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Rapid Responses: Rapid Responses published:
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A Misconception
- Syed Rashid Ali (14 January 2005)
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Hajj Pilgrimage
- Das.S.P Sabapathy (14 January 2005)
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Where is the evidence for increased risk of HIV during Hajj?
- Wasim Hanif (17 January 2005)
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Some more misconceptions
- Ali Akbar (18 January 2005)
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Malaria prophylaxis is not a requirement
- N M ALY (18 January 2005)
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Health risks during Hajj. Are they enormous?
- Shahid Barlas, (Previously Consultant Physician, King Abdul Aziz Hosptal & Oncology Center, Jeddah, Saudi Arabia.1983-2003) (19 January 2005)
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Education and information is important for the pilgrims
- Jamal Hossain (19 January 2005)
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Balancing the concern
- Shalina Akther (28 January 2005)
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FITS, FEVER AND FOREIGN TRAVEL: AN INSTRUCTIVE CASE
- Haitham El Bashir, Kamal Ali, Robert Booy (4 February 2005)
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Syed Rashid Ali, Consultant Physician Dibba Hospital, Dibba AlFujairah, UAE 11560
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The author stated in the section of General Advice that ' menstruating women are not permitted to perform the Hajj'. The only obligatory part in the whole ritual of Hajj is to be within the boundries of the plains of Arafat on the 9th of Zil Hijja at sunset, even if it is for a short while. Saudi Authorities therefore make special arrangements to take everyone, even hospitalised patients, who have come with the intention of performing Hajj, to Arafat on this date. Likewise, in Islamic Law there is no prohibition for a mentstruating woman to spend that crucial period there. She can perform the rest of the rituals later when her menses have ended. Competing interests: None declared |
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Das.S.P Sabapathy, Retired Nil
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During the time I was a part-time family physician in sri lanka, during the Hajj season, several muslim women and/or their husbands requested advice on prevention of menstruation during the pilgrimage. On my advice, they commenced taking oral contraceptive tablets before the commencement of the journey and stopped taking them on return.All of them were quite satisfied with this intervention. Competing interests: Nil |
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Wasim Hanif, Consultant Physician University Hospital Birmingham University Hospital Birmingham B29 6JD
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The authors in the article mention about the possiblity of increased risk of HIV and Hepatiits B during Hajj and the probable source they claim is sharing of blades during shaving of head. Interestingly the authors do not provide any referrence to that claim. I searched the Medline using the words Hajj and HIV and did not come across a single paper showing an increased risk of HIV during the Hajj season. During their visit to Mecca the authors would have noticed that most barbers tend to use disposable blades which they change before each shave. In this day of evidence based medicine it would have been better if the authors had referrenced such an important article well. Competing interests: None declared |
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Ali Akbar, Consultant Paediatrician City Hospital, Dudley Road, Birmingham. B18 7QH. UK
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I have read this article with great interest and I must congratulate the authors on providing useful practical information. There however remain some additional misconceptions, in addition to those already commented upon. The authors equate wearing of the Hajj dress to performing a dress reherasal for the final standing before God on Judgement Day. This is not mentioned anywhere in the islamic literature. In fact the wearing of two plane sheets is equivalent of the burial dress for the Muslims, and not for the Day of Judgement. I also disagree with authors that most health professionals are unaware of what the Hajj entails. There has been a concerted effort to organise educational programmes for the intended pilgrims and a considerable workforce of NHS is from the Indian Subcontinent, very aware of the Hajj background and its practical implications. Authors advise "good quality" footwear, but forget the fact that men can only wear certain type of shoes which would not meet their intended advice. Competing interests: None declared |
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N M ALY, Consultant Physician University Hospital Aintree, Liverpool L9 7AL
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The authors in the article mention that vaccination against hepatitis A and malaria prophylaxis, together with advice on measures to minimise the risk of exposure, are important. I’ve checked the BNF section on malaria prophylaxis (BNF September 2004; edition 48-section 5.4.1:page 326 -328) and it is clearly stating that “no risk in Mecca” and very little risk in the western border cities. Since most of the Hajj rites are performed in Mecca and the surrounding area, I don’t see any indication for malaria prophylaxis.In addition, the Suadi embassy web site, although has not been updated since last Hajj season, is not mentioning malaria prophylaxis as a requirement for Hajj visa to be issued and insisiting only on the quadrivalent ACYW meningitis vaccine. Perhaps the authors need to clarify the exact source of this advice. One more point, reference “13” is not related to the statement in the article about heatstroke treatment, and probably reference”14” is the true evidence for this line of management. Competing interests: None declared |
