The association between pre-morbid conditions and respiratory tract manifestations amongst Malaysian Hajj pilgrims

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1 Tropicl Biomedicine 27(2): (2010) The ssocition etween pre-morid conditions nd respirtory trct mnifesttions mongst Mlysin Hjj pilgrims Zkun Ziny Deris 1*, Hsh Hsn 2, Mohd Suhimi A. Wh 3, Siti Amrh Sulimn 3, Nyi Nyi Ning 4 nd Nor Hyti Othmn 5 1 Deprtment of Medicl Microiology nd Prsitology, School of Medicl Sciences, Universiti Sins Mlysi Helth Cmpus, Kung Kerin, Kelntn, Mlysi 2 Infection Control nd Epidemiology Unit, Hospitl Universiti Sins Mlysi, Kung Kerin, Kelntn, Mlysi 3 Deprtment of Phrmcology, School of Medicl Sciences, Universiti Sins Mlysi Helth Cmpus, Kung Kerin, Kelntn, Mlysi 4 Unit of Biosttistics nd Reserch Methodology, School of Medicl Sciences, Universiti Sins Mlysi Helth Cmpus, Kung Kerin, Kelntn, Mlysi 5 Clinicl Reserch Pltform, Universiti Sins Mlysi, Kung Kerin, Kelntn, Mlysi * Corresponding uthor emil: zkun@k.usm.my Received 4 Ferury 2010; received in revised form 5 My 2010; ccepted 12 My 2010 Astrct. In very closed nd overcrowding environment, influenz trnsmission during Hjj seson is lmost inevitle. The im of this study ws to determine the ssocition etween pre-morid conditions nd influenz-like illness (ILI) mongst Hjj pilgrims. A cross-sectionl study ws conducted mongst Mlysin Hjj pilgrims in yer Survey forms were distriuted t Mdintul-Hujjj, Jeddh nd Tung Hji Clinic, Medin, Sudi Ari where pilgrims sty on trnsit efore returning to Mlysi. Allergic rhinitis ws significntly ssocited with sore throt (p=0.047), longer durtion of cough (p= 0.017) nd runny nose (p=0.016). Pilgrims who suffered from chronic ostructive pulmonry diseses (COPD) hd significnt ssocition with longer durtion of cough (p=0.041) nd those with dietes mellitus hd significnt ssocition with longer durtion of sore throt (p=0.048). Underlying sthm ws significntly ssocited with severe influenz like illness requiring dmission to hospitl for further tretment of respirtory symptoms (p=0.016). Bsed on these findings, we suggest those with underlying sthm should e discourged from prticipting in the hjj nd they should seek erly tretment if they develop respirtory symptoms. INTRODUCTION Every yer, Sudi Ari hosts the lrgest nnul gtherings in the world; the Hjj. This event gthers pproximtely three million people together from vrious countries into one confined geogrphicl re. According to the 5th tenet of Islm, ll dult Muslims who re physiclly nd finncilly competent re required to perform the Hjj once in their lifetime. During the ritul, the pilgrims move from one holy site to nother in Mkkh to complete the Hjj ctivities (Gtrd & Sheikh, 2005). The rituls of Hjj re physiclly very demnding. Extreme physicl stressors such s extreme het, sun exposure, prolonged stys t Hjj sites, dryness of environment, overcrowding, trffic congestions, minimum toilet fcilities, ir pollution nd rough nd uneven ground increse the risk of communicle nd noncommunicle diseses (Ahmed et l., 2006; Shfi et l., 2008). Idelly; only those who re physiclly fit hve religious 294

