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The Hajj

BMJ 2011; 343 doi: http://dx.doi.org/10.1136/bmj.d5593 (Published 15 September 2011)
Cite this as: BMJ 2011;343:d5593

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21 December 2011

Elisabeth Botelho-Nevers a, Camille Aubry a, Catherine Atlan b, Philippe Gautret a*
a Institut Hospitalo Universitaire en Maladies Infectieuses et Tropicales, Hôpital Nord, AP-HM, Marseille, France.
b Department of Endocrinology, Metabolic Diseases and Nutrition, CHU Nord

*Corresponding author:
Tel: 0033 (0) 4 91 96 35 35/36
Fax: 0033 (0)4 91 96 89 38
e-mail: philippe.gautret@club-internet.fr

Diabetes and infections at the Hajj

Keeping well during Hajj is a challenge for people with diabetes, as emphasized by our colleagues Gatrad and Sheikh. 1Poor compliance with treatment, extreme temperature, strenuous physical exertion, risk of injury—particularly to the feet, which must be bare in the Mosque—and crowed conditions might affect the control of diabetes and lead to infectious complications. Among French pilgrims attending our clinic for pre-travel advice more than 21% are diabetic.2 In a study conducted over pilgrims hospitalized in a tertiary care teaching hospital in Makkah, Saudi Arabia during the 2005 Hajj, 32% of patients were diabetics and diabetes complications accounted for 4.2% of primary diagnosis and 5.5% of secondary diagnosis with a mortality rate of 11.6%. 3 Diabetic foot was one of the most common causes (16.3%) for admission to surgical wards in two general hospitals in Mina and Arafat during the 2003 and 2004 Hajj seasons. 4 In a prospective survey that we conducted over 447 French pilgrims participating to the Hajj, the attack rate of influenza like illness during their stay in Saudi Arabia was 40% in diabetic individuals compared to 25% in non-diabetic individuals (adjusted OR = 2.85 (1.37–5.92), p =0.005).5
Infectious diseases complicating diabetes in pilgrims may also be diagnosed soon after leaving Saudi Arabia, when returning at home country, as exemplified bellow. Three diabetic Hajj pilgrims were admitted to our Hospital and managed by our team of infectious diseases specialists in late November 2011, two with respiratory infection and one with a skin infection (table). Of note, the three pilgrims had a specialized pre-travel consultation at our Infectious disease out-patient unit before departing and received recommended vaccinations (with the exception of influenza vaccination that was not yet available in France before the date of first departures to the Hajj). They also received information and documents about face-mask and disposable handkerchief use, and hand hygiene, but no specific information about control of diabetes during the Hajj. In one case, the diabetes treatment was disrupted during the Hajj. All three patients had uncontrolled diabetes at admission. Several diabetes units in the UK are now holding pre-Hajj education seminars. 6 We are planning to organize in the next future global pre-Hajj advice for diabetics including a consultation with a diabetologist, a nurse specialized in therapeutic education for diabetics and a consultation with a specialist in travel medicine. Information about glucose control, insulin or oral antidiabetic medications, nutrition, hydration, prevention of diabetic foot ulcers, information about physical measures aiming to prevent gastro-intestinal and pulmonary infections, and vaccinations will be provided.

1.Gatrad AR, Sheikh A. The Hajj. BMJ 2011;343:d5593. (15 September.)
2. Gautret P, Parola P, Brouqui P. Risk factors for H1N1 influenza complications in 2009 Hajj pilgrims. Lancet. 2010 Jan 16;375(9710):199-200.
3. Khan NA, IshagAM, Ahmad MS, El-Sayed FM, Bachal ZA, Abbas TG. Pattern of medical diseases and determinants of prognosis of hospitalization during 2005 Muslim pilgrimage Hajj in a tertiary care hospital.A prospective cohort study.Saudi Med J. 2006 Sep;27(9):1373-1380.
4. Salamah SM. General surgical problems encountered in the Hajj pilgrims.Saudi Med J. 2005 Jul;26(7):1055-1057.
5. Gautret P, Yong W, Soula G, Gaudart J, Delmont J, Dia A, Parola P, Brouqui P. Incidence of Hajj-associated febrile cough episodes among French pilgrims: a prospective cohort study on the influence of statin use and risk factors.ClinMicrobiol Infect. 2009 Apr;15(4):335-40.
6. Figueira E. Diabetes and the pilgrimage of Haj: Piloting ofan education programme formuslim patients with diabetes. Diabetes Today 2003; 6: 41–42.

Competing interests: None declared

PHILIPPE GAUTRET, Travel Medicine Specialist

Elisabeth Botelho-Nevers, Camille Aubry, Catherine Atlan

aInstitut Hospitalo Universitaire en Maladies Infectieuses et Tropicales , Hôpital Nord, AP-HM, Marseille, France.

