Annals of Saudi Medicine, Vol 19, No 1, 1999 55 HOW TO REDUCE CARDIOVASCULAR MORTALITY AND MORBIDITY AMONG HAJJ PILGRIMS: A MULTIPHASIC SCREENING, INTERVENTION AND ASSESSMENT Farsad Afshin-Nia, MD; Hamid M. Dehkordi, MD; Mohammad-Reza Fazel, MD; Mostafa Ghanei, MD Each year, thousands of pilgrims travel to Saudi Arabia to perform Hajj ceremonies. Complete and correct performance of the obligatory rites, usually in hot weather and often in the midst of a huge crowd, is sometimes difficult even for healthy subjects. It is considerably more difficult for patients with cardiovascular disorders, because of their potential underlying disabilities. These considerations prompted the Hajj Medical Group in Isfahan to design guidelines to screen potential pilgrims with cardiovascular disorders. The main objectives were: 1) to screen cardiovascular disorders among subjects older than 50 years before Hajj; 2) to adopt appropriate intervention measures; and 3) to assess the outcome of the intervention measures. The objective was the prevention of increasing mortality and morbidity among pilgrims during the pilgrimage. We had the opportunity to conduct the medical evaluation of all the applicants in standard situations based on the protocol, so that the methods could be used by any health policymakers among the nations whose citizens perform the pilgrimage. Patients and Methods This study consisted of two phases. The first phase, in which the pilgrims were screened, was a cross-sectional study conducted in 1993. The second phase was a cohort study in which a number of patients with cardiovascular disorders were selected randomly before, and followed up after the ceremony to evaluate morbidity and mortality. The target population included all applicants of Isfahan City aged 50 or more, who wanted to participate in the Hajj ceremonies in 1993. There was a 100% participation rate in the screening program. All the pilgrims were referred to Al-Zahra General Medical Hospital for screening. From the Isfahan University of Medical Sciences and Health Services (Drs. Afshin-Nia and Ghanei), Isfahan, and the Tehran University of Medical Sciences and Health Services (Drs. Dehkordi and Fazel), Tehran, Iran. Address reprint requests and correspondence to Dr. Afshin-Nia: Consultant Physician, Isfahan University, P.O. Box 81745-151, Isfahan, Iran. Accepted for publication 12 September 1998. Received 6 December 1997. Screening In the first phase of the study, data about age, sex, height, weight, family history, drug history, and past and present medical history were gathered through a questionnaire. The subjects then underwent general medical and cardiovascular evaluations. Routine tests such as CBC, FPG, BUN and uric acid were requested. Sitting blood pressure was determined, based on the Hypertension Detection and Follow-up Program protocol, using the mean of the second and third measurements from the right arm. 1 Hypertension was defined as systolic and diastolic blood pressures higher than 160 and 90 mm Hg, respectively, or past history of hypertension. Ischemic heart disease was screened by criteria of standard epidemiological methods on the basis of past medical history of myocardial infarction and history of angina pectoris (Rose criteria), and 12-lead ECG (Minnesota Code criteria). 2,3 Chest x-ray, echocardiography and exercise test were also requested as needed. Intervention The patients with poorly controlled hypertension, advanced heart failure, unstable angina and recent history of myocardial infarction (MI) were prohibited from attending the pilgrimage of 1993. There were 1019 patients with controlled hypertension, mild heart failure, stable angina and any other cardiovascular disorders. They were informed of the nature of their disease and given appropriate medications. These patients were then asked to contact our internist during the Hajj upon the appearance of any problems. From the 1019 patients, 220 were randomly selected to be followed up during the ceremony, and to be compared with indices of other provinces. Assessment The indices of comparative morbidity before and after Hajj were based on the rate of drug ingestion and also on evaluation of signs and symptoms (by history-taking and physical examination) by our internist before and after Hajj. The rate of hospitalization and the mortality rate of the Isfahan pilgrims were compared with those of other provinces. The patients’ ability to perform the obligatory rituals was compared with that of healthy pilgrims, based