WHOLE1.indd ABSTRACT Objective: To analyse the pattern of patients attending the Out Patient Department (OPD) during the Hajj season 423H with respect to their age, sex, nationality, services provided to them, and most importantly the disease trends and the medica- tion given. Method: A descriptive study was done at the OPD department in Al-Noor Specialist Hospital, Holy Makkah for the 5 days period of the Hajj, i.e., -5 /2/423 corresponding to 2-6/ 02/2003. All patients who arrived at the OPD during that time whether on Hajj or non-Hajj and those who registered at OPD service became part of our study. With the help of standard “Blue Form”(provided annually by Ministry of Health exclusively for the OPD patients for every Hajj season), their age, sex, nationality, clinics attended, diagnosis and medications were noted. Results: The results revealed that 3876 patients arrived and 3856 got registration at OPD. Of the registered cases, 282 (33%) were Hajj patients and of those 873 (22%) were males. The Hajj patients were mostly non-Saudi (30.8%). The majority of patients, 384 (26.%), were from the Middle East. The largest category, 240 (6.2%), of Hajj patients were in the age range 5-60 years. The medical clinic was the one attended by the maximum number of patients, 675 (43.4%), and respiratory disease cases, 582 (4%), were the commonest. Single medication as monotherapy accounted for 3644 (94.5%) of patients. Conclusion: Non-Hajj patients were in the majority at OPD. Respiratory diseases were the commonest complaints. This study highlights a precarious situa- tion during the Hajj where cross-infection proliferates in a dense population. Effective services and preventative measures need to be contemplated in the light of the present finding. Key Words: Hajj, Hajj season, Out Patient Department (OPD), Ministry of Health (MOH), Antibiotics. Outpatient Services during (423h) Hajj Season *Haani A S Shakir, Zohair J Gazzaz, Khalid O Dhaffar and Javeria Shahbaz SULTAN QABOOS UNIVERSITY MEDICAL JOURNAL JUNE 2006 VOL 6, NO. 1 SULTAN QABOOS UNIVERSITY© HAJJ IS A ISLAMIC PILGRIMAGE OF MUSLIMS, when around two million muslims gather for a period of about six weeks between the Holy cities of Makkah and Medina in Kingdom of Saudi Arabia (KSA).1 The Hajj season is the time of maximum population in every sector of life in Saudi Arabia especially the Holy Makkah region. The medi- cal services are one of the most affected sectors of the administration of the Holy Capital. As Hajj has to be completed in a specified period of time, and many of the pilgrims use their lifetime savings for this purpose, they are often reluctant to seek early medical advice as Health Research Centre, Al-Noor Specialist Hospital, P.O. Box 6251, Holy Makkah, Kingdom of Saudi Arabia *To whom correspondence should be addressed. Email: hrd_alnoor@yahoo.com O R I G I N A L S T U D Y (١٤٢٣ للهجرة) احلج موسم اخلارجية خالل العيادة خدمات باجلنس، يتعلق فيما للهجرة ١٤٢٣ لسنة احلج موسم خالل اخلارجية العيادة قسم راجعوا الذين املرضى نوع حتليل و دراسة الهدف: امللخص: اخلارجية العيادة قسم في الوصفية الدراسة هذه الطريقة: أجريت العالج. ونوع األمراض نزعة ذلك من أهمية املقدمة، واألكثر واخلدمات اجلنسية، كل .٢٠٠٣ /٢/ ٢-١٦ من املوافق /١٤٢٣ للهجرة ١٢/ ١-١٥ من أي ١٥ يوما، البالغة احلج فترة خالل مبكة املكرمة التخصصي مستشفى النور في سجلنا البحث. هذا مادة شكلوا العيادة تلك في سجلوا والذين غيرهم من أو احلجاج من كانوا سواء اخلارجية العيادة إلى قدموا الذين املرضى وزارة قبل من اهزة -القياسية- الزرقاء االستمارة في والعالج والتشخيص زيارتها مت التي والعيادة واجلنسية واجلنس بالعمر املتعلقة املتغيرات ٣٨٥٦ سجلوا وأن املستشفى زاروا ٣٨٧٦ مريضا أن النتائج النتائج: أظهرت احلج. مواسم في العيادة اخلارجية ألقسام فقط واصصة الصحة سنويا السعوديني غير من احلجاج املرضى معظم الذكور. من (٪٢٢) ٨٧٣ احلجاج، منهم من كانوا (٪٣٣) ١٢٨٢ هؤالء املسجلني، من اخلارجية. العيادة في العيادة حصلت ٥١-٦٠ سنة. بني (٪٢٢ - مريضا ٢٤٠) انتشارا األكثر مدى العمر كان .