Health Issues of Nigerian Muslim Pilgrims in The Immediate Post-Covid-19 Era Hajj Year 2022– Part II (Non-Communicable Diseases)

ABSTRACT


Introduction
This piece should be regarded as part of a two-series publication, the complementary part was focused on communicable health issues while this part objective is to elaborate the non-communicable diseases among Nigerian pilgrims and the necessary mitigating efforts.
Regarding Nigeria, other low and middle-income countries {LAMICs) as well as high income countries, pilgrims have so many prevailing health issues even in the pre-COVID-19 era aside from communicable diseases.These include increased risk of stampedes and injuries, fire outbreak, disease transmission, worsening of non-communicable diseases, complications of exposure to unaccustomed climate such as heat stroke, sunburns, harmattan, dehydration, psychological illness, health hazards from food and environmental hygiene (Memish et al., 2012).Challenges of crowd management, safety, security, and emergency preparedness, are posed.Provisions need to be made for these health factors and it will involve non-health specialists including venue engineers, event planners, security personnel etcetera.to enable the successful performance of hajj rites as well as ensure optimal health of every member of the global community within and beyond the geographical area of the pilgrimage rites.
The optimal health still needs to be  et al., 2012), improving on this will serve as a useful mode of risk management and international collaboration in mass gatherings.Inhalers and other necessary medications should be carried along with their recent prescriptions during the journey to enable early intervention during symptom exacerbation before hospital presentation.

Screening
Lukewarm water or warm beverages are preferred to cold water as a thirst quencher in people at risk of airway disease (Saketkhoo et al., 1978).Arsenic is a heavy metal, beneficial though to a large extent but has also been described to be carcinogenic (WHO, 2018).

Cardiometabolic system
Organ

Epilepsy
Epilepsy is a common neurological illness as well.Affected pilgrims are better stabilized on antiepileptic drugs (AEDs) before being certified fit to proceed with Hajj by the medical team (Saad, 2017).'

Psychiatric Illnesses
The prevalence of mental illnesses among Hajj pilgrims ranges between less than 1% (Raja et al., 2017)

Musculoskeletal System
Prevalence of musculoskeletal pain was reported to be as high as 80.46% among pilgrims of different nationalities that were interviewed at various sites of hajj rites such as Grand Holy Mosque, Mina, Arafat and Muzdalifah (Alshehri et al., 2021).The  This has been tried as part of technological approaches for easing hajj tasks.Some recognized limitations therein include non-compatibility of some devices with the apps, the requirement of valid and specific types of credit cards, affordability, and availability of internet access.

Pregnancy and Pilgrimage
Islam encourages accompaniment by This should be done after discussing such with her gynecologist to avert the possibility of any adverse effect that may arise upon the use of such medication (Islam et al., 2019).

Conclusion and Recommendation
A holistic approach to healthcare is applicable in a mass gatherings like hajj as it is for other aspects of the health sector.LAMICs.Pilgrims should be encouraged to disclose their health status and assured that this may not necessarily prevent them from performing hajj but may serve to improve their health during hajj.Warm water/ beverages should be made available the same way as cold water is made to be readily available as a thirst quencher, prophylactic and therapeutic modality for people who are prone to respiratory illnesses (Saketkhoo et al., 1978) .
maintained or improved upon after completion of hajj rites and remain in the cyclical path till the onset of the next hajj season which is usually about 11 days less than the same date of the preceding year in the Gregorian calendar.Non-Muslim imperial European powers were actively involved in hajj management before the emergence of the Saudi petrodollar and modern hajj management which is now being done entirely by the Muslims.Saudi Arabia's safety, security, environmental and health policies have evolved after several decades of conducting hajj rites for the Muslim populace (Memish

(
AED) (figure 1) at strategic places in the premises of the sacred mosques for use in resuscitation during emergencies like cardiac arrest and syncope attacks.The security personnel in the premises of the Grand Holy Mosque (as well as other mosques) should be trained on the basic life support skills and the usefulness of AED in such emergencies before the arrival of an ambulance for conveyance to the hospital.

