1. No category

www.dwepi.org
DOI: 10.14360/dwe.e0005
Original Contribution
Health Care
Surgical admissions during the Muslims’ journey of a lifetime
1,2
1,2
1
2
*Ali Riaz , Tabatabaie , Navab Shamspour , Mohammad Taghi Hollisaaz , Masoud
Saghafinia 3, Mahan Shakeri 4,5
1 Institute of Higher Education & Research and Education Deputy of Iran Red Crescent Society, Tehran, Iran 2 Health Office, Hajj
Organization, Tehran, Iran 3 Trauma Research Center, Baghyatallah University of Medical Sciences 4 Medicine and Health Promotion institute,
Tehran, Iran 5Universal Network for Health Information Dissemination and Exchange (UNHIDE), Tehran, Iran
Submitted: May 2012 Accepted: April 2013 Published: October 20113
Abstract
Background: Little information exists regarding the surgical admission during Hajj, a religious obligatory journey for all the
Muslims around the world. Aim: This study aimed to investigate surgical causes of hospitalization among Iranian pilgrims during
Hajj. Methods: This retrospective study used a census sampling of all patients who were hospitalized in surgery wards in two
Iranian hospitals in Mecca and Medina, Saudi Arabia, from January 2005 to January 2007. Demographics, hospital location,
route of admission, length of hospital stay, past medical history, cause of admission, type of treatment, and outcome were
registered. Descriptive statistics were used for data analysis. Results: From the total number of 600 hospitalizations, 9.2% were
admitted in the surgery service. In 32.7% of the patients, trauma was the cause of admission, while 67.3% were admitted for
causes other than trauma. The most common traumatic cause was injury to extremities (55.6%). The most common non-traumatic
causes were gastrointestinal problems and diabetic foot. Mean (SD) length of hospital stay was 3(2) days. Only 61.8% of patients
were discharged in a good condition and 29% of patients were transferred to a tertiary hospital. About 5.5% of patients were
discharged against medical advice. Two patients died in the hospital. Conclusion: The information provided may help with the
resource allocation and management of surgical health care during Hajj.
Keywords: Hospitalization, Surgery, Hajj, Muslims, Pilgrims
Dev World Epidemiol 2013; 1(1): e0005
Many people around the world voluntarily travel to
receive sophisticated medical and surgical services1-4.
Another group of people unwillingly get sick or need
emergency care during their travels5. Requiring
emergent surgical care while on travel imposes
significant burden and costs on the traveler.
Hospitalization during Hajj is one of many examples6-13.
There are 1.5 billion Muslims who live around the
world, making Islam as the second major religion in the
world.
In fact, 21% of the world population is composed of
Muslims14,15. All this shows the large number of Hajj
*Corresponding Author: Ali Riaz, Institute of Higher Education
& Research and Education Deputy of Iran Red Crescent Society,
Tehran, Iran, Tehran, Iran Tel: 98 21 8126 4070 Fax: [98 21
8126 4070] Email: ab.tavallayee@gmail.com
Dev World Epidemiol. 2013; 1(1)
travels (a religious obligation for all Muslims) each year
during which pilgrims may face diseases or accidents
which require emergency surgical interventions16. In
some cases, this event can lead to leaving Hajj rituals
unfinished because not being able to perform Hajj
thoroughly, imposing substantial costs, both financial
and emotional, on patients5,16.
Iran is a country with 99.4% Muslims14. Although a few
studies have been conducted on causes of hospitalization
during Hajj17,18, data is very limited regarding the
surgical causes of admissions among Iranian
pilgrims19,20. This study aimed to investigate causes of
admission of Iranian pilgrims to surgery wards during
Hajj.
METHODS
This retrospective study with census sampling of
patients who were hospitalized in surgery wards of two
Surgical admissions during Hajj-Hollisaaz et al.
Iranian hospitals in Mecca and Medina, Saudi Arabia,
was done from January 2005 until January 2007. This
study was performed in coordination with Hajj and
pilgrimage Organization, an organization responsible for
coordination and management of the Iranian pilgrims
who perform Hajj rituals.
Samples and Sampling
Inclusion criteria were Iranian nationality, admission
during Hajj for a surgical procedure. Patients with
surgical care needs, regardless of having received
operative treatment or managed conservatively, were
enrolled. Patients who died in the emergency room,
before entry to surgical ward or those who were
received to the hospital dead were not included in this
study.
Process
Only minor surgery such as abscess derenageis, debries,
suturing done in these hospitals, and all procedures
including laparotomies, orthopedic surgeries, and
thoracic surgeries are done in Saudi hospitals. For the
surgical patients, patients are admitted to this hospital,
and pre and post operative care is provided by the
Iranian hospitals.
Patients receive outpatient care from physicians
in the residential places of pilgrims and are then
transferred to Iranian hospitals for further care, if
needed. The patients are being admitted via some
different ways, in some cases such as trauma, EMS
ambulances transfer the patients to the emergency room
of the Iranian hospitals, or physicians refer them to the
hospital polyclinic, in which specialists admit the
patients when needed.
