Hajj: journey of a lifetime
http://www.100md.com
《英国医生杂志》
1 Manor Hospital, Walsall WS2 9PS, 2 Division of Community Health Sciences: GP Section, University of Edinburgh, Edinburgh
Correspondence to: A R Gatrad sec.gatrad@walsallhospitals.nhs.uk
Introduction
We drew on materials identified from searches of Medline, internet searches of Islamic websites, fatwa banks, and our personal libraries. To supplement these sources, we drew on our personal experiences of having travelled to Saudi Arabia on both Hajj and Umrah, running Hajj preparatory courses, and issuing medical advice to people intending to travel on Hajj and Umrah.
Summary points
Hajj, the journey to the Sacred Mosque in Mecca, is a once in a lifetime obligation for all adult Muslims who are physically and financially able
Each year, more than two million people globally, including 1% of the British Muslim community, take part in the Hajj
If the pilgrim is unprepared, the health risks associated with the Hajj are considerable; most important are the risks of heat exhaustion, heatstroke, and infectious diseases
All pilgrims must be vaccinated against meningococcal disease; a "Hajj travel consultation" is thus mandatory, offering the ideal opportunity for health promotional advice
The rites of Hajj
Problems of sun and heat
Travelling to Mecca in advance of the Hajj is sensible, particularly for people unaccustomed to the oppressive climate of the Arabian desert (box 3). Pilgrims need to be made aware that acclimatisation to very high temperatures—which occurs through a gradual increase in sweat production, thereby facilitating cooling through increased water evaporation—can take between one and two weeks.7
Sunburn is an important hazard, particularly for light skinned people. An appropriate strength sun block will minimise the risks of burning, with its associated risk of malignant tumours. Sun exposure must be kept to a minimum as discussed below.
Even when Hajj occurs during winter, the average temperature is over 30°C during the day and 20°C at night. Heat exhaustion and heatstroke are common and can be fatal, as evidenced by one study that reported more than 1700 fatalities in a single Hajj season, most of which were judged to be heat related.8 The Saudi authorities, in their role as the pilgrims' hosts, undertake valuable health promotional work, distributing leaflets and issuing radio and television warnings of the dangers of excessive sun exposure. The number of people who still die of heat is evidence that the message needs to be reiterated at every possible opportunity.
During the Hajj, men are prohibited from directly covering their heads (with a hat or scarf, for example), thereby increasing the risk of heat exposure. The usefulness of a good quality umbrella, preferably white in colour, to deflect the sun "away," cannot be overemphasised (fig 2). Such simple measures could be life saving if the pilgrim was to lose his or her bearing in the desert, as is easily and not infrequently done. Box 4 summarises other important precautions.
Fig 2 Umbrellas (preferably white) provide useful shade
Heat exhaustion typically occurs in people who are not acclimatised and undertake strenuous exercise. Water depletion or a combination of salt and water depletion due to excessive sweating is the underlying cause. Up to 5 litres of water and up to 20 g of salt a day may be lost. Most cases are relatively mild, with symptoms of weakness, lightheadedness, and muscle cramps that will respond to a combination of rest, cooling, and fluid and salt replacement. Without adequate treatment, however, heatstroke may occur.9 10 Although salt tablets may be taken, they can cause vomiting and gastrointestinal upset, so we suggest that a quarter of a level teaspoon of salt (approximately 1 g) is added to a pint, or two level teaspoons to a gallon (approximately 5 l), of drinking water during travel; this concentration is below the taste threshold.11
Box 4: Precautionary measures to minimise the risk of heat exhaustion and heatstroke
Avoid spending long periods in the sun, particularly when it is at its zenith
Travel by night whenever possible (which may also avoid stampedes)
Keep your head covered during the day (with an umbrella if necessary)
Consume large volumes of fluid throughout the day
Always keep a canister of fluid in your possession
Increase dietary salt intake or use salt tablets
Avoid travelling in "open top" buses
Heatstroke is a medical emergency (box 5) and can occur within 20 minutes of severe exertion.12 Skin is hot to the touch, and there is a notable absence of sweating. Young children, elderly people, and people with diabetes are most at risk. The extreme rise in body temperature makes prompt and appropriate treatment imperative. Patients should be moved into the shade, stripped, cooled with a combination of fanning and spraying the body with tepid water, and, if conscious, given fluid replacement, while expert medical attention is urgently sought.
Since the early 1980s, cooling units have been installed along the pilgrim route. Emergency services will often suspend patients in a hammock-like bed and spray them liberally with an air-water mixture. The water is warm and cools the body through evaporation, simultaneously preventing further dehydration. These simple devices are significantly quicker in reducing body temperature than the usual method of placing patients in an ice bath, possibly because vasoconstriction and shivering are not induced—responses that ultimately cause the body temperature to rise.13
Most pilgrims travel on foot, so good quality footwear is important, although in our experience it is often overlooked. During the day, the desert sand typically becomes burning hot. Care needs to be taken to avoid walking barefoot because of the serious risk of burns to the foot. This is particularly important for people with diabetic neuropathy, as very extensive damage may quickly occur, often compounded by the problems of poor wound healing and the increased risk of infection. Footwear must be removed before prayers, and people who have not been on Hajj are often unaware of the ease with which footwear can become confused with another pilgrim's and thus be inadvertently taken. Pilgrims may be forced to walk barefoot in an attempt to reclaim their footwear, with potentially devastating consequences. Thus pilgrims should be advised to carry footwear in a bag at all times.
Box 5: Symptoms suggesting heat exhaustion and heatstroke
Fatigue, weakness, and leg cramps
Headache, nausea, and vomiting
Giddiness
Delirium
Syncope and coma
Infectious diseases
An outbreak of group A meningococcal meningitis occurred among British Muslim pilgrims after the 1987 Hajj. Eighteen primary cases occurred among pilgrims and 15 subsequent cases among their direct and indirect contacts.14 15 Similarly, outbreaks of W135 meningococcal disease occurred among British pilgrims in 2000 and 2001. The Saudi authorities now insist that all pilgrims are vaccinated with two doses of ACWY Vax (three months apart) with conjugate meningitis vaccination.16 Immunity is thought to last for approximately three years. A medical certificate confirming vaccination is now required before visas will be issued.
Vaccination against hepatitis A and malaria prophylaxis, together with advice on measures to minimise the risk of exposure, are important. We recommend vaccination against hepatitis B (see below). In addition to checking tetanus and polio status, typhoid and diphtheria vaccination should be considered. Many people decide to travel on from the Hajj, particularly to Africa and the Indian sub-continent, so taking details of travel plans is important. Pilgrims need to be reminded of the importance of seeking medical attention for any unexpected symptoms, such as fever, diarrhoea, or jaundice, or a high fever on their return. A persistent cough is also significant because of the reported high incidence of pneumonia (particularly tuberculous) among pilgrims.17 18
One of the rites of the Hajj is for men to have the head shaved (although trimming the hair is also acceptable). Most will have their heads shaved, often in makeshift centres run by opportunistic "barbers." A razor blade is commonly used, and it may be used on several scalps before being ultimately discarded. The risks of important bloodborne infections such as HIV and hepatitis B and C are obvious, especially considering that many pilgrims will come from regions where such infections are now endemic. Pilgrims need to be aware of these dangers and should insist on the use of a new blade. Physical relationships are prohibited during Hajj, even between husband and wife, so the risks of acquiring sexually transmitted diseases are minimal.
Injuries
Minor injuries are relatively common, particularly to the toes; these typically result from inadvertently being stamped on while circumambulating the Ka'bah barefoot. More serious injuries, some of which prove to be fatal, occur each year during stampedes in Mina as pilgrims undertake the stoning rite (fig 3). Pilgrims should be advised to avoid peak times, and old and infirm people should be advised to consider appointing a proxy for the performance of this rite. Major trauma and death from road traffic crashes is a further important cause of injury in pilgrims.19
Fig 3 The stoning rite in Mina
Chronic disorders
Travellers with chronic medical conditions should take sufficient supplies of their usual drugs and also carry a written record of these, giving their generic names, in case further supplies are needed. A letter documenting medical problems and drugs will allow rapid assessment should an illness occur and will also be of help through customs.
Diabetes
Diabetes is common among South Asian Muslims and often leads to health problems during the Hajj. During travel, insulin should not be put in the luggage hold of an aircraft as it may freeze. Insulin should be refrigerated, but not in the freezer compartment, during the stay in Saudi Arabia.
If any illness occurs, diabetic control will need careful monitoring and insulin may be temporarily needed in people with type 2 diabetes. Although problems of hyperglycaemia and hypoglycaemia can occur, the second of these is more common as a result of increased physical activity.20 Food intake may therefore have to be increased before exertion. Hypoglycaemia may also occur if the insulin in Saudi Arabia is different from that of the patient's country of origin, so anyone accompanying a person with diabetes should be aware of the symptoms of hypoglycaemia.
We are aware of an education programme that includes classes on factors relating to diabetes, along with more practical matters concerning the Hajj.21 During these classes advice on footwear, insulin storage, food, drug doses, and immunisations are discussed. Such innovative projects could be further promoted by the Department of Health working collaboratively with, for example, the Muslim Council of Britain.
Box 6: Considerations in the "Hajj travel consultation"
Fitness to perform the Hajj
Heat exhaustion and heatstroke
Foot burns and sunburn
Infectious diseases
General travel advice
Emergency numbers: ambulance 997; police 999
General advice
Menstruation is considered a state of ritual impurity, so menstruating women are not permitted to perform the Hajj. This often causes a great deal of concern, which is perfectly understandable if one remembers the importance of the journey and the time, effort, and money that may have been invested. Delaying menstrual bleeding, by using the combined contraceptive pill or daily progesterone, for example, is perfectly acceptable; many women consult their general practitioners or family planning clinics for this reason in the run up to the Hajj season.
Contact lenses are also often problematic, particularly in arid conditions where sand can be blown into the eyes. Ocular lubricants (such as hypromellose 1% eye drops) should be used liberally to stop lenses adhering to the cornea. Temporarily using spectacles may be another option.
Although several makeshift dispensaries are erected during the Hajj season, these are often difficult to access, largely on account of the human mass. Pilgrims should ensure that they take small supplies of common remedies, such as analgesics and clove oil for dental pain. A simple travel pack containing adhesive dressings, an insect repellent, antiseptic cream, and water sterilisation tablets is also useful.
The "Hajj travel consultation"
Carlyle T. On heroes, hero-worship and the heroic in history. Lincoln: University of Nebraska Press, 1966: 49-50.
Eaton G. Islam and the destiny of man. London: George Allen and Unwin, 1985: 242.
Muslim Council of Britain. www.mcb.org.uk (accessed 7 Dec 2004).
Sarwar G. Islam: beliefs and teachings. London: Muslim Educational Trust, 1998: 78-81.
Sabiq AS. Fiqh us-sunnah: Hajj and Umrah. Indianapolis: American Trust Publications, 1992: 5.
Wolfe M. The Hadj. London: Seeker & Warburg, 1994: 194-5.
Clarke CRA, Clark ML. Environmental medicine. In: Kumar PJ, Clark ML, eds. Clinical medicine. London: Ballière Tindall, 1994: 756-7.
Al Ghamdi SM, Akbar HO, Qari YA, Fathaldin OA, Al-Rashed RS. Patterns of admission to hospitals during Muslim pilgrimage (Hajj). Saudi Med J 2003;24: 1073-6.