(٪٢٦٫١) ٣٨٤- األوسط دول الشرق من والغالبية .(٪٣٠٫٨) .(٪٤١ -١٥٨٢) انتشارا األكثر التنفسي اجلهاز حاالت كانت بينما ، (٪٤٣٫٤ - (١٦٧٥مريضا املرضى من عدد أكبر على الباطنية لألمراض اخلارجية أن غريبا وليس احلجاج، غير من اخلارجية العيادة زاروا الذين املرضى غالبية كانت اخلالصة: .(٪٩٤٫٥ -٣٦٤٤) كان األكثر شيوعا بدواء واحد العالج ٪٥٫٥ فقط . املضادات احليوية هي وصفا األكثر األدوية غيرها. من األكثر انتشارا كانت األمراض التنفسية .١:٨ غيرهم إلى السعوديني املراجعني نسبة أو السعوديني غيرهم من أما فقط، للحجاج مخصصة احلج موسم في تكون اخلدمات أن السبب نوصي لهذا دواء. من أكثر استخدموا املرضى من كاهل املستشفيات التخفيف عن إلى وجهة نظرنا سيساعد من هذا اخلفيفة. احلاالت لعالج األولية الصحية املراكز مراجعة فاألفضل احلجاج غير الرعاية املطلوبة. تقدمي في كفاءتها على إيجابا ما سينعكس وهذا الساعة مدار على اخلدمات تقدم التي الكبيرة H A A N I A S S H A K I R , Z O H A I R J G A Z Z A Z , K H A L I D O D H A F FA R A N D J AV E R I A S H A H B A Z 48 this might affect their tight time schedule. When they do seek medical advice, they are always in a hurry to leave the hospital so as to avoid missing any of the Hajj rituals.2 ,3 so the percentage of illnesses increases dur- ing the Hajj season. Even the KSA residents who are not performing the Hajj also suffer perhaps due to the population increase and cross-infection. M E T H O D Al-Noor Specialist Hospital is one of the largest and most renowned tertiary care hospitals in the Western region of the KSA. This study was conducted in the OPD of Al-Noor Hospital for a period of 15 days i.e., 1st of Dhu Al-Hijjah 1423 Hejre to 15th of Dhu Al-Hi- jjah 1423 Hejre (2-16 February 2003). All the cases either coming directly or referred from other primary or secondary health care units to OPD were included. The data was collected from the standard “Blue Form” which was provided annually by Ministry of Health (MOH) for every season. These forms were collected, the data was processed and then analyzed on a daily basis. The information includes the age, sex, national- ity, diagnosis, referred clinic and the prescribed medi- cations. R E S U L T S Approximately 3876 patients arrived at OPD for that period of Hajj and 3856 patients got registrations. Only 20 (1%) were not registered because these pa- tients could not get the standard “Blue Form” or for some other reason. Thus we interpreted the data of registered OPD (n=3856) patients. Table 1 shows that, of 3856 patients, 1282 (33%) were Hajj patients and 2574 (67%) were non Hajj patients. Among the Hajj patients 837 (22%) were males and 445 (11%) patients were females showing the ratio of 2:1 respectively. In non Hajj patients, males dominate over females (1536 (40%) males, and 1038 (27%) females). The OPD pa- Characteristics Hajj patients Non-Hajj patients Total n=1282 % n=2574 % n=3856 % Sex Male 837 22 1536 40 2373 62 Female 445 11 1038 27 1483 38 Nationality Saudi 38 1 2175 56.4 2213 57.4 Non Saudi 1191 30.8 281 7.3 1472 38.2 Unknown 53 1.4 118 3.1 171 4.4 Age in Years <1 1 0.0 34 0.9 35 0.9 1-25 150 3.9 1020 26.5 1170 30.3 26-30 104 2.7 386 10.0 490 12.7 31-35 134 3.5 154 4.0 288 7.5 36-40 161 4.2 247 6.4 408 10.6 41-45 190 4.9 289 7.5 479 12.4 46-50 194 5.0 197 5.1 391 10.1 51-60 240 6.2 146 3.8 386 10 61-65 71 1.8 81 2.1 152 3.9 >65 37 1.0 20 0.5 57 1.5 * Age groups confined to “Blue Form” officially Table 1. Demographic data of 3856 registered outpatients during Hajj 1423H Regions of the world Hajj pts Non-Hajj pts Total n % n % n % Middle East 384 26.1 58 3.9 442 30.0 Subcon- tinent 268 18.2 142 9.6 