2 oligtion to perform Hjj. But unfortuntely some with preexisting helth conditions nd in very extreme ge re still mitious to perform Hjj. Old ge nd co-morid condition of the Hjj pilgrims re known importnt risk fctors for hospitl dmission during Hjj seson (Al-Ghmdi et l., 2003). It is not unusul for people to shre tent overnight in Min during Hjj (Gtrd et l., 2006). Respirtory infections continue to increse the disese urden of Hjj pilgrims ut there is lck of studies to overcome this prolem (Alzeer, 2009). In this very closed nd overcrowding re, the trnsmission of pthogens especilly influenz virus is lmost inevitle. This study ws imed to find out the ssocited fctor of influenz-like illness mong Hjj pilgrims. Becuse of the lnguge rrier nd logistic prolem, the scope of the sujects ws Mlysin Hjj pilgrims tht performed Hjj during 2007 seson. MATERIALS AND METHODS Study design nd sujects A cross-sectionl study ws conducted mongst Mlysin Hjj pilgrims in yer Over the yers, round Mlysin Hjj pilgrims trvel to Mkkh. They re mnged y Mlysin Hjj Fund (Tung Hji), i.e. government linked compny to tke cre of Mlysin Hjj pilgrims. They sty in the holy lnd for out forty dys. Around two third of the Hjj pilgrims go to Medin first for eight dys. Then they reside t Mkkh for the rest of the Hjj journey. After completing the Hjj ritul, they go to Jeddh nd sty t Medintul-Hujjj of Jeddh for two nights to wit their flight to come ck to their home. Another one third of the Hjj pilgrims goes directly to Mkkh nd come ck vi Medin. Survey forms were distriuted t Mdintul-Hujjj, Jeddh nd Tung Hji Clinic, Medin, Sudi Ari where pilgrims sty on trnsit efore returning to Mlysi. The response to the survey ws on voluntry sis. The clculted smple size ws 276 respondents. After including 20% expected drop-out, totl required miniml smple size ws 331. Ethicl pprovl ws otined from Universiti Sins Mlysi Reserch nd Ethics Committee. Definition It is difficult to define the syndromes of respirtory trct infections ecuse of gret vrition in the severity, durtion, nd types of symptom (Eccles, 2005). Cse definitions of ILI for influenz surveillnce vry widely worldwide (Thursky et l., 2003). The CDC definition of ILI i.e. temperture of >37.8ºC nd either cough nd/or sore throt in the sence of known cuse other thn influenz hs een shown to hve low sensitivity in clinicl prctice (Bcock et l., 2006; Rshid & Rfiq, 2006). During Hjj, s suggested y Rshid et l. (2008), ILI ws defined s the trid of cough, sujective fever nd sore throt. This study lso focused more on specific symptoms of cute respirtory trct mnifesttion such s cough, sore throt, runny nose nd fever. Sttisticl nlysis Dt ws entered nd nlyzed using SPSS softwre (SPSS, Chicgo) version Results were expressed in term of the numer nd percentge or the men nd stndrd devition. For ctegoricl vriles, the differences in ptient s chrcteristics nd risk fctors were tested using Chi-squre or Fisher s exct test. For continuous vriles, they were ctegorised in groups nd nlysed similr to ctegoricl vrile. P vlue of < 0.05 ws considered to e sttisticlly significnt. RESULTS Out of 394 pilgrims who returned the questionnires, seven were excluded from nlysis s grossly incomplete. The underlying diseses mong Mlysin Hjj 295