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Shahid Barlas, Concultant Physician( Locum) Bellford Hospital,Fort William, PH34 4EX, UK., (Previously Consultant Physician, King Abdul Aziz Hosptal & Oncology Center, Jeddah, Saudi Arabia.1983-2003)
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The authors in the article mention enormous health risks for pilgrims during Hajj. However on ground things have changed dramatically due to awareness of travel epidemiology, prophylactic measures and excellent health care facilities. Recent major health hazards have been due to stampede and fires. The last major epidemic of meningococcal meningitis was in 1987(1).Since then mandatory vaccination initially with bivalent (A & C) and more recently with quadrivalent vaccine (A, C, Y, W135) has virtually eliminated the epidemics amongst pilgrims. Limited outbreaks with W135 strain has been witnessed in many countries and not all of them are in returning pilgrims or their close contacts. WHO does not recommend malaria prophylaxis in Mecca and Madinah. No reference has been given for advising for vaccination against hepatitis A, hepatitis B, polio, diphtheria, tetanus and typhoid. Though the precautionary advice is very pertinent, heat stroke or heat exhaustion is extremely unlikely in present weather and for many years. Direct exposure to sun is not essential as heat stroke can develop in hot, humid room overcrowded with pilgrims. Absence of sweating is one of the cardinal symptoms of heat stroke and I will add it in box 5. Invariably all pilgrims suffer from viral upper respiratory tract infections (URTI) and there is no way to escape from it. URTI can be quite debilitating as they occur in the final days of Hajj when pilgrims are extremely exhausted. References: Barlas.S.,Chaudhry.S.A.,Safdar.M.Al Rashid.,Ahamad.T.,Hasmi.I.A. Clinical Profile of Meningococcal disease in 99 patients. Annals of Saudi Medicine. May 1993. 13 (3) 237-241 Competing interests: None declared |
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Jamal Hossain, Consultant Physician William Harvey Hospital, Ashford, Kent TN24 oLZ
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Dear Sir, This is a timely review for major health hazard during a mass congregation in Mecca. I was privileged to serve as a Hajj doctor in heat stroke unit during my tenure at King Khalid University Hospital, Riyadh in 1983-84 Hajj pilgrimmage. My own observation was that the majority of pilgrims came from developing countries and mostly of low socioeconomic group with very little educational background and information about health hazard posed during Hajj by the governments. The major problem was upper respiratory tract infection and it is still prevalent as highlighted by Balkhy HH et al(1). Secondly, sanitation facilities although may have improved over the years , because lack of personal hygiene it remains a health risk such as diarrhoeal illness. The pilgrims eat undercooked meat and carry some of the sacrificial meat to their individual country after soaking it in the hot sun on the top of individual tents. Although indidual governments provide medical teams attached to the pilgrimmage group, the vast number of pilgrims outnumber the medical profession. Thirdly, during the Hajj, mass emotional scenes dawn amongst people from developing counties and tend ignore whatever medical advice is provided as the authors state about head cover and adequate water intake. Although neurological complications due to heat stroke are minimal and few cases of fatality had been reported by BA Yacoub(2), I personally observed a young male die of cerebral haemorrhge due to coagulation disoder. My impression is that educational information by both the host country and individual government must make joint effort to educate the mass to minimise the health hazard. References: 1.Balkhy HH, Memesish ZA et al. Influenza a common viral infection among Hajj pilgrims: time for routine survillance and vaccination: J Infection .1998May ;36(3) 303-6. 2. BA Yacoub.J Trvel Medicine.2004 Mar-Apr;11(2):82-6 Competing interests: None declared |
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Shalina Akther, Medical student Leeds university
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I have read the clinical review with much interest. On the whole I feel that the paper raises important health issues that should be considered by those people intending to do the Hajj and their respective GPs and healthcare advisors. Dehydration and sun/heat exposure related conditions are easily managed by those who are made aware of the simple measures to take to maintain health during the pilgrimage. It is clearly apparent that the majority of acute morbidities that occur during the Hajj time are due to the two aforementioned aetilogical categories. Aside from this I dont think that the extent of disease or potential illness should be considered by any persons as deterrants for completing the Hajj. My advice is that those PCTs serving relatively significant populations of Muslims should work together to educate GPs and their fellow healthcare professionals upon educating their Muslim patients with regards to suitable measures to maintain optimum health during Hajj. The most important point is that this is done so in a sensitive, careful manner because the sense of spirituality in all potential pilgrims is at such a peak and is so saturated with the intent to do the Hajj whole heartedly and at all costs, that health at the pre-hajj time can seem superficial and overlooked and only really considered having returned to their home countries. Prevention IS better than cure, so lets tackle this carefully! Competing interests: None declared |
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Haitham El Bashir, Clinical Lecturer in Community Paediatrics Research Centre for Child Health, St Bartholomew’s and The London School of Medicine and Dentistry, Kamal Ali, Robert Booy