410 27.9 South East Asia 147 10.0 49 3.3 196 13.3 Arabian Gulf 190 12.9 5 0.3 195 13.2 Sub Sahara 120 8.2 25 1.7 145 9.9 Former So- viet Union 41 2.8 1 0.1 42 2.9 Western Countries 41 2.8 1 0.1 42 2.9 Total 1191 80.9 281 19.1 1472 100 Table 2. Regional distribution of Non Saudi, Hajj & non Hajj Outpatients during Hajj season 1423H O U T PAT I E N T S E R V I C E S D U R I N G ( 1 4 2 3 H ) H A J J S E A S O N 49 tients’ nationality question revealed that 2213 (57.4%) were Saudi. Among the Saudia, 38 (1.0%) were Hajj patients and 56.4% were non Hajj patients, whereas in non-Saudi patients 1191(30.8%) were Hajj patients and 2819 (7.3%) were non Hajj patients. The age of the patients was recorded according to the age groups in the “Blue Form”. Among the Hajj patients, the larg- est category, 240 (6.2%), was in the age group 51-60 and among the non-Hajj patients the majority, 1020 (26.5%), were in the younger age group 1-25, as shown in Table 1. The nationalities of non-Saudi cases were classified into seven groups according to geographical zones: Middle East, Indo-Pak subcontinent, South East Asia, Gulf and Arabian Peninsula, African countries, West- ern countries and Russian states. The majority, 442 (30%), were from the Middle East as shown in Table 2. Table 3 presents the different clinics attended by Hajj and non-Hajj patients. The maximum load was on the Medical clinic with 1675 (43.4%) patient visits and the least burden was on the Psychiatry clinic. As to the diseases or diagnoses found, the largest number of patients came with respiratory diseases, 1582 patients (41%), and the smallest number with diseases of the ear and mastoid process, 67 patients (1.7%). There were 21 groups of diagnosis according to the CD 10 coding system. The ten diagnoses with more than 1% patients are shown in Table 4. Last but not least, the medications given by the OPD doctors were also noted. The medicines recom- mended in the “Blue Form” provided by the Ministry were dispensed. The data collected for medication re- vealed that 3644 (94.5%) patients used medicine as a single therapy. Looking into individual medicines, the most commonly used were antibiotics and then anal- gesics in descending order as shown in Table 5. The remaining 5.5% patients were using medicines in com- bination of two or more than two drugs. D I S C U S S I O N Our study was of short duration and restricted to OPD but it gives a reflection of the pattern of patients dur- Clinics attended by pts Hajj Patients Non-Hajj Patients Total n % n % n % Medical 636 16.5 1039 26.9 1675 43.4 Ear, Nose and Throat 148 3.8 245 6.4 393 10.2 Orthopedic 148 3.8 159 4.1 307 8.0 A.K.U 126 3.3 573 14.9 699 18.1 Dermatology 78 2.0 108 2.8 186 4.8 General Surgery 58 1.5 82 2.1 140 3.6 Dental 39 1.0 81 2.1 120 3.1 Obstetric 23 0.6 38 1.0 61 1.6 Paediatric 17 0.4 229 5.9 246 6.4 Psychiatric 9 0.2 20 0.5 29 0.8 Total 1282 33.2 2574 66.8 3856 100 Table 3. Hajj & non-Hajj Outpatients in different clinics during Hajj season 1423H SN ICD-10 Codes Diagnosis Hajj pts Non-Hajj pts Total n % n % n % 1 J00-J99 Diseases of respiratory system 570 14.8 1012 26.2 1582 41.0 2 N00-N99 Diseases of genitourinary system 115 3.0 635 16.5 750 19.5 3 S00-T98 Injury, poison & certain other consequences of extra cause of death 113 2.9 113 2.9 226 5.9 4 L00-L99 Diseases of skin & soft tissue 99 2.6 174 4.5 273 7.1 5 K00-K93 Diseases of Gastro Intestinal Tract 92 2.4 169 4.4 261 6.8 6 M00-M99 Diseases of musculoskeletal syst & connective tissue 83 2.2 93 2.4 176 4.6 7 R00-R99 Symptoms, Signs & Clin/Lab findings not elsewhere classified 60 1.6 92 2.4 152 3.9 8 I00-I99 Disease of circulatory system 35 0.9 86 2.2 121 3.1 9 A00-B99 Infectious & parasitic