Deployed national healthcare services in Hajj mass gathering settings: emergency department experience of Makkah Diyanet Hospital during the 2025 Hajj period.

Introduction

Hajj, one of the five pillars of Islam, is a sacred obligation that every eligible Muslim must fulfill at least once in their lifetime [ 1 – 3 ]. This act of worship, which brings together millions of people in Makkah within a limited timeframe each year, constitutes one of the largest recurring mass gatherings on earth, drawing Muslims of diverse demographic and epidemiological backgrounds [ 1 , 4 , 5 ]. Crowding, heat, dust, close contact, and extreme physical exertion drive a range of health hazards, including communicable disease transmission, chronic-illness exacerbation, and heatstroke [ 6 – 9 ]. These risks are amplified by the shifting demographic profile of the pilgrim population [ 10 ].

In recent years this profile has shifted toward an older population with a high prevalence of chronic disease, raising age-related frailty and disease burden [ 11 ]. Roughly half of pilgrims carry comorbidities such as hypertension, diabetes mellitus, and cardiovascular disease, and more than half use regular medications [ 12 – 14 ]. Disruption of routine medical care, medication non-adherence, and intense physical exertion during the rituals drive acute exacerbations of chronic disease and a rise in emergency department visits [ 15 – 17 ]. This complex health profile demands specialized care.

Mass gathering medicine has emerged as a distinct discipline addressing the health risks and logistical challenges of large-scale events [ 18 , 19 ]. Lessons from the Hajj experience have shaped disaster preparedness strategies, communicable disease surveillance systems, and emergency response protocols [ 20 , 21 ], in which the host country’s healthcare infrastructure plays the central role.

The Saudi Arabian Ministry of Health has established a comprehensive, tiered healthcare infrastructure of thousands of personnel and numerous facilities to meet pilgrims’ medical needs [ 22 – 25 ]. Existing literature has focused predominantly on this central system. However, some countries operate independent facilities for their own citizens during the Hajj period. These facilities also relieve the central system, yet research on their operational efficiency, patient load, and emergency response requirements remains scarce [ 7 , 26 , 27 ]. The Republic of Türkiye activates the Makkah Diyanet Turkey Hospital and its primary healthcare center system annually throughout the roughly three-month Hajj period.

Addressing this gap, our study aimed to evaluate a national Hajj healthcare facility by analyzing the clinical and operational data of its emergency department during the 2025 Hajj season. By systematically examining the demographic and clinical characteristics, presentation patterns, and outcomes of Turkish pilgrims, we aimed to provide evidence for resource planning, pilgrim selection criteria, and healthcare strategies in future Hajj seasons.

Methods

This retrospective, cross-sectional, analytical study examined emergency department utilization at the Diyanet Turkey Hospital, Makkah, