Triggers, Risk Factors, and the Prevalence of Syncope Among Domestic Hajj Pilgrims, 2023: A Cross-Sectional Study

Background: Syncope and other transient loss of consciousness episodes in crowded and unfamiliar environments may lead to major health hazards. Despite numerous publications, data on syncope among Hajj pilgrims in Makkah is lacking. Objectives: To identify the triggers, risk factors, and prevalence of syncope and other transient loss of consciousness episodes among domestic pilgrims. Methodology: This cross-sectional study included a convenient sample of domestic pilgrims who performed Hajj in July 2023 using an online Google Forms questionnaire (Alphabet Inc., Mountain View, CA). Results: Out of 388 participants, 69 (18.1%) reported a history of syncope during the Hajj pilgrimage. Among these, 57 (82.6%) reported complete loss of consciousness, and 56 (81.2%) noted warning symptoms preceding the episode. The syncopal attack occurred once in 49 respondents (71%). Several triggers for syncope were identified, with sudden standing from a sitting position being the most prevalent (100%). Additional co-triggers were crowding (n=43; 62.3%), stressful conditions (n=30; 43.2%), prolonged standing (n=21; 30.4%), and walking (n=11; 15.9%). Traumatic injuries were reported in 33 (47.8%) as a result of syncope. Standing for long periods of time on the day of Arafat (Arafat standing) emerged as the most common triggering situation (n=48; 69.6%). There were multiple medical factors contributing to syncopal episodes; the most common medical explanations were heat exhaustion (n=48; 69.6%), dehydration (n=24; 34.8%), over-exertion (n=48; 69.6%), low blood sugar (n=10; 14.5%), and low blood pressure (n=17; 24.6%). Significant predictors were the presence of cardiac disease (odd ratio (OR) 7.6, 95% confidence interval (CI) 2.71-21.45, p<0.001), anemia (OR 2.5, 95% CI 1.01-6.09, p=0.049), previous syncope (OR 2.5, 95% CI 1.02-6.27, p=0.049, and family history of syncope (OR 10.1, 95% CI 2.08-49.32, p=0.004). Conclusion: Syncope during the domestic Hajj pilgrimage is frequent, especially on the day of Arafat, and carries the risk of traumatic injury. People with previous episodes of syncope and comorbidities, especially cardiac patients and those who have a family history of syncope, are particularly prone to this risk. Healthcare should focus on at-risk patients, particularly on critical pilgrimage days, and increase pilgrims' awareness about triggers of syncope including sudden and prolonged standing, exertion, and heat exposure.