Figure 1 .
Figure 1.Automated Electrical Defibrillators (AED) Stationed at Strategic Places in the Precincts of Grand Holy Mosque and 7.2 % (Alzahrani et al., 2021).Patients with Major mental illnesses (like Schizophrenia and related disorders, bipolar, depressive, and anxiety disorders) should be encouraged to disclose their illness to the medical team who should advise or refer such pilgrims to a psychiatrist for assessment of their fitness to proceed on Hajj.An illness remission state must be attained before proceeding on hajj.The stock of medication and prescription notes should be carried along as done for other chronic ailments during the hajj journey for ease of refill and sustaining the maintenance dose to avert recurrence.It is not uncommon for mental illness to recur due to the strenuous nature of hajj rites.Early warning signs and relapse signatures characteristic of the patient illness should be identified and the patient educated on the need for early presentation and early intervention to avert full relapse.Psychoactive Substance Use/Misuse Hajj season is an opportunity for people who abuse a psychoactive substances to abstain from their addictive behavior as much of their time and attention should be dedicated to worship and not recreational drug use/activities.Consumption of alcoholic beverages is a punishable offense in Islam, the same applies to buy, selling or using in the Kingdom of Saudi Arabia as well as most other Islamic countries of the world.Smoking is prohibited in most holy sites to avert the exposure of other pilgrims to passive smoking and prevent fire accidents in congested settings/mass gatherings.Most other psychoactive substances are considered khamr (intoxicants) whose consumptions are also sinful in Islam and should be avoided to enable the attainment of the desired spiritual benefit of the hajj.There are anecdotal reports that consumption of Zamzam water reduces addictive behavior possibly because of its sub-therapeutic lithium content (Sudhir Gadh, 2020).Lithium concentration of Zamzam water may be of therapeutic value in people with suicidality, mood, other behavioral disorder, and lead neurotoxicity (Brown et al., 2018).Emotional Distraught Some intending pilgrims could not perform the 2022 Hajj due to the stringent measures dictated by the COVID19 pandemic, and the limited period is given to prepare for the operation by the Hajj Ministry of Saudi Arabia, which make NAHCON title it as an "emergency hajj" (Abubakar, 2022).Such people are emotionally distraught as this translated to missing the hajj chance for three consecutive years.NAHCON put measures in place to ensure that such individuals should be given topmost consideration during the subsequent year (2023) hajj year.
painful conditions (especially lower limb pain) are more prevalent in females, older age groups, and the obese(Alshehri et al.,   2021)  Disorders of the musculo-skeletal system are next to respiratory tract infection in order of commonality of hospital presentation amidst Nigerian pilgrims(Abubakar, 2022), same was reported in a study of Pakistani pilgrims presenting in Pakistani Hajj Medical Mission` Hospital and Dispensary in Meccas(Raja et al., 2017).This is due to the need to walk in performing most tasks by pilgrims.Some pilgrims also miss their ways and end up walking long distances in search of their destinations.The language barrier makes it difficult for most pilgrims to get appropriate guidance from Saudi security personnel.Making use of a wrist straps which can be read by the Saudi personnel, and the use of maps (including google Maps) can ameliorate this.Pilgrims should also try to make use of the free transport systems (eg train services) provided by Saudi authorities.Footwear should not be tight fitting (note that shoes and socks are not allowed for men).It is advisable to use old footwear than new ones to avoid soring and blisters during rigorous tasks like tawaf and sa'ay.Voluntary health workers (VHW eg Red Crescent Society of Saudi Arabia) are readily available and accessible on most walkways to the sites of performance of rigorous rites to assist people that have muscle cramps, osteoarthritis, sprains etcetra.People with disabling illnesses and advanced age should be informed about the permissibility of delegating a healthier younger person to perform the Hajj on their behalf.This will reduce the burden of illness, cost, and associated discomfort.Stampedes, accidents, injuries, and exhaustion are a common occurrences during the hajj (Al-Harthi & Al-Harbi, 2001).This can be minimized by following Islamic guidelines of rites performance, adoptions of permissible options, devices, and technologies.Most activities can be done at convenient periods of different parts of the day.Pilgrims can be grouped into batches of genders, regions, or nationalities in performing tasks like the stoning of satan effigy to avert congestion, fall, and stampede that may occur during the task.People with physical disabilities are permitted to do the stoning at an earlier part of the day or delegate a healthy person to perform it on their behalf while able-bodied pilgrims are encouraged to do their stoning by mid-day.The use of wheelchairs, electronic carts etcera is permissible for the disabled.These are available for rent at some cost which may not be affordable to most Nigerian pilgrims.