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The article Hajj: journey of a lifetime (BMJ 2005; 330:133-7) focused on particular heath risk issues associated with Hajj. Pilgrims come to Hajj from all over the world bringing and contracting many illnesses including serious infectious diseases such as meningitis, influenza and tuberculosis. Such illnesses not only pose risks to pilgrims but may spread on return to their home countries to their households and local communities. This case report describes 2 siblings who developed meningitis due to serogroup W135 Neisseria meningitidis, 2 weeks following their father return from the Hajj. A previously healthy 18-month female was referred to our hospital in March 2004 by her general practitioner (GP) following a one day history of fever and photophobia and a short generalised seizure. GP treatment included intravenous lorazepam and intramuscular penicillin. She was up to date with her immunisations including 3 doses of meningococcal serogroup C conjugate vaccine. On examination, she looked ill but well perfused. The pulse was 139/min, respiratory rate 40/min, temperature 38.2ºC and oxygen saturation in air 98%. She had photophobia, hyper-extended neck, arched back and was extremely irritable. There was no skin rash. The rest of her physical examination was unremarkable. Investigation showed a peripheral white blood cell count of 18.4x109/L (74% neutrophils), C-reactive protein (CRP) 197mg/l (normal range 0-8mg/l). Cerebrospinal fluid (CSF) white cell count was 436; CSF glucose 3.9 mmol/l; protein 505 mg/dl and Gram stain was negative. CSF latex agglutination tests for Streptococcus pneumoniae, Neisseria meningitides, Escherichia Coli and Haemophilus influenzae type b were all negative. Immunoflourescence screening was negative for respiratory syncytial virus, influenza A, influenza B, adenovirus and parainfluenza virus. Brain computerised tomography scan was normal. The following day, her younger sister (7 months old) presented directly to the hospital with similar symptoms. She too was up to date with her immunisations and had no significant past medical history. On examination she was fully conscious but irritable. Her heart rate was 210/min, respiratory rate was 44/min and her axillary temperature was 39ºC. She had neck stiffness, arching of the back and a bulging anterior fontanelle. There was no skin rash and the rest of examination was normal. CSF white cell count, glucose and protein concentrations were within normal limits. CSF Gram stain was negative. At this point a travel history was looked into; the father had been to the Hajj four times before, most recently having returned 2 weeks prior to the children’s presentation. He had received the meningococcal quadrivalent polysaccharide vaccine (A, C, Y and W135) in December 2002. Despite lack of rash in both children, meningococcal disease was clinically deemed highly likely and appropriate treatment begun. Polymerase chain reaction (PCR) on the CSF sample of the first case proved positive for meningococcus W135; 2a:P1.2, 5 and the blood culture from her sister grew the same W135 strain. Throat swabs from the father and a 3-year-old brother grew N.meningitidis (W135: 2a:P1.2, 5.) Complement tests and immunoglobulin levels for both cases were normal suggesting an undisturbed humoral defence, and intact classic and alternative complement pathways. As the parents were cousins, the possibility of homozygous mannose binding lectin (MBL) deficiency was investigated; one child proved to heterozygous and the other was wild-type.1 Both children were treated with intravenous ceftriaxone, and both improved quickly and went home after a week of treatment. Close contacts were given oral rifampicin and the 3 year old brother was given the meningococcal quadrivalent polysaccharide vaccine. Meningococcal serogroup W135 was recently responsible for worldwide outbreaks of meningococcal disease among Muslim pilgrims and their close contacts. The case fatality rate (CFR) from the outbreak strain (W135;2a:P1.2, 5) was observed to be high compared to other serogroups.2 Although vaccination can protect pilgrims against invasive meningococcal disease, it is unlikely to prevent acquisition of carriage in vaccine recipients,3 and therefore returning pilgrims represent an ongoing threat to the community. Since both sisters were less than 2 years of age, the quadrivalent polysaccharide vaccine would have had little effect in the prevention of these cases because of the poor immunogenicity of polysaccharide vaccines in younger children.4 The father’s travel history was key to the diagnosis in these cases who had clinical meningitis but without a rash to suggest meningococcal disease. A travel history should be obtained in any febrile child; it may point to the diagnosis earlier. Further teaching points include, i) the finding of a completely normal CSF result despite clear clinical signs of meningitis; a lumbar puncture performed very early in the clinical course can give a misleadingly normal result,5 and ii) multiple cases of meningococcal disease in a family should prompt enquiry regarding consanguinity and testing for immune deficiency. Our first case was treated with penicillin in primary care before referral to the hospital, a practice that is strongly recommended for cases of suspected meningococcal disease. Awareness of increased risk of serogroup W135 disease among the Muslim community and the contacts of returning pilgrims is important for early recognition of the disease. REFERENCES 1.Hibberd ML, Sumiya M, Summerfield JA, Booy R, Levin M, Meningococcal Research Group. Association of variants of the gene for mannose –binding lectin with susceptibility to meningococcal disease. Lancet 1999; 353:1049-53. 2.Hahne SJM, Gray SJ, Aguilera JF, Crowcroft NS, Nicholas T, Kaczmarski EB, Ramsay ME. W135 meningococcal disease in England and Wales associated with Hajj 2000 and 2001. Lancet 2002; 359:582-3. 3.Rosenstein NE, Perkins BA, Stephen DS, Popovic T, Hughes JM. Meningococcal disease. N Engl J Med 2001; 344:1378-88. 4.van Deuren M, Brandtzaeg P, van der Meer JWM. Update on meningococcal disease with emphasis on pathogenesis and clinical management. Clin Microbiol Rev 2000; 13:144-66. 5. Onorato IM, Wormser GP, Nicholas P. 'Normal' CSF in bacterial meningitis. JAMA 1980; 244:1469-71. Competing interests:
None declared
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