stimulate the spread of infection especially upper respiratory tract infections URTIs followed by diseases of the skin, GIT, rheumatology [18,19], and URTIs as reported among the most common cause of illness among Iranian pilgrims [20].Other hazards include traffic accidents and fire injuries are reported in the literature [21].Due to the hazards like accidents, overcrowding situation, and human jam many www.ijacsa.thesai.orgpilgrims divert from their groups and get lost, where pilgrims are walking shoulder to shoulder in such massive Hajj gathering.

Search strategy for identification of studies
Selection Period: 2008-2016 A total of 30 studies related to communicable diseases or infectious diseases and non-communicable diseases/ problems or chronic diseases were used for analyzing the result.Regarding the study design of the selected articles; most of the studies were based on cross-sectional studies 46.67%, prospective cohort study 16.67%, descriptive study 10%, comparative study 6.67%, retrospective cohort analysis 3.33%, comparative study 3.33%, case-control study 3.33%, and Cohort study 3.33% as depicted in Fig. 3. Different types of instruments were used in the quantitative studies.Out of 30 selected studies, 22 articles had concluded that respiratory diseases include pneumonia, influenza, and asthma 73.33% were the main health problems encountered by the pilgrims during Hajj as presented in Table III and Fig. 4. The above findings followed by heat stroke/ attack, sunlight effects 16.67%, diabetic/ diabetes mellitus 13.33%, cardiovascular disease, heart disease 10%, hypertension 6.67%, dehydration 6.67%, musculoskeletal 6.67%, urinary tract problems 3.33%, meningococcal disease 3.33%, diarrhea and jaundice 3.33%, finally, traffic accidents and trauma 3.33%.Health problems or diseases are categorized into two main classes, namely communicable or infectious diseases and noncommunicable or chronic diseases.According to the studies, as shown earlier in Table I and Table III, 62.5% are noncommunicable diseases and 37.5% are communicable diseases, as shown in Fig. 5, encountered by the pilgrims during Hajj.This concise review is intended to present a structured analysis of published articles of health problems and emergency situation over the past ten years with regards to Hajj pilgrim.Health problems and their challenges for pilgrims during the pilgrimage, related outcomes, and suggestions for future investigators are highlighted in this study.
Respiratory Tract Infections were considered as the predominant clinical health patterns which encountered by Hajj pilgrims.It continues to be the increasing burden of diseases among Hajj pilgrims, but there is still a lack of studies being conducted to overcome these problems.Researchers had identified respiratory diseases as the most common cause of hospital admission (52.5%) during Hajj, with pneumonia being the leading reason for hospitalization.A prospective study was conducted in two different hospitals during Hajj 2011 [24].The overall mortality rate in the ward among pilgrims with pneumonia was 2.4% and in the ICU was 21.45% during Hajj period 2004-2013 which is similar to the mortality rates in West [23].Out of 30 selected studies, 22 of articles had concluded that respiratory diseases includes pneumonia, influenza and asthma 73.33% were the main health problems encountered by the pilgrims during Hajj [ Meningococcal Disease: A crowded environment with high humidity and dense air pollution are the main reasons for a meningococcal disease which is defined as an infection as high as 3.33% among all the diseases encountered by pilgrims during Hajj [28].

Skin Infections:
Bacterial skin infection is one of the pilgrims' health problems where Makkah is one of the hottest places in the world with the temperature range of 38 to 42°C during Hajj.The studies revealed that 23.6% dermatitis and 11.2% pyoderma patients were reported during Hajj.Among 80 pyoderma cases, 52.5% were primary pyoderma where impetigo the leading causes for primary pyoderma.Whereas, 47.5% were secondary pyoderma led by Staphylococcus aureus responsible as main causative agents and followed by Streptococcus pyogenes [24] [27] [28] [36].

Environmental Heat Injury:
The main factor of heat stress during Hajj as revealed from the literature are extreme summer temperature, direct and long time heat exposure from the sun, heat from vehicles and internal heat which lead to heat exhaustion or heat stroke among pilgrims [25] [28] [30] [44] [49].
Cardiovascular Diseases: Over the past few years, the study revealed cardiovascular disease with hypertension is one of the important causes of pilgrims' intensive care unit-ICU admission with high mortality rate [24] [40].During 2002 Hajj, the percentage of cardiovascular diseases was 45.8 [35].
Gastrointestinal infections: Major food-borne outbreaks of gastroenteritis with high mortality rates are common at all religious festivals, including the Hajj [25] [27] [36].