diseases 26 0.7 63 1.6 89 2.3 10 H60-H95 Disease of ear & mastoid process 19 0.5 48 1.2 67 1.7 Diagnosis with < 1% cases 70 1.8 89 2.3 159 4.1 Total 1282 33.2 2574 66.8 3856 100 Table 4. Outpatients according to diagnosis during Hajj season 1423H H A A N I A S S H A K I R , Z O H A I R J G A Z Z A Z , K H A L I D O D H A F FA R A N D J AV E R I A S H A H B A Z 50 ing the Hajj season. It is based on a standard form provided officially. It highlights the personal as well as the hospital data of each patient. It displays the serv- ices of Al-Noor Hospital for Hajj pilgrims that could be compared with other hospitals in Makkah. It also gives us a picture of different nationalities of Hajj pa- tients, male dominancy and also the dominancy of non-Hajj patients over Hajj patients especially on dif- ferent clinics of OPD. The age group 51-60 years of Hajj patients correlates to the fact that Muslims from most of the nationalities perform Hajj after fulfilling their liabilities, such as marriages of their daughters etc. There were more patients from Middle East, com- pared to other regions of the world, due to its close ness to Holy Makkah. Our study highlights the per- centage of various medical problems as compared to other studies.4,5,6 Up to twenty years ago, cholera was the main cause of morbidity and mortality among pilgrims.7 Even recently, gastroenteritis was respon- sible for 76% of hospital admission.8 Now pneumonia infection in patients needs hospitalization.9 This time the Hajj occurred during winter so our study shows a large number of respiratory illnesses. Unfortunately, the data only shows the number of respiratory illness- es, not the specific diseases of the respiratory system. Among medications most commonly used were the antibiotics that reflect the preponderance of respira- tory cases. This finding should be taken into account for future Hajj. ACKNOWLEDGEMENTS We are eternally grateful for the services of female staff (Umairah, Fatima, Nur Insan, Merly and Jerinia) from the Medical Records Department. R E F E R E N C E S 1. Yousaf M, Chaudry S. Diabetic Ketoacidosis in Pilgrims Visiting Madina Al-Munawarah, Saudi Arabia. Int Dia- betes Digest 8: 14-16. 2. Elhassan OM, Hameed MIS. The Pattern of General Surgical Problems Among Pilgrims Admitted to King Fahad Hospital: Madinah Al-Munawarah in 1987. Sau- di Med J 1990; 4: 290-292. 3. Yousaf M, Zafar MO, Maqbool M. Medical Problems of Pakistan Pilgrims in Saudi Arabia. Pak J Med Res 1993; 32: 172-175. 4. Fatani MI, Al-Afif KA, Hussain H. Pattern of Skin Dis- eases During Hajj Season in Makkah, Saudi Arabia. Int J Dermatol 2000; 39: 493-496. 5. Al-Harthi AS, Al-Harbi M. Accidental Injuries During Muslim Pilgrimage. Saudi Med J 2001; 22: 523-525. 6. Khogali M. Epidemiology of Heat Illness During the Makkah Pilgrimage in Saudi Arabia. Int J Epidemiol 1983; 12: 267-273. 7. Rahim MA. Pilgrimage and Cholera Epidemic in Saudi Arabia: A Bibliographic Survey from 1813-1979. Ham- dard Medicus 1986; 29: 121-125. 8. Ghaznawi O. Health Hazards and Risk Factors in the 1406H (1986) Hajj Season. Saudi Med J 1988; 9: 274- 282. 9. Yousaf M, Al-Saudi DAA, Sheikh RA, Lone MS. Pattern of Medical Problem Among Hajj Pilgrims Admitted to King Abdul Aziz Hospital, Madinah Al-Munawarah. Ann Saudi Med 1995; 15: 619-621. SN Names of drug categories Single Therapy % 1 Antibiotics 1669 43.3 2 Analgesics and Anti-pyretics 972 25.2 3 Medication for *(IHD , CRF, CNS disorder) 610 15.8 4 Miscellaneous drugs, Medications other than for IHD, CRF&CNS disorders 393 10.2 Total 3644 94.5 IHD Ischemic Heart Disease CRF Chronic Renal Failure CNS Central nervous system disorder Table 5. The most common medications dispensed during the Hajj