Introduction
The Hajj pilgrimage is one of the largest religious journeys in the world, presenting unique public health challenges.The season of the Hajj varies due to its adherence to the Islamic lunar calendar.The Hajj takes place in month 12 of the lunar calendar for five days, from 8 to 12 [1].
Hajj rites are grouped into Tawaf (circumambulation of Kaaba, an aggregate distance of about 40 km), a ritual of Saee (running seven times between two small hills, Safa and Marwah), the day of Arafat (8 miles east of Makkah, a highlight of the Hajj), spending the night at Muzdalifa, stoning the Jamarat (the densest crowds during the Hajj), animal sacrifice, staying in Mina, and culminating with the final farewell ritual of Tawaf and Saee [1].
In 2023, the Hajj took place in July, a summer month.Therefore, the pilgrims were exposed to diverse and significant health risks due to the excessive heat, limited time, the confined geographical area of the event, and the large numbers of people, amounting to millions of people [2].Over decades, various health risks at the Hajj were reported, affecting even domestic pilgrims residing in the Kingdom of Saudi Arabia (KSA).
For decades, various health risks have been documented during the Hajj, including among domestic pilgrims residing in the Kingdom.The healthcare system has implemented rigorous preparations to monitor the vast numbers of pilgrims in a relatively confined space considering diverse cultural, linguistic, and, most significantly, medical backgrounds [1,3].Syncope, a sudden loss of consciousness associated with the inability to maintain a postural tone, followed by spontaneous recovery, is relatively common.Although syncope has many possible causes, the cardiac cause is the most serious category and may be linked to increased mortality.Patients with cardiac syncope constitute a high-risk group predisposed to morbidity and premature mortality from cardiovascular disease and should be monitored closely.Even for those with unknown cause for syncope, it appears that they are at an increased risk for death.Moreover, there is an increased risk of stroke among those with underlying neurologic causes for their syncope [4].Additionally, syncope can lead to serious traumatic injuries in case the patient falls in crowded or unfamiliar environments.
The prevalence of syncope among pilgrims could vary according to destination, length of their journey, pilgrim's age, and health status.Many risk factors can provoke it, including low blood pressure, dehydration, heat illnesses, heart problems, and other complications.Triggers of syncope during the Hajj include high environmental temperature, prolonged standing and walking, psychological stress, or sudden changes in posture [4,5].Previous studies have investigated different aspects of health risks (2), including cardiovascular diseases [5] and heat-related illnesses [6] during pilgrimages.However, separate studies are lacking in the literature regarding syncope and other transient loss of consciousness such as seizures, especially generalized tonic-clonic seizures, and metabolic disturbances conditions such as hyperventilation and electrolyte imbalances.
Identifying the triggers and risk factors associated with syncope during pilgrimages is important for developing effective preventive measures and improving the safety of pilgrims during their journey.Therefore, this study was conducted to identify the triggers, risk factors, and prevalence of syncope and other transient loss of consciousness episodes among domestic pilgrims during the 2023 Hajj period.

Materials And Methods
The study design is a cross-sectional population-based survey that included male and female resident pilgrims of all ages and nationalities who undertook the pilgrimage from inside KSA in July 2023, considered to be the hottest month of the year in the region.The required sample size was estimated using the Qualtrics calculator (Qualtrics International Inc., Provo, UT; Seattle, WA) at a 95% confidence level, a margin of error of ±5%, and an assumed prevalence of 50%.The required minimum sample size was determined to be 385.Sampling was performed using a non-randomized, convenient, consecutive technique.Data was collected using an online multiple-choice, anonymous questionnaire distributed through social media portals of internal pilgrims' groups using Google Forms (Alphabet Inc., Mountain View, CA).The questionnaire included questions about demographic data, risk factors of syncope, details of syncopal events, triggering factors, and medical consultation.The questionnaire was constructed based on the literature review by an expert (consultant internist) and reviewed by three other consultants (one family medicine consultant and two consultant internists) for validity.

Ethical consideration
A detailed online informed consent was obtained from each participant before replying to the questionnaire.All data involved in the questionnaire were used for the sole purposes of this research.The study was conducted after the approval of the Institutional Research Review Board at Ibn Sina National College ISNC (IRRB-01-17092023).

Statistical analysis
Statistical data was analyzed using SPSS software (version 22.0; SPSS Inc., IBM Corp., NY).Data were reported as the number and the frequency of categorical variables.Significant risk factors and triggers were identified using binary regression analysis.Binary regression analysis included all demographic data, chronic illness, family, and past history for the model prediction with odd ratio (OR) and 95% confidence interval estimation for significant predictors.A two-sided P-value <0.05 was considered the level of significance for all tests.Binary regression analysis showed that the chi-square model was 75.97, df 18, p <0.001 with a Nagelkerke R square of 29.3%.The model was well-fitting with the goodness of fit test (Hosmer and Lemeshow test was > 0.05 p=0.723).