3 pilgrims were dietes mellitus 12.1%; hypertension 9.6%; sthm 9.0%; chronic ostructive pulmonry diseses (COPD) 8.8%; llergic rhinitis 7.2%; rthritis nd muscle che 1.3%; hert diseses 0.5%; mlignncy 0.26% nd gstritis 0.1%. An 8.8% of Mlysin Hjj pilgrims were smokers. There were lso no significnt difference etween ILI nd non-ili in term of underlying diseses nd smoking hit (Tle 1). This study found tht underlying llergic rhinitis ws significntly ssocited with sore throt during Hjj seson (p=0.047; OR % CI 0.99, 5.75). Allergic rhinitis lso ws significntly ssocited with cough nd runny nose more thn two weeks with p= (OR % CI 1.2, 5.6) nd p=0.016 (OR % CI 1.2, 5.6) respectively. Dietes mellitus ws significntly ssocited with sore throt for more thn two weeks (p=0.048 OR % CI 0.99, 4.71). COPD significntly ssocited with cough more thn two weeks with p=0.044 (OR % CI 1.0, 4.4) respectively (Tle 2). Tle 3 shows the ssocition etween underlying conditions of Hjj pilgrims nd the hospitl dmission due to cute respirtory symptoms. Underlying sthm ws significntly ssocited with ptient dmission to hospitl for the tretment of respirtory symptoms (p=0.012). DISCUSSION Previous studies hd shown tht influenz A virus ws only detected in 0.6% (Blkhy et l., 2004), 8.1% (Rshid et l., 2007), 8.6% (Rshid et l., 2008c), 10.2% (Rshid et l., 2008) nd 9.8% (Adolvh et l., 2009) respectively mong Hjj pilgrimges. Tking the lowest percentge of influenz A infection to the totl two million pilgrims, it ws estimted tht t lest 400,000 pilgrims would develop URTI symptoms nd 24,000 would develop influenz (Blkhy et l., 2004). This did not include those ecoming ill from contct with Hjj pilgrims returning home. Hjj could potentilly initite wves of outreks Tle 1. Associted fctors of influenz-like illness mong hjj pilgrims in 2007 Influenz Like Illness * Vrile Yes No p vlue # OR (95%CI) Men (sd)/ n (%) Men (sd)/ n (%) Gender Mle.085 (54.8).131 (56.5) ( ) Femle.070 (45.2).101 (43.5) Age (y) 49.8 (10.6) 50.7 (11.2) Underlying diseses Dietic.019 (12.3).028 (12.1) (0.55, 1.90) Hypertension.014 (9.0)0.023 (9.9) (0.45, 1.81) COPD **.013 (8.4)0.021 (9.1) (0.45, 1.90) Asthm.015 (9.7)0.020 (8.6) (0.56, 2.29) Rhinitis.015 (9.7)0.013 (5.6) (0.83, 3.91) Hert diseses.002 (1.3)0.000 (0.0) c Smoking while in Mlysi.011 (7.1)0.023 (9.9) (0.33, 1.47) Person Chi squre Independent-t test c Fisher s Exct test # Significnce level ws set t 0.05 * Influenz-like illness ws defined s trid of cough, sujective fever nd sore throt ** COPD Chronic Ostructive Pulmonry Diseses 296

4 Tle 2. Assocition etween specific respirtory symptoms nd common underlying conditions mong hjj pilgrims in 2007 Symptom Dietes Mellitus Asthm Allergic Rhinitis COPD** Smoking hit Yes No p Yes No p Yes No p Yes No p Yes No p (%) (%) Vlue (%) (%) Vlue (%) (%) Vlue (%) (%) Vlue (%) (%) Vlue Cough (97.9) (90.6) (88.6) (91.2) (92.9) (91.4) (100) (90.7) (88.2) (91.8) Durtion of cough more thn two weeks* (39.1) (39.6) (30.3) (40.5) (60.7) (37.9) (56.3) (38.0) (31.3) (40.4) Runny nose (80.3) (72.3) (71.4) (80.1) (82.1) (79.1) (73.5) (79.9) (82.4) (79.0) Durtion of runny nose more thn two weeks* (23.4) (24.2) (21.9) (24.3) (42.9) (22.6) (33.3) (23.2) (15.2) (25.0) Sore throt (51.1) (57.9) (54.3) (57.4) (75.0) (55.7) (58.8) (56.9) (64.7) (56.4) Durtion of sore throt more thn two weeks* (21.3) (11.1) (12.1) (12.4) (17.9) (11.9) (15.2) (12.1) (11.8) (12.4) Fever (59.6) (59.1) (60.0) (59.1) (64.3) (58.8) (61.8) (58.9) (50.0) (60.1) Durtion of fever more thn two weeks* (0.0) (3.0) (3.1) (2.6) (3.6) (2.6) (8.8) (2.0) (0.0) (2.9) Fisher s Exct test Person chi squre test # Significnce level ws set t 0.05 * The hjj pilgrims with no history of symptom were nlysed s 0 dy of symptom ** COPD Chronic Ostructive Pulmonry Diseses 297

