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

Abstract

The Hajj, a mass-gathering of over 3.5-million pilgrims, faces challenges to global health-security, housing, food, water, transportation, communication, sanitation, crowd-control and security. The Indian Medical Mission extended health-security to approximately 140,000 pilgrims, through outreach medical teams, primary-care clinics, tent-clinics, secondary-care hospitals and evacuation capabilities. Data on medical attendance, bed-occupancy, investigations, referrals, medication usage and deaths was compared. Outpatient attendance was 374,475 in static-clinics, 5135 in tent-clinics and 13,473 through task-forces. 585 (62.90%) in-patients were hospitalized amongst 930 secondary-care referrals. Secondary-care bed-days were 2106 with average bed-occupancy being 77.78%. 495 patients were institutionalized in tertiary-care Saudi-Arabian hospitals. Infectious diseases were most commonly (53.26%) encountered due to overwhelming respiratory-infections, followed by trauma (24.40%). Analgesics (66.38/100 patients) and antibacterials (48.34/100 patients) were frequently prescribed. Crude mortality amongst Indian pilgrims was 11.99/10,000. Risk-factors associated with high morbidity were old-age and pre-existing comorbidities. Overwhelming surge of patients facilitates transmission of communicable infections and leads to stress induced physical, mental and compassion fatigue amongst healthcare personnel. Respiratory infections are highly prevalent and easily transmissible during Hajj leading to significant morbidity, increased burden to existing health facilities, overwhelming costs on health systems and globalization of multiresistant pathogens. Diabetic patients should avoid heat exposure and use protective footwear during Hajj rituals. Mass-gathering medicine at Hajj can be optimized by improving patient knowledge on performing Hajj at a younger age, medicine compliance, avoiding self-medication, self-monitoring of hypertension, blood glucose, and preventive health measures; screening of pre-existing comorbidities; and resource augmentation with telemedicine networks and decision-support systems.

Indian Medical Mission at Hajj-2016: Mass-Gathering Medicine Perspectives, Challenges, and Opportunities in a Mission Posture

“…Mass gathering medicine involves higher rates of morbidity and mortality attributable to infections, trauma, environment, occupation, lifestyle, substance abuse, and disasters. 4,5,13,14 Astute preparedness is imperative across critical policy arenas bearing direct snowballing connotations to the number of casualties. The Sendai Framework gives a mandate for disaster risk reduction (DRR) in mass gatherings.…”

“…Interactions with multinational medical teams, the South Asian Moassasa (regional coordinating body), and Saudi Arabian hospitals were maintained. 5,10 Public health preparedness was ensured through pre-departure mandatory immunoprophylaxis for meningococcus, tetanus, and influenza. Patient education posters and advisories regarding hand hygiene, respiratory precautions, food-water safety, social distancing, avoidance of exertion, dehydration, heat exposure, injuries, and infections were disseminated.…”

“…[19][20][21] Healthcare for pilgrims from all countries is completely sponsored by Saudi Arabia through 141 Hajj medical centers and 100 ambulances; however, there are limitations in bed availability, ambulance transfers, and the daily follow-up of transferred patients. 5,11,22 Trend analysis from 2012 to 2016 revealed a modest decrease in patient attendance, largely attributable to the increase in self-care for chronic comorbidities. Mortality among Indian Hajj pilgrims is largely attributable to patientspecific causes comparable with pilgrims of other countries because of the large geriatric population with pre-existing health conditions.…”

“…3,4 Pre-existing cardiorespiratory and multisystem diseases lead to high morbidity and mortality during Hajj. [5][6][7][8] While the outbreak of El Tor cholera during the 1905 Hajj is historic, the international outbreak of meningitis following the Hajj pilgrimages in [1987][1988][1989][1990]1992, and 2000-2001 had serious repercussions. 2,9,10 Surging troupes led to stampedes in 1990,1994,1998,2001,, and 2015 and resulted in the trampling-induced deaths of approximately 5100 pilgrims and injuries to 550 pilgrims.…”

“…3,11,12 The meteoric growth in the number of Hajj pilgrims from 58 000 in 1920 to 3 160 000 in 2012 has instigated novel challenges to the interdependent dimensions of health and human support systems. 4,5,11,12 Saudi Arabia has reinvented Hajj management systems; nevertheless, the safety and security of pilgrims remains a national obligation of participating countries. Major countries fielding more than 100 000 Hajj pilgrims annually, such as Indonesia (29 000 pilgrims), Pakistan (180 000 pilgrims), India (150 000 pilgrims), and Egypt (125 000 pilgrims), are obliged to operate medical contingents during the Hajj pilgrimage to address barriers of language, culture, and alienation in terra incognita.…”