Blood-borne diseases:
To shave head during Hajj is compulsory which leads to transmission of blood-borne diseases including hepatitis B, C, and HIV.Illegal unlicensed barbers continue to operate the act whether the Saudi Ministry of health-MoH promotes and encourages all pilgrims to receive hepatitis B vaccination before travel to Hajj [22,29].
Malaria: Although WHO classifies Saudi Arabia as a low, geographically restricted malaria transmission area and since 2008 has been listed as being in the elimination stage of the program, but the risk during Hajj is still exist.In 2011 Hajj season 19 cases of P vivax malaria was reported where 75% such cases found among the Indian and Ethiopian pilgrims.In 2012, 48 cases of malaria were recorded in Makkah and 78 cases were recorded in Madinah among Pakistan, Nigeria, Guinea, India, Mouritania, Chad, Mali, Afghanistan, Somalia, Ethiopia, Yemen and Ivory Coast pilgrims.

Trauma risks:
During Hajj trauma is one of the major causes of morbidity and mortality.In a prospective study of 713 trauma patients, who were injured while performing Hajj, presenting to the emergency room, 248 (35%) were admitted to surgical departments and intensive care.The most common surgical presentations were orthopedic and neurosurgical [35].For a large part of the Hajj, pilgrims travel either by foot, walking through or near dense traffic, or in vehicles themselves.

Fire-related injury:
In 1997, fire devastated the Mina area when makeshift tents were set ablaze by open stoves since banned at the Hajj.There were 343 deaths and more than 1500 estimated casualties.Since then all makeshift tents have been replaced by permanent fiberglass installations.At Hajj time, Teflon-coated awnings are added, and the aluminum frames remain in place the rest of the year.No pilgrim is permitted to set up his own tent.Additionally, pilgrims are not allowed to cook food at Mina.Smoking is forbidden during the Hajj by Islamic teaching, thus reducing the risk of a naked flame.Continuous public education is being undertaken to further reduce fire risk.
Environmental heat injury: Heat exhaustion and heatstroke are a leading cause of morbidity and mortality during the Hajj, particularly in summer.Temperatures in Mecca can rise higher than 45ºC.Lack of acclimatization, arduous physical rituals, and exposed spaces with limited or no shade, produces heatstroke in many pilgrims.Adequate fluid intake and seeking shade is essential.Supplicating pilgrims might not notice the dangers of extreme heat exposure until their symptoms are pronounced.Water mist sprayers operate regularly in the desert at Arafat, a time of high risk for heatstroke, when many stand for long hours during the day.Performing rituals at night, using umbrellas, seeking shade, and wearing high-SPF sunblock creams are all advisable and permissible during the Hajj.Children accompanying their parents must be specially protected.The timings of rites are flexible and acceptable at the pilgrim's convenience-it is key that pilgrims are aware of this since, through fear of committing errors, they might not make sensible choices in completing their rituals [25] [28] [30] [44] [49].Although the Hajj is not due to fall in the summer for www.ijacsa.thesai.orgseveral years, Saudi winters are warmer (35-50ºC) than most pilgrims will be used to, and they must seek shade and drink plenty of fluid during their rites.
Occupational hazards of abattoir workers: Abattoir workers at the Hajj are exposed to unique traumatic risks.Over a million cattle are slaughtered each Hajj, up to half a million before noon on the 10 th day of the Hajj.In one study, 298 emergency visits for hand injury were treated in Mecca over four Hajj seasons.More than 80% were injuries from animal slaughter; many avoidable injuries were sustained by lay people and not trained abattoir workers.Pilgrims need to be that professional slaughtering arrangements are easily available at the Hajj, and far safer.

VI. CONCLUSION
Both communicable and non-communicable health issues are the most common health problems encountered by pilgrims during Hajj.But, due to lack of existing studies associated with this research area, a definite conclusion could not be made.However, our findings demonstrated the necessity of new research to find solutions to pilgrims' health problems during Hajj.

Fig. 1 .
Fig. 1.Statistics of number of pilgrims performed Hajj during the year 2006-2016 1990: 1426 pilgrims killed by stampede/asphyxiation in tunnel leading to holy sites 1994: 270 killed in a stampede 1997: 343 pilgrims died and 1500 injured in a fire 1998: 119 pilgrims died in a stampede 2001: 35 pilgrims died in a stampede 2003: 14 pilgrims died in a stampede 2004: 251 pilgrims died in a stampede 2006: 76 pilgrims died after a hotel housing pilgrims collapsed; a stampede wounded 289, killing 380 2015: 4173 pilgrims died in a stampede www.ijacsa.thesai.org

Fig. 4 .Fig. 5 .
Fig. 4. Percentage of studies according to major health problems What are the major diseases do the pilgrims carry and suffering from?What are the reasons behind emergency incidents during Hajj?What are the emergency incidents occur during Hajj?

TABLE II .
CHRONICLE OF DISASTER: 1990-2015 Fig. 3. Percentage of studies based on pilgrims' health problems and emergency incidents during Hajj

TABLE III .
MAJOR HEALTH PROBLEMS ENCOUNTERED BY PILGRIMS ACCORDING TO THE STUDIES AND CATEGORIZATION OF DISEASES