Seraj ME. Heat stroke during Hajj (pilgrimage)—an update. Middle East J Anaesthesiol 1992;11: 407-41.
Ghaznawi HI, Ibrahim MA. Heat stroke and heat exhaustion in pilgrims performing the Hajj (annual pilgrimage) in Saudi Arabia. Ann Saudi Med 1987;7: 323-6.
Adam JM. Effect of climatic extremes. In: Dawood R, ed. Travellers' health. Oxford: Oxford University Press, 1986: 238.
Moxham J, Souhami RL, Walker JM. Physical and environmental causes of disease. In: Souhami RL, Moxham J, eds. Textbook of medicine. London: Longman, 1990: 77-8.
Keatinge WR. Environmental factors and disease. In: Ledingham JGG, Warrel DA, eds. Concise Oxford textbook of medicine. New York: Oxford University Press, 2000: 1904-5.
Henahan J. Treating heat stroke in pilgrims to Mecca. JAMA 1982;247: 3302.
Salisbury D, Begg N, eds. Immunisation against infectious diseases. London: Stationery Office, 1996: 146.
Jones DM, Sutcliffe EM. Group A meningococcal disease in England associated with the Haj. J Infect 1990;21: 21-5.
Salisbury D, Begg N, eds. Immunisation against infectious diseases. London: Stationery Office, 1996: 147-54.
Alzeer A, Mashlah A, Fakim N, Al-Sugair N, Al-Hedaithy M, Al-Majed S, et al. Tuberculosis is the commonest cause of pneumonia requiring hospitalization during Hajj. J Infect 1998;36: 303-6.
Al-Harthi ASM, Al Harbi M. Accidental injuries during Muslim pilgrimage. Saudi Med J 2001;22: 523-5.
Khan SA, Bhat AR, Khan LA. Hypoglycaemia in diabetics during Hajj. Saudi Med J 2002;23: 1548.
Figuera E. Diabetes and the pilgrimage of Hajj: piloting of an education programme for Muslim patients with diabetes. Diabetes Today 2003;6: 41-2.(Abdul Rashid Gatrad, consultant paediatr)
Correspondence to: A R Gatrad sec.gatrad@walsallhospitals.nhs.uk
Introduction
We drew on materials identified from searches of Medline, internet searches of Islamic websites, fatwa banks, and our personal libraries. To supplement these sources, we drew on our personal experiences of having travelled to Saudi Arabia on both Hajj and Umrah, running Hajj preparatory courses, and issuing medical advice to people intending to travel on Hajj and Umrah.
Summary points
Hajj, the journey to the Sacred Mosque in Mecca, is a once in a lifetime obligation for all adult Muslims who are physically and financially able
Each year, more than two million people globally, including 1% of the British Muslim community, take part in the Hajj
If the pilgrim is unprepared, the health risks associated with the Hajj are considerable; most important are the risks of heat exhaustion, heatstroke, and infectious diseases
All pilgrims must be vaccinated against meningococcal disease; a "Hajj travel consultation" is thus mandatory, offering the ideal opportunity for health promotional advice
The rites of Hajj
Problems of sun and heat
Travelling to Mecca in advance of the Hajj is sensible, particularly for people unaccustomed to the oppressive climate of the Arabian desert (box 3). Pilgrims need to be made aware that acclimatisation to very high temperatures—which occurs through a gradual increase in sweat production, thereby facilitating cooling through increased water evaporation—can take between one and two weeks.7
Sunburn is an important hazard, particularly for light skinned people. An appropriate strength sun block will minimise the risks of burning, with its associated risk of malignant tumours. Sun exposure must be kept to a minimum as discussed below.
Even when Hajj occurs during winter, the average temperature is over 30°C during the day and 20°C at night. Heat exhaustion and heatstroke are common and can be fatal, as evidenced by one study that reported more than 1700 fatalities in a single Hajj season, most of which were judged to be heat related.8 The Saudi authorities, in their role as the pilgrims' hosts, undertake valuable health promotional work, distributing leaflets and issuing radio and television warnings of the dangers of excessive sun exposure. The number of people who still die of heat is evidence that the message needs to be reiterated at every possible opportunity.