Hajj is being performed in two main forms,
Tamattu or Omra. These types last 30 and 14 days,
respectively. Each year, from Iran, 700,000 people
participate in Omra, and 100, 000 people in Tamattu.
The Health condition of pilgrims is assessed by Hajj
Physicians before the travel. Although there is no age
limit, pilgrims should have the function to be able to do
without help: People with disability are not allowed for
Hajj.
What determines if someone can undertake the
pilgrimage or not is the function of the patient, not the
health status only. Hajj is not allowed for those with a
communicable disease such as tuberculosis, Myocardial
Infarction (MI) or cerebro-vascular disease (CVA) in the
past 6 month, psychotic disorders, drug addiction or
pregnancy. Several chronic conditions such as skeletal
conditions, rheumatologic conditions can go to Hajj,
after a letter from their physician.
Data was collected using patients’ charts. Collected data
included demographic characteristics (age, sex),
information on hospital location, route of admission
(from clinic, emergency room), length of hospital stay,
past medical history (Diabetes Mellitus; DM,
Cardiovascular diseases and psychiatric disorders,
chronic obstructive pulmonary disease (COPD),
presenting illness (clinical manifestations, duration of
signs and symptoms, diagnosis, number of physician
visits) type of treatment (surgical and medical), and
outcome (discharged in good general condition, referred
to Saudi hospital, sent back to Iran for further
intervention, passed away).
Outcome
Cause of hospitalization was categorized into traumatic
and non-traumatic. According to the location of trauma,
it was further subdivided into extremity, pelvis,
abdomen, chest, head, and multiple traumas. The nontraumatic admissions were grouped further into
gastrointestinal problems, orthopedic problems, soft
tissue problems, and others. Unfortunately, retrospective
collection of data did let us to determine the cause of the
trauma, if related to the pilgrimage or not.
Statistical Analyses
Data was analyzed by SPSS Ver.13, using frequency
tables and mean (SD) or median (inter-quartile range)
when appropriate. Chi square was used to compare the
pattern of hospitalizations between male and female
pilgrims. P less than 0.05 considered significant.
RESULTS
From the total number of 1,700,000 Iranian pilgrims in a
two-year period, 600 patients were hospitalized in the
Iranian Hospitals in Saudi Arabia, and from this number,
55 (9.2%) were admitted in the surgery service.
Hospitalized Patients
The mean (standard deviation) age of the patients in
surgery ward was 54.8 ( 16.2) ranging from 24 to 89
years of age with 19 (34.5%) of them being female and
36 (65.5%) being male. Forty (72.7%) patients were
hospitalized in Mecca and 15 (27.3%) were admitted in
Medina. 41 (74.5%) were admitted from polyclinic and
other fourteen patients (25.5%) were admitted from
emergency room. Past medical history of patient is
shown in table 1.
Hospitalization Causes
Eighteen patients (32.7%) were admitted for trauma, and
37 (67.3%) for non-traumatic causes. Causes of
hospitalizations of patient are shown in table 2.
Hospital Services
The length of hospitalization ranged from 1 to 12 days
and 22 (40%) of the patients stayed in the hospital for
two days. Mean (SD) length of stay was 3 2 days. The
number of physician visits varied widely ranging from
one visit to more than 10 visits. Thirty four patients
Surgical admissions during Hajj-Hollisaaz et al.
(56.4%) had 2 to 4 visits during their stay in the surgery
ward.
Outcomes
Table 3 shows the outcomes of the patients. From 55
surgical patients, 2 died. One was a 35 year-old man
with no past medical history who was admitted with
knee fracture. The other was an 81 year-old woman with
intertrochanteric fracture who had hyperthyroidism in
her past medical history. Cause of death of these two
cases was not reported clearly.
Male and Female patients:
There was no significant difference between female and
male patients by means of admission for surgical care,
primary diagnoses, medical history and outcomes
(p>0.05 for all).
DISCUSSION
About 9.2% of all hospitalizations of Iranian pilgrims
during Hajj was for surgical causes. Similar rates of
11%16 and 13%17 have been reported from other
countries.
According to our series, most of the surgical admissions
were non-traumatic, with gastrointestinal problems and
diabetic foot as the most common diagnoses. In previous
studies, exact diagnosis of patients admitted to the
surgical wards has not been listed16,17. Generally, during
Hajj, little information exists regarding the pattern of
surgical problems 19,21, and these problems are being
neglected22.
In our population, trauma was responsible for one third
of surgical admissions, and 3% of total hospital
admissions. In one study, trauma was the third most
common (9.4%) hospital admission cause17. In another
report, 3% of admissions of Pilgrims was caused by
accidents23. In our patients, from traumatic causes,
trauma to the extremities (55.6%) was the most common
diagnosis. Literature lists blunt abdominal trauma due to
traffic accidents as s common surgical cause during
Hajj. Main injuries include stampede and motor vehicle
trauma, fire-related burn injuries and accidental hand
injuries24. 60% of injuries seem to be related to traffic
accidents and 15% to Holy Haram25.