5 Tle 3. Assocition etween underlying conditions nd hospitl dmission for cute respirtory symptoms mong hjj pilgrims 2007 Underlying Conditions Admitted to hospitl Yes No n (%) n (%) p vlue Dietes Mellitus 3 (27.3) 44 (12.2) Hypertension 0 (0.0) 34 (9.4) Asthm 4 (36.4) 30 (8.3) Allergic Rhinitis 1 (9.1) 26 (7.2) Smoking 1 (9.1) 32 (8.8) COPD** 1 (9.1) 33 (9.1) Other underlying diseses 0 (0.0) 13 (3.6) Fisher s Exct test # Significnce level ws set t 0.05 * Only hjj pilgrims with respirtory symptoms were included in the nlysis ** COPD Chronic Ostructive Pulmonry Diseses worldwide nd urden helth-cre systems (Erhim et l., 2009). In the er of H1N1 pndemic influenz, the ILI cses increse five times more thn seline rte (CDC, 2009). We hve reported the prevlence of ILI mong Mlysin Hjj pilgrims ws 40.1% (Deris et l., 2009). The secondry ttck rte of pndemic H1N1 mong household ws estimted to e 27.3% (Yng et l., 2009). The ttck rte mong Hjj pilgrims ws expected to e much higher due to the overcrowding, winter seson, overexertion nd limited resources condition. The pndemic influenz hs creted fer mong Muslim communities nd governments. Egypt, Omn, Irn nd Tunisi were mong these countries (Erhim et l., 2009). The Sudi Helth uthority hs implemented infection control mesures tht effectively controlled the previous H1N1 pndemic during hjj. Their mesures were grouped s screening nd isoltion; surveillnce, epidemiology, nd informtics; lortory testing; infection control; nd tretment of the 2009 pndemic influenz A H1N1 infection (Memish et l., 2009). These prepredness plns hve een shown effective in minimising the disese trnsmission during the mss gthering nd on their return home. Among the most chllenging recommendtion is tht the popultion groups considered to e t high risk for complictions from influenz voluntrily refrin from the 2009 Hjj (Erhim et l., 2009). In this pre-pndemic study, we documented tht llergic rhinitis, dietes mellitus nd COPD ssocited with some respirtory symptoms nd/or prolongtion of the respirtory symptoms ut these did not fulfil the ILI criteri. It ws resonly sfe for Muslims with controlled underlying diseses to perform Hjj presuming tht they hve hd pproprite pre-hjj counseling on their illness. As prcticed in mny countries, Hjj pilgrims need to hve helth screening efore going for Hjj nd tke sufficient supplies of their usul medictions. They were dvised to ring letter documenting medicl prolems nd tretments to llow for rpid ssessment of the illness nd lso help them go through customs (Gtrd & Sheikh, 2005; Shfi et l., 2008). The Hjj pilgrims with these underlying diseses need to hve medicl consulttion should they develop respirtory symptoms. On the other hnd underlying sthm ws significntly ssocited with ptients eing dmitted to hospitl for the tretment of cute respirtory symptoms. The previous study hs shown tht COPD nd sthm were the most common cuses of severe sepsis during Hjj in which 54.7% of severe sepsis cses dmitted to criticl cre units hving the diseses (Bhroon et l., 2008). Bronchil sthm ccounted for 9.2% of hospitl dmission (Mdni et l., 2006) nd directly cused 8.6% of intensive cre dmission during Hjj (Mdni et l., 2007). Asthm is known to cuse cute respirtory distress when the ptients re exposed to llergens nd upper respirtory trct pthogens. This study supports the recommendtion to refrin high risk group from prticipting in the 2009 Hjj. In conclusion, this study showed tht pilgrims who hd underlying chronic diseses such s dietes mellitus, llergic rhinitis, COPD nd sthm needed to hve their diseses controlled efore emrking 298

6 on the pilgrimge to Mkkh. Those with underlying sthm should voluntrily refrin from hjj during pndemic influenz seson nd if they re going for hjj, they should seek erly medicl ttention whenever they develop respirtory symptoms. Acknowledgement. We would like to cknowledge the Ministry of Higher Eduction through Universiti Sins Mlysi Hjj Reserch Cluster for funding of the reserch; The Custodin of Two Holylnd Hjj Reserch Center, University Umm l Qur, Mkkh for support the ccommodtion nd trnsporttion during reserch in Mkkh; Tung Hji Mlysi for continuous support nd recommendtion; nd Ms Rohn Che Yusof nd Mr Mohd Bzln Hfidz Mukrim for helping in the dt key-in. REFERENCES Adolvh, A., Mohmmd Hsn, A., Mzyr, Z., Mrzieh, J., Mhs, M., Bhmn, P. & Amin, A. (2009). Virl etiology of cute respirtory infections mong Irnin Hjj pilgrims, Journl of Trvel Medicine 16: Ahmed, Q.A., Ari, Y.M. & Memish, Z.A. (2006). Helth risks t the Hjj. The Lncet 367: Al-Ghmdi, S.M., Akr, H.O., Qri, Y.A., Fthldin, O.A. & Al-Rshed, R.S. (2003). Pttern of dmission to hospitls during muslim pilgrimge (Hjj). Sudi Medicl Journl 24: Alzeer, A.H. (2009). Respirtory trct infection during Hjj. Annls of Thorcic Medicine 4: Bcock, H., Merz, L. & Frser, V. (2006). Is Influenz n Influenz-Like Illness? Clinicl Presenttion of Influenz in Hospitlized Ptients. Infection Control nd Hospitl Epidemiology 27: Bhroon, S., Al-Jhdli, H., Al Hshmi, J., Memish, Z.A. & Ahmed, Q.A. (2008). Severe sepsis nd septic shock t the Hjj: Etiologies nd outcomes. Trvel Medicine nd Infectious Disese 7: Blkhy, H.H., Memish, Z.A., Bfqeer, S. & Almuneef, M.A. (2004). Influenz Common Virl Infection mong Hjj Pilgrims: Time for Routine Surveillnce nd Vccintion. Journl of Trvel Medicine 11: CDC (2009). Surveillnce for the 2009 pndemic influenz A (H1N1) virus nd sesonl influenz viruses - New Zelnd, Moridity nd Mortlity Weekly Reports 58: Deris, Z.Z., Hsn, H., Sulimn, S.A., Wh, M.S., Ning, N.N. & Othmn, N.H. (2009). The Prevlence of Acute Respirtory Symptoms nd Role of Protective Mesures mong Mlysin Hjj Pilgrims. Journl of Trvel Medicine. In Press. Erhim, S.H., Memish, Z.A., Uyeki, T.M., Khoj, T.A.M., Mrno, N. & Mcn, S.J.N. (2009). Pndemic H1N1 nd the 2009 Hjj. Science 326: Eccles, R. (2005). Understnding the symptoms of the common cold nd influenz. The Lncet Infectious Diseses 5: Gtrd, A.R., Shfi, S., Memish, Z.A. & Sheikh, A. (2006). Hjj nd the risk of influenz. British Medicl Journl 333: Gtrd, A.R. & Sheikh, A. (2005). Hjj: journey of lifetime. British Medicl Journl 330: Mdni, T.A., Ghrh, T.M., Al-Hedithy, M.A., Alhzmi, M.A., Alzrqi, T.A., Alrrk, A.M. & Ishq, A.H. (2006). Cuses of hospitliztion of pilgrims in the Hjj seson of the Islmic yer 1423 (2003). Annls of Sudi Medicine 26:

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