Figure 3 .
Figure 3. Pilgrims performing strenuous Hajj rites n Electric Scooters one's legally married spouse(s) in the hajj ritual, sexual cohabitation is however a forbidden act during Hajj and can nullify the validity of Hajj.Separate accommodation facilities are provided for each gender during hajj.Pregnancy is not a contraindication for pilgrimage.The pregnancy test is part of a routine tests conducted for women during pre-hajj medical screening.Pregnant women are encouraged not to perform Hajj to avert possible complications that may arise due to the strenuous nature of the rites.At least, a case of miscarriage was reported among Nigerian pilgrims in the Hajj year 2022 (Gbadamosi, 2022) despite the inclusion of pregnancy tests and ultrasound scanning as parts of pre-hajj medical screening.There are possibilities that such women get fecundated after the conduct of the pregnancy test.It may therefore be recommended during pre-hajj health education that married female pilgrims should practice sexual abstinence or be on contraceptives after the conduct of medical screening, especially during the menstrual cycle preceding their departure for Hajj, if there are no other gynecological reasons against such.Menstruation Menstruating women have some limitations in performing most of their worship generally in Islam as seen in solat (prayer) and sawm (fasting).However, most of the Hajj and Umra activities are not limited by menstruation factors except Tawafs which is one of the obligatory aspects of the pilgrimage rites.It however allowed for women to defer the period of performance of compulsory Tawafs (tawaful ifada) till the cessation of menstruation, while other forms of the (voluntary) tawaf (eg Tawaful wada: farewell tawaf) may be left undone.It is also allowed for a woman to take medications (eg norethisterone, combined oral contraceptive pills) that can suppress/ postpone her menstruation cycle during the Hajj period till a later time to enable prompt/timely performance of these rites.
To avert dehydration from extremely hot arid weather, pilgrims are advised on the need for frequent water drinking.Bottled Zamzam and non-Zamzam water are readily available, and freely distributed in the city of Mecca and the precinct of the Holy Mosques.Dysuria may be a feature of urine hyper concentration in an individual that is not taking enough water.Heat stroke characterized by a sudden loss of consciousness can result from excessive heat.Pilgrims are therefore advised to make use of an umbrella to avert heat from intense sunshine.
lowest mortality (3/10000) in the preceding ten years (Aremu, 2022).Despite strong scriptural admonition of performing Hajj when one is healthy, so many wheelbound pilgrims partake in Hajj and Umrah.Some sick pilgrims anecdotally give advance DNR (do-not-resuscitate) directives/orders if they go into cardiac arrest that they may attain the spiritual benefits of dying during the hajj (Memish et al., 2012).This has big ethical and religious implications.To avert such occurrence, people deemed unfit for hajj should be sermonized of the permissibility of a younger /healthier person to perform the hajj on their behalf while they will still get the spiritual benefit/reward as documented in the authentic hadith of the Noble Prophet Muhammad PBUH.Pilgrims should be advised (if not mandated) to undergo post-hajj health screening.Similar importance given to prehajj screening should be accorded to posthajj screening to mitigate the risk of disease transmission in the native countries of all pilgrims.