During the Hajj, men are prohibited from directly covering their heads (with a hat or scarf, for example), thereby increasing the risk of heat exposure. The usefulness of a good quality umbrella, preferably white in colour, to deflect the sun "away," cannot be overemphasised (fig 2). Such simple measures could be life saving if the pilgrim was to lose his or her bearing in the desert, as is easily and not infrequently done. Box 4 summarises other important precautions.
Fig 2 Umbrellas (preferably white) provide useful shade
Heat exhaustion typically occurs in people who are not acclimatised and undertake strenuous exercise. Water depletion or a combination of salt and water depletion due to excessive sweating is the underlying cause. Up to 5 litres of water and up to 20 g of salt a day may be lost. Most cases are relatively mild, with symptoms of weakness, lightheadedness, and muscle cramps that will respond to a combination of rest, cooling, and fluid and salt replacement. Without adequate treatment, however, heatstroke may occur.9 10 Although salt tablets may be taken, they can cause vomiting and gastrointestinal upset, so we suggest that a quarter of a level teaspoon of salt (approximately 1 g) is added to a pint, or two level teaspoons to a gallon (approximately 5 l), of drinking water during travel; this concentration is below the taste threshold.11
Box 4: Precautionary measures to minimise the risk of heat exhaustion and heatstroke
Avoid spending long periods in the sun, particularly when it is at its zenith
Travel by night whenever possible (which may also avoid stampedes)
Keep your head covered during the day (with an umbrella if necessary)
Consume large volumes of fluid throughout the day
Always keep a canister of fluid in your possession
Increase dietary salt intake or use salt tablets
Avoid travelling in "open top" buses
Heatstroke is a medical emergency (box 5) and can occur within 20 minutes of severe exertion.12 Skin is hot to the touch, and there is a notable absence of sweating. Young children, elderly people, and people with diabetes are most at risk. The extreme rise in body temperature makes prompt and appropriate treatment imperative. Patients should be moved into the shade, stripped, cooled with a combination of fanning and spraying the body with tepid water, and, if conscious, given fluid replacement, while expert medical attention is urgently sought.
Since the early 1980s, cooling units have been installed along the pilgrim route. Emergency services will often suspend patients in a hammock-like bed and spray them liberally with an air-water mixture. The water is warm and cools the body through evaporation, simultaneously preventing further dehydration. These simple devices are significantly quicker in reducing body temperature than the usual method of placing patients in an ice bath, possibly because vasoconstriction and shivering are not induced—responses that ultimately cause the body temperature to rise.13
Most pilgrims travel on foot, so good quality footwear is important, although in our experience it is often overlooked. During the day, the desert sand typically becomes burning hot. Care needs to be taken to avoid walking barefoot because of the serious risk of burns to the foot. This is particularly important for people with diabetic neuropathy, as very extensive damage may quickly occur, often compounded by the problems of poor wound healing and the increased risk of infection. Footwear must be removed before prayers, and people who have not been on Hajj are often unaware of the ease with which footwear can become confused with another pilgrim's and thus be inadvertently taken. Pilgrims may be forced to walk barefoot in an attempt to reclaim their footwear, with potentially devastating consequences. Thus pilgrims should be advised to carry footwear in a bag at all times.
Box 5: Symptoms suggesting heat exhaustion and heatstroke
Fatigue, weakness, and leg cramps
Headache, nausea, and vomiting
Giddiness
Delirium
Syncope and coma
Infectious diseases
An outbreak of group A meningococcal meningitis occurred among British Muslim pilgrims after the 1987 Hajj. Eighteen primary cases occurred among pilgrims and 15 subsequent cases among their direct and indirect contacts.14 15 Similarly, outbreaks of W135 meningococcal disease occurred among British pilgrims in 2000 and 2001. The Saudi authorities now insist that all pilgrims are vaccinated with two doses of ACWY Vax (three months apart) with conjugate meningitis vaccination.16 Immunity is thought to last for approximately three years. A medical certificate confirming vaccination is now required before visas will be issued.
