The HajjBMJ 2011; 343 doi: http://dx.doi.org/10.1136/bmj.d5593 (Published 15 September 2011) Cite this as: BMJ 2011;343:d5593
- A R Gatrad, consultant paediatrician and honorary professor1,
- A Sheikh, professor of primary care research and development2
- 1Manor Hospital, Walsall and University of Kentucky, Lexington, KY 40506
- 2Centre for Population Health Sciences, The University of Edinburgh, Edinburgh EH8 9DX
- Correspondence to:
- Accepted 12 August 2011
A 68 year old Muslim man with diabetes, which is reasonably well controlled on twice daily insulin and who has a history of myocardial infarction 12 months previously, wants advice on his fitness to go on pilgrimage (the Hajj) to Mecca.
What you should cover
Explore his understanding of the Hajj
Hajj is one of the five pillars of Islam that is compulsory for every Muslim, once in a lifetime. Is he aware that those who are physically unable to perform the Hajj because of illness or infirmity are exempt from going?
Does he experience angina?
Ask if he has chest pain at rest or on exertion. More than 40% of deaths during Hajj are related to cardiovascular disease.1
Does he appreciate the possible effects of heat, physical exertion, crowds, and altered routine on his health?
Annually, more than two million people travel to Mecca during Hajj and this results in overcrowding.2 The Hajj rituals might, depending on the time when Hajj falls, need to be undertaken in extreme temperatures that can reach more than 45°C.2 Dehydration and heat stroke are particular risks,3 and they are exacerbated by the strenuous physical exertion associated with performing the various Hajj rites.2 For example, the seven circuit circumambulation around the Ka’ba (the centre point of the Grand Mosque) can—because of the crowds—take several hours. This ritual could also expose him to risk of injury—particularly to his feet, which must be bare in the Mosque—and airborne respiratory infections.2 The altered daily routine and increased exertion might affect the control of his diabetes and ischaemic heart disease.
Has he been vaccinated?
After outbreaks of meningitis in pilgrims, the quadrivalent meningococcal A, C, Y, and W-135 vaccine is now a mandatory requirement for a Hajj visa.4 5 Ask if his influenza,6 pneumococcus, typhoid, hepatitis A, hepatitis B, and other childhood vaccinations such as polio, are up to date.2
Will he be travelling elsewhere after the Hajj?
After the Hajj many people travel on to their countries of origin. Further related travel advice and vaccination might be needed—for example, for malaria.
What you should do
Assess whether it is safe for him to travel taking into account, among other things, his age, and mental and physical health. If your assessment is that it is not, make this clear because medical exemptions are meant to be religiously binding and could help remove any feelings of guilt associated with not performing Hajj. Postponing the Hajj for a few years might be appropriate in those with recent myocardial infarction. The Hajj period alters by 10 days each year so he could choose a period when the weather is more tolerable. Be prepared to accept that he might travel against your advice.
Advise him to gradually increase physical activity—for example, building up to walking a few miles a day—before he travels.
Explain the need to ensure adequate diabetic control by eating regular meals, maintaining good compliance with treatment, and frequent checking of blood sugar. Provide him with a letter detailing his diagnosis and his need to carry syringes and needles through airports, and remind him to store insulin away from direct sunlight. The time difference between—for example, the UK and Saudi Arabia is 2-3 hours. Generally, time zone changes of less than four hours do not require major alteration in the injection schedule.7 With the advent of the basal bolus regimen less disruption should occur when crossing time zones.8
Discuss strategies to avoid heat and dehydration—for example, avoiding the midday sun, using an umbrella to reflect the sun (head coverings are prohibited for men during the Hajj), and always to have access to ample water.
Explain that exposed skin needs protection with a high factor sun cream. Walking long distances in the heat can cause the groin area to get irritated with associated risk of fungal infection; a barrier agent such as petroleum jelly can help. Emphasise the importance of appropriate footwear and explain that it is easy to burn or injure feet by walking barefoot on hot sand.
Advise against visiting roadside “barbers”—shaving the head is a ritual marking the end of the Hajj—and to use designated ones. He should insist on use of a new blade to minimise the risk of acquiring blood borne infections.9
Arrange for him to be vaccinated against meningococcus at least 10 days before he travels, and discuss the merits of the new conjugated vaccine.4 Recommend the need for typhoid and hepatitis A vaccines, and any others that could be relevant if there are plans for onward travel. Offer the flu and pneumococcal vaccines.2 10
Ensure that he has adequate supplies of drugs and that he is aware of the need to seek medical help if he develops fever, headaches, photophobia, jaundice, or diarrhoea, particularly on his return.
Essential medical travel kit for those travelling on Hajj
Clove oil for toothache
Drugs regularly used
Oral rehydration salts
Plasters, bandages, scissors
A white umbrella, sunglasses
Water sterilisation tablets
Cite this as: BMJ 2011;343:d5593
This is part of a series of occasional articles on common problems in primary care. The BMJ welcomes contributions from GPs
Acknowledgments: We are grateful to the peer reviewers for their constructive comments on an earlier draft of this manuscript.
Contributorship: ARG conceived this paper. AS and ARG both contributed to writing the paper and are joint guarantors.
Conflict of interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and AS declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years. ARG is on a panel of experts which include members of the Muslim Doctors and Dentists Association (MDDA), the Meningitis Trust, and Novartis which produces Menveo meningococcal vaccine; he gives lectures sponsored by the MDDA and Novartis on health at Hajj.