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Thanks to Gatrad & Sheikh for keeping the topic of the Hajj on the agenda, and for their series of informative articles on management of Muslim people's health. Trish Greenhalgh is right to say that any 'patient information' should be designed in a culturally (and religiously) sensitive fashion and I like her suggestions. In fact, it is not just the doctor and the patient who need this advice - much travel medicine advice is given by nurses, and the pharmacist plays (or should do) a significant role in advising people about their medication.

Shaghahi also reminds us that this is an international issue - and of course, there are a variety of 'Islamic health and Advice' websites, of varying authority. The question is, perhaps, what 'sponsorship' would give such guidance more universal acceptance and sustainability, since in the past I have seen many excellent 'health information' resources of the type Greenhalgh advocates, which have been separately developed in multiple places, and/or lost to memory and access when their short-term funded hosts (this includes many NHS bodies) have disappeared.

Maybe we can keep this debate going until it becomes an essential element of all clinical education curricula - although given the progress in these since the research I was involved in, way back in 1987 (1), I shall not hold my breath.

Reference: 1 'Medical teaching of the cultural aspects of ethnic minorities' Medical Education 20, pp492-497 1987 (J Poulton, G Rylance, Johnson MRD)

Competing interests: Dr Johnson is in fact trying to bring together relevant experts to compile a guideline on this topic

Mark RD Johnson, Professor of Diversity in Health

Mary Seacole Research Centre, De Montfort University

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As Professor Trisha Greenhalgh (Professor of Primary Health Care, Queen Mary University of London) stated (written communication, 17 Sep 2011), advising Muslims who are planning to perform their religious compulsory travel to Mecca is a provoking task for health professionals in many multi-ethnic and multi-religious societies. Professor A R Gatrad and Professor A Sheikh tried to highlight routine health assessments that GPs should be aware when approaching Muslims who come for medical advice before making their pilgrimage. (1) This is while, both in Muslim and non-Muslim countries, academic curricula are lacking formal educational topics to bring Hajjis' health assessments to the view of trainees and indeed future practitioners. This is even pivotal in non-Muslim countries where non-Muslim trainees naturally may not have real life experience or knowledge of the health constraints a pilgrim may face in performing his/her religious travel.

Muslims are now a sizable subgroup of populations in many non-Muslim countries and their health and equal access to the health care is an ethical mandate for health care systems. (2, 3) Thus to ensure hajjis' health and prevent several risks this travel may impose, formal training to cover all aspects of health risks including epidemiology of new emerging or re-emerging diseases (4) on the occasion of Hajj are needed.

In many educational institutions currently the offered educational curricula do not comprise this important aspect of community health and they should be revised to fulfil all sub-sections of populations' needs equally.

Dr A Shaghaghi
1 Head of the Medical Education Research Centre, R & D Campus, Tabriz University of Medical Sciences, PC: 5165665811, Tabriz, Iran. (Email: shaghaghir@tbzmed.ac.ir, ar.shaghaghi@gmail.com),
2 Assistant Professor of Community Health, Health Education & Promotion Department, Faculty of Health & Nutrition, Tabriz University of Medical Sciences, PC: 5166614711, Tabriz, Iran.


1. Gatrad AR, Sheikh A. Hajj: journey of a lifetime. BMJ 330:133 doi: 10.1136/bmj.330.7483.133.

2. Sheikh A. Should Muslims have faith based health services? BMJ 334 :74 doi: 10.1136/bmj.39072.347720.68.

3. Laird LD, Amer MM, Barnett1 ED, Barnes LL. Muslim patients and health disparities in the UK and the US. Arch Dis Child 2007;92:922-926 doi:10.1136/adc.2006.104364.

4. Gatrad AR, Shafi S, Memish ZA, Sheikh A. Hajj and the risk of influenza. BMJ 333 :1182 doi: 10.1136/bmj.39052.628958.BE.

Competing interests: None declared

Shaghaghi, Assistant Professor of Community Health

Tabriz University of Medical Sciences,Medical Education Research Centre&Faculty of Health&Nutrition

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Well done on an excellent piece on how to advise patients on the Hajj - an increasingly common scenario in general practice in multi-ethnic areas. Many patients who consult me about the Hajj are limited English speakers, and some are understandably suspicious about advice offered by a white non-Muslim. What we need more than anything else is a set of downloadable leaflets in the priority languages (Arabic would be a good start) which we can download and pass to patients so as to reinforce advice. Those leaflets must begin not with a medical statement but with an appropriate acknowlegdement to Allah (otherwise people won't take them seriously).

This would surely be an excellent initiative for an interdisciplinary student group. The medical students could adapt this article into a patient advice leaflet, linguists could translate it, art/design students could make it visually appealing, and students of Islam could address cultural/religious sensitivity. A patient panel for advice and piloting would be essential. Perhaps the BMA, Wellcome Trust, RCGP or some similar organisation might provide some financial suppport?

Competing interests: None declared

Trisha Greenhalgh, Professor of Primary Health Care

Queen Mary University of London

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