Vaccination against hepatitis A and malaria prophylaxis, together with advice on measures to minimise the risk of exposure, are important. We recommend vaccination against hepatitis B (see below). In addition to checking tetanus and polio status, typhoid and diphtheria vaccination should be considered. Many people decide to travel on from the Hajj, particularly to Africa and the Indian sub-continent, so taking details of travel plans is important. Pilgrims need to be reminded of the importance of seeking medical attention for any unexpected symptoms, such as fever, diarrhoea, or jaundice, or a high fever on their return. A persistent cough is also significant because of the reported high incidence of pneumonia (particularly tuberculous) among pilgrims.17 18
One of the rites of the Hajj is for men to have the head shaved (although trimming the hair is also acceptable). Most will have their heads shaved, often in makeshift centres run by opportunistic "barbers." A razor blade is commonly used, and it may be used on several scalps before being ultimately discarded. The risks of important bloodborne infections such as HIV and hepatitis B and C are obvious, especially considering that many pilgrims will come from regions where such infections are now endemic. Pilgrims need to be aware of these dangers and should insist on the use of a new blade. Physical relationships are prohibited during Hajj, even between husband and wife, so the risks of acquiring sexually transmitted diseases are minimal.
Injuries
Minor injuries are relatively common, particularly to the toes; these typically result from inadvertently being stamped on while circumambulating the Ka'bah barefoot. More serious injuries, some of which prove to be fatal, occur each year during stampedes in Mina as pilgrims undertake the stoning rite (fig 3). Pilgrims should be advised to avoid peak times, and old and infirm people should be advised to consider appointing a proxy for the performance of this rite. Major trauma and death from road traffic crashes is a further important cause of injury in pilgrims.19
Fig 3 The stoning rite in Mina
Chronic disorders
Travellers with chronic medical conditions should take sufficient supplies of their usual drugs and also carry a written record of these, giving their generic names, in case further supplies are needed. A letter documenting medical problems and drugs will allow rapid assessment should an illness occur and will also be of help through customs.
Diabetes
Diabetes is common among South Asian Muslims and often leads to health problems during the Hajj. During travel, insulin should not be put in the luggage hold of an aircraft as it may freeze. Insulin should be refrigerated, but not in the freezer compartment, during the stay in Saudi Arabia.
If any illness occurs, diabetic control will need careful monitoring and insulin may be temporarily needed in people with type 2 diabetes. Although problems of hyperglycaemia and hypoglycaemia can occur, the second of these is more common as a result of increased physical activity.20 Food intake may therefore have to be increased before exertion. Hypoglycaemia may also occur if the insulin in Saudi Arabia is different from that of the patient's country of origin, so anyone accompanying a person with diabetes should be aware of the symptoms of hypoglycaemia.
We are aware of an education programme that includes classes on factors relating to diabetes, along with more practical matters concerning the Hajj.21 During these classes advice on footwear, insulin storage, food, drug doses, and immunisations are discussed. Such innovative projects could be further promoted by the Department of Health working collaboratively with, for example, the Muslim Council of Britain.
Box 6: Considerations in the "Hajj travel consultation"
Fitness to perform the Hajj
Heat exhaustion and heatstroke
Foot burns and sunburn
Infectious diseases
General travel advice
Emergency numbers: ambulance 997; police 999
General advice
Menstruation is considered a state of ritual impurity, so menstruating women are not permitted to perform the Hajj. This often causes a great deal of concern, which is perfectly understandable if one remembers the importance of the journey and the time, effort, and money that may have been invested. Delaying menstrual bleeding, by using the combined contraceptive pill or daily progesterone, for example, is perfectly acceptable; many women consult their general practitioners or family planning clinics for this reason in the run up to the Hajj season.
Contact lenses are also often problematic, particularly in arid conditions where sand can be blown into the eyes. Ocular lubricants (such as hypromellose 1% eye drops) should be used liberally to stop lenses adhering to the cornea. Temporarily using spectacles may be another option.
Although several makeshift dispensaries are erected during the Hajj season, these are often difficult to access, largely on account of the human mass. Pilgrims should ensure that they take small supplies of common remedies, such as analgesics and clove oil for dental pain. A simple travel pack containing adhesive dressings, an insect repellent, antiseptic cream, and water sterilisation tablets is also useful.
The "Hajj travel consultation"
Carlyle T. On heroes, hero-worship and the heroic in history. Lincoln: University of Nebraska Press, 1966: 49-50.
Eaton G. Islam and the destiny of man. London: George Allen and Unwin, 1985: 242.
Muslim Council of Britain. www.mcb.org.uk (accessed 7 Dec 2004).
Sarwar G. Islam: beliefs and teachings. London: Muslim Educational Trust, 1998: 78-81.
Sabiq AS. Fiqh us-sunnah: Hajj and Umrah. Indianapolis: American Trust Publications, 1992: 5.
Wolfe M. The Hadj. London: Seeker & Warburg, 1994: 194-5.
Clarke CRA, Clark ML. Environmental medicine. In: Kumar PJ, Clark ML, eds. Clinical medicine. London: Ballière Tindall, 1994: 756-7.
Al Ghamdi SM, Akbar HO, Qari YA, Fathaldin OA, Al-Rashed RS. Patterns of admission to hospitals during Muslim pilgrimage (Hajj). Saudi Med J 2003;24: 1073-6.
Seraj ME. Heat stroke during Hajj (pilgrimage)—an update. Middle East J Anaesthesiol 1992;11: 407-41.
Ghaznawi HI, Ibrahim MA. Heat stroke and heat exhaustion in pilgrims performing the Hajj (annual pilgrimage) in Saudi Arabia. Ann Saudi Med 1987;7: 323-6.
Adam JM. Effect of climatic extremes. In: Dawood R, ed. Travellers' health. Oxford: Oxford University Press, 1986: 238.
Moxham J, Souhami RL, Walker JM. Physical and environmental causes of disease. In: Souhami RL, Moxham J, eds. Textbook of medicine. London: Longman, 1990: 77-8.
Keatinge WR. Environmental factors and disease. In: Ledingham JGG, Warrel DA, eds. Concise Oxford textbook of medicine. New York: Oxford University Press, 2000: 1904-5.
Henahan J. Treating heat stroke in pilgrims to Mecca. JAMA 1982;247: 3302.
Salisbury D, Begg N, eds. Immunisation against infectious diseases. London: Stationery Office, 1996: 146.
Jones DM, Sutcliffe EM. Group A meningococcal disease in England associated with the Haj. J Infect 1990;21: 21-5.
Salisbury D, Begg N, eds. Immunisation against infectious diseases. London: Stationery Office, 1996: 147-54.
Alzeer A, Mashlah A, Fakim N, Al-Sugair N, Al-Hedaithy M, Al-Majed S, et al. Tuberculosis is the commonest cause of pneumonia requiring hospitalization during Hajj. J Infect 1998;36: 303-6.
Al-Harthi ASM, Al Harbi M. Accidental injuries during Muslim pilgrimage. Saudi Med J 2001;22: 523-5.
Khan SA, Bhat AR, Khan LA. Hypoglycaemia in diabetics during Hajj. Saudi Med J 2002;23: 1548.
Figuera E. Diabetes and the pilgrimage of Hajj: piloting of an education programme for Muslim patients with diabetes. Diabetes Today 2003;6: 41-2.(Abdul Rashid Gatrad, consultant paediatr)