The Hajj Pilgrimage and Diabetes

Hajj is the Arabic word for pilgrimage; it commemorates the patriarch Abraham's readiness to sacrifice his son Ishmael in Biblical times. Diabetes is one of the most common underlying health conditions among Hajj pilgrims. Many diabetics manage their condition using insulin, which requires appropriate storage conditions to maintain its stability and effectiveness.

Islam is the religion of nearly 2 billion Muslims throughout the world, comprising about 24% of the world population. Islamic faith necessitates strict observance of the injunctions of its holy book, the Qur’an, and the sayings and actions of the Prophet Muhammad. Muslims must fulfill a number of religious obligations, the essence of which are known as the five pillars of Islam:

??????????????????????Shahadah – the declaration of faith;

??????????????????????Salah – five compulsory daily prayers;

??????????????????????Zakat – annual alms tax, to poor and needy;

??????????????????????Sawm – fasting during month of Ramadan;

??????????????????????Hajj – pilgrimage to Mecca.

Hajj, the sacred pilgrimage performed by Muslims at the holy mosque of Masjid al-Haram in Makkah, Saudi Arabia, is a must-do for all adult Muslims once in their life, provided they are able to do it. Considering the 8.8% global prevalence of diabetes, coupled with the number of Muslims performing Hajj yearly (about 2 million adult Muslims), it is estimated that about 220000 Muslims with diabetes perform Hajj every year.

According to Islamic rules, Hajj should not cause severe difficulties for Muslims. The Holy Qur’an specifically exempts from this duty Muslims who are unable physically or financially if it might lead to harmful consequences for the individual. In theory, this should be applicable to subjects with diabetes considering its severe and chronic complications. But this exemption from the duty of the Hajj is not considered a simple permission; As Muhammad the Prophet of Islam says, ‘God likes his permission to be fulfilled, as he likes his will to be executed’. So most Muslims with diabetes prefer to do the Hajj duty, even if this can cause major medical challenges for them. Pilgrims with diabetes may face many health hazards during the Hajj, including but not limited to the ‘killer triad’: hypoglycemia, foot injury and infections. During the Hajj, diet, amount of fluid intake and physical activity may be altered significantly. Many precautions are necessary in the prevention and treatment of possible serious complications.

While diabetes affects about 5% of the white Caucasian population, its levels are much higher in Arab and Muslim countries. For example, it affects 30.8% of Pakistani and 24.9% of the Kuwait Muslim population (aged 25–74 years). Moreover, a large number of people performing the Hajj are ever 60 years old, and the prevalence of diabetes increases with age. Hence, the number of people with diabetes during the Hajj could be considerably higher.

Most (over 95%) pilgrims bring their insulin with them from their country of origin. There are oftenn inadequate knowledge and inappropriate practices regarding insulin handling and storage among diabetic Hajj pilgrims, which compromises the quality of insulin and leads to health hazards.

Insulin is a labile drug, sensitive to extreme temperatures, sunlight, and shaking and needs to be appropriately handled and stored to be effective. Insulin needs to be stored in refrigerators between 2 and 8°C (not frozen), almost always with a maximum usage/storage period of four weeks at standard room temperature (20-25°C) and away from sunlight. Extreme temperatures should be avoided to prevent loss of potency, clumping, frosting, or precipitation. Improper storage of insulin decreases its potency and its pharmacological action and effectiveness, which may lead to failure to achieve optimal glycemic control amongst users. Ensuring optimal storage of insulin is particularly challenging for travelers as storage conditions and facilities may not be appropriate or available both during the travel journey and at the arrival destination.

Hajj Pilgrims come from over 180 different countries with different socioeconomic, cultural, and health system backgrounds as well as varying levels of education, beliefs, and health literacy. Many international pilgrims face numerous hours of flight, long transit times, and extended waiting times while traveling to Saudi Arabia. During the Hajj, pilgrims are faced with physically demanding outdoor religious rites, changes in diets, and suboptimal hydration as well as hot temperatures (up to 50°C), which may impact their physiology, absorption of insulin, and interfere with its storage. In particular, accessibility to appropriate storage facilities for insulin can be an issue for pilgrims during their Hajj journey. These factors impact insulin therapy among diabetic pilgrims and negatively affect their wellbeing.

The Hajj journey involves stays in Makkah city and the holy sites of Mina and Arafat and may also include visits to the city of Madinah. How and where pilgrims chose to store their insulin varies depending on the pilgrimage journey. This may be a reflection of the differences in availability and accessibility to cool storage facilities at these locations. During their stay in Makkah and Madinah, most pilgrims reside in typical hotels and have access to a fridge. This is not the case in the holy sites of Mina and Arafat, where only a small proportion of pilgrims have access to a fridge. Pilgrims stay in these sites for only a few days, where they reside in large purposefully built tents; therefore, they lack sufficient cool storage facilities.

In areas with reduced access to fridges, pilgrims often use alternative approaches to keep their insulin cool, including storage of insulin in water bottles. Such techniques have been used among diabetics for many years in limited-resource settings or during travel. In such instances, insulin is stored in water-filled clay pots, goatskin, vegetable gourds, or other traditional storage devices of various designs using evaporating cooling. Some of these techniques keep storage temperatures close to standard room temperature (20-25°C) even in hot climates. However, these techniques can be a source of health hazards, and their use is generally discouraged. For instance, keeping insulin in clay pots is likely to cause contamination as it is challenging to keep it clean. Similarly, insulin in use should never be kept immersed underwater as it carries a high risk of contamination, leading to loss of potency and the likelihood of causing injection abscesses.

There are also a few practices among pilgrims that could compromise the overall quality of insulin and lead to health hazards. A large proportion of pilgrims bring their insulin to Saudi Arabia in their standard luggage. When traveling by air, it is recommended that insulin be carried in the cabin, baggage, or handbags. Luggage that is checked in is stored in the aircraft’s hold and may freeze, and any insulin in this luggage may lose its potency.

A number of pilgrims also leave their insulin in their accommodations while performing the Hajj rituals. This can be physically demanding and may last many hours, during which pilgrims may require sustenance and access to their insulin. Pilgrims should keep some insulin stored appropriately, accessible to them at all times during their Hajj journey to avoid practices that may negatively influence their health and diabetes management, such as skipping meals, having food without injecting insulin, and sharing of medication with other pilgrims.

The Hajj duty includes significant physical activity, including circumambulation (circling the Kaaba seven times counterclockwise) and walking (Saay), and both are integral parts of the Hajj; the total walking distance can exceed 64 kilometres depending on the ability of the individual. Staying on Mount Arafat at daytime is mandatory, which usually has a very high temperature.

Pilgrims may be subjected to specific illnesses due to many factors, which could be unique to the Hajj duty. These include but not limited to carrying infections already existing in their countries, overcrowding, inadequate nutrition, poor access to drinking water, hot weather and physical exertion. People with diabetes are at a greater risk of illness due to the nature of the disease and also the altered daily routine, which may affect diabetes control.

The health risks for pilgrims with diabetes include:

?????????????????????Hypoglycemia.

?????????????????????Dehydration.

?????????????????????Foot injuries and infection.

?????????????????????Hyperglycemia, diabetic ketoacidosis, and hyperosmolar state.

?????????????????????Heat exhaustion and heat stroke.

?????????????????????Infections, such as chest infections and diarrhea.

?????????????????????Heart problems due to increased physical exertion.??????

The Hajj duties can be demanding in terms of physical activities and mental effort. People performing it may be preoccupied by the religious rituals and self-management may be neglected. This may be further complicated by the language barrier making it difficult to access medical services when necessary. Recorded temperatures during Hajj range between 37°C and 45°C. Overcrowding and the hot climate subject the pilgrims to environmental and health hazards.

The Checklist of diabetic Hajj pilgrims

With some careful preparation, having diabetes should not prevent you from performing Hajj. However, it is required to take preventive measures to avoid health problems that you may encounter during your trip.

Before travel:

1) If you are diabetic and you are about to perform Hajj, you should see your doctor to discuss your ability and readiness for it, as well as the medications you should be taking. Your doctor may reduce your dose of medications given the effort you will be making during rituals, such as long walks.

2) Carry a detailed medical report on your health condition and take your needles on the plane you’re boarding.?

3) Wear a bracelet around your wrist or carry an identification card stating that you are diabetic and the type of treatment you take in case you needed emergency help.

4) Bring an adequate amount of medicines and needles. Moreover, take all necessary vaccinations before traveling.

5) Take a glucometer with you to monitor your blood sugar level daily, especially when you feel an imbalance in your glucose level.?

6) Bring an escort that is familiar with your condition.

7) Carry a piece of candy or juice and snacks with you for emergency situations or flight delays.?

8) If your treatment includes an insulin pump, make sure you have sufficient information on its use on board of a plane.

Suitcase contents:

It is recommended to take a dedicated diabetes kit. It should include:

1) A medical report

2) Identification card of yourself and your disease

3) Sufficient quantity of insulin and medication

4) Low blood sugar emergency needle (glucagon)

5) A glucometer and its accessories?

6) Umbrella

7) Candy or juice and a snack

8) Notebook and pen to write any notes or changes. This helps keep your doctor updated on your condition

9) A suitable isothermal bag for the transport of your insulin at the right temperature

The EasyBag Classic, a tailor-made solution for transporting insulin during Hajj?

The EasyBag technology was developed specifically to transport insulin. It is a perfect adjunct to the Hajj because it does not require electricity. The EasyBag contains super absorbent polymers that will absorb 600 times their weight in water and will then cool down insulin using evaporation. To use the EasyBag, simply soak the inner pouch in tap water and it will then keep insulin at a temperature between 16 and 25°C for 4 days.

The EasyBag works on evaporation, so paradoxically, the hotter it is outside, the better it works. As it heats up, the water evaporates, and the evaporation cools down the insulin. After 4 days, simply wet again with tap water, and you're good for another four days.

Discover the EasyBag on the MedActiv www.medactiv.com