In our study, patients had a mean age of 55 years, and
one third had a somatic comorbidity. Other reports also
confirm high age for pilgrims, especially those who
admit to hospitals17,20,23,26. Old age might be a risk factor
for hospital admissions during Hajj26. In one study, 39%
of hospitalized pilgrims had at least one comorbid
condition17. In another study 1 of 4 pilgrims had somatic
chronic conditions23. The high prevalence of comorbid
somatic conditions might be secondary to the high age
of most pilgrims at Hajj rituals, especially those who are
being admitted.
In our study, about one third of the surgical patients had
DM. In a study of Hajj performers in Oman, DM was
reported by %1.6 of pilgrims27. In another study on
hospitalized pilgrims, 15% of patients had comorbid
DM26. These high prevalence rates can explain our
results that more than 20% of the surgical admissions
were due to diabetic foot. In one study, diabetic foot was
the second most common admission cause of pilgrims in
surgical wards20. These data highlights the need for
controlling DM and its complications during Hajj.
Although we did not assess the cause for diabetic foot in
the pilgrims, literature highlights the failed precautions
during the pilgrimage (missed or forgotten medication,
poor glucose control, barefoot walking within the
mosques, etc) as a common cause for diabetes
complications during Hajj28-31.
Regarding the outcome of our patients, 61.8%
discharged in good condition, 29% transferred to a more
equipped hospital, 5.5% discharged against medical
advice and 3.6% died. In another study on surgical
patients, 11.3% left hospital against medical advice and
0.5% were referred for a higher level of care20. In one
study, 0.8% of patients who had been admitted to
surgical wards during Hajj died25. In another study 80%
of the patients were discharged with stable condition,
17.3% were transferred to other hospitals in Mecca for
more specialized services, 2.3% were discharged against
medical advice and 0.7% died17. In another study, 7% of
patients died and 3% were discharged against medical
advice16. Another short-term follow up (24-48 hours) of
hospitalized pilgrims in 2002 showed 1.3% deaths, 59%
transfer to other hospitals and 40% discharged in good
condition26.
Conclusion:
Some two to three million pilgrims from all over the
globe visit Mecca and Medina during hajj period. This is
a very important event in the lives of millions of
Muslims during which each pilgrim should participate in
many religious rituals and ceremonies17. Surgical needs
should be considered as important part of health care
need of pilgrims. To improve the health care to the
pilgrims, health care planers should consider surgical
care needed by the pilgrims during Hajj.
ACKNOWLEDGEMENT
We should declare our great thanks to the
Drugs Control Headquarters in Iran for funding and
the opportunity.
Statement of Authorship:
Category 1
(a) Conception and Design: SMA; SA
(b) Acquisition of Data: MML
(c) Analysis and Interpretation of Data: SA
Category 2
(a) Drafting the Article: MML, AAZ
Surgical admissions during Hajj-Hollisaaz et al.
(b) Revising It for Intellectual Content: SA, SMA
Category 3
(a) Final Approval of the Completed Article: SMA,
MML, SA
Conflict of interest: None declared.
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www.dwepi.org
DOI: 10.14360/dwe.e0005
Table 1- Frequency of different chronic medical conditions in patients
n
%
Non coronary heart disease (e.g. arrhythmia, valvular heart disease )
13
3
23.6%
5.5%
Neurologic history
3
5.5%
Hypertension
2
3.6%
Respiratory (e.g. asthma, chronic obstructive pulmonary disease)
2
3.6%
Coronary artery disease
1
1.8%
Chronic Disease
Diabetes mellitus
Dev World Epidemiol. 2013; 1(1)
Surgical admissions during Hajj-Hollisaaz et al.
Table 2- Frequency of different causes of admission for patients admitted to surgical wards
n
%
Cause of admission
Trauma
5.6
1
Head injury
55.6
10
Extremity injury
5.6
1
Chest injury
1
Abdominal injury
5.6
2
Pelvic injury
11.1
3
Multiple trauma
16.7
18
Total
100
Non-trauma
Gastrointestinal problems
Diabetic foot
Orthopedic problems
Soft tissue problems
Others
Total
13
12
4
4
4
37
35.1
32.5
10.8
10.8
10.8
100
Surgical admissions during Hajj-Hollisaaz et al.
Table 3- Frequency of various outcomes among surgical patients
Outcome
Discharged in good
condition (Hajj Continued)
Transferred to Iran (Hajj
discontinued)
Transferred to a Hospital
in Saudi Arabia (Hajj
Continued)
Discharged against
medical advice (Hajj
Continued)
Death
Total
n
%
34
61.8
8
14.5
8
14.5
3
5.5
2
55
3.6
100.0