Discussion
The results of the present study provide characteristic data regarding the prevalence, triggers, and predictors of syncope among domestic pilgrims who performed Hajj during one of the hottest summer months in 2023.
Results showed an 18.1% prevalence of syncope, sometimes more than once, with reported traumatic injuries in almost half of them.Syncope happened for the first time in 10.31%, with a 2.5-fold increase in the likelihood of occurrence among those with a previous history of syncope.People with recurrent syncope start fainting by age 30, and many clinical studies report syncope recurrences over subsequent decades [7], suggesting a genetic origin for their vasovagal syncope [8].Pooling family data [9,10] reported that 36-51% of patients who experienced fainting had a positive family history with a pattern compatible with incomplete penetrance of autosomal dominance [11].This is in accordance with our results, where the strongest predictor of syncope was the positive family history.
In this study, cardiac patients have a 7.6-fold increased likelihood of developing syncope during the pilgrimage.This finding is of utmost importance as there is enough evidence that cardiac patients have increased rates of both mortality and morbidity during the pilgrimage [5].Syncope of cardiac origin results from compromised cardiac output secondary to either structural, mechanical, or dysrhythmic causes.Anemia among domestic pilgrims increased the likelihood of syncope by 2.5-fold.It is well known that the gradual onset of anemia is associated with compensatory mechanisms that minimize the symptoms.In anemia, due to acute blood loss, the reduction in oxygen-carrying capacity and hypovolemia results in hypotension with a risk of syncope.Hajj situation exposes pilgrims to multiple situations, which can lead to hypovolemia that precipitates symptoms even in patients with chronic anemia.
Triggers of syncope were mainly the combinations of orthostatic intolerance with other aggravating factors like prolonged standing in a stressful crowding.These triggers are common during Hajj rituals, especially on the day of Arafat.Orthostatic intolerance is defined by a sustained reduction of systolic blood pressure of at least 20 mmHg or diastolic blood pressure of 10 mmHg within three minutes of standing [12].
Around 18.8% of cases of syncope didn't seek medical advice, which may be attributed to the transient nature of loss of consciousness.However, this finding represents a clue to the absence of awareness of pilgrims about the associated risk of syncope, especially among cardiac patients [5].However, the diagnosis of syncope is often challenging, as the causes are complex and often multifactorial.This is clearly seen in this study as medical consultation provided multiple explanations in 42% of cases with syncope, with heat illness and its associated dehydration as the major possible causes.During mass gatherings, a one-degree increase in temperature could result in an 11% increase in the number of individuals requiring medical attention.Excessive exertion during pilgrimage rituals was the cause in 26.1% of cases [13].Exerciseassociated collapse is seen even among healthy athletes [14], possibly due to exercise-induced postural hypotension.Postexercise systolic blood pressure may drop by 20 mmHg below supine values on assuming the upright posture [15].
In extreme conditions, a combination of heat exposure and exertion may lead to exertional heat stroke, characterized by collapse or syncope associated with hyperthermia [16].

Limitations
This study has some limitations.First, the cross-sectional study design allows recall bias.Second, only domestic pilgrims from KSA were included.Domestic pilgrims are at an advantage compared to external pilgrims as they are accustomed to the weather, habits, and cultures.This could limit the generalization of the results to all pilgrims.However, many faced the risk of syncope, drawing attention to the increased risk among other pilgrims.Third, there are only a few seniors in the study population (1.4%), which again limits the generalization of the results to the elderly populations in whom cardiovascular morbidity plays a more important role in the etiology of syncope [17].

Conclusions
Syncope during domestic pilgrimage is common, especially on the day of Arafat, and carries the risk of traumatic injury.People with personal or family history of syncope and comorbidities, especially cardiac patients, are prone to this risk.Healthcare should focus on risky patients on days and increase pilgrims' awareness about triggers of syncope, especially sudden and prolonged standing, exertion, and heat exposure, and seeking medical help immediately.

Appendices Appendix A
Table 4 shows the pilgrimage data collection sheet of syncope among Hajj domestic pilgrims, 2023.

TABLE 1 : Demographic characteristics of the participants
Data is represented as numbers (n) and percentages (%)

TABLE 3 : Predictors of syncope during performing domestic pilgrimage
P-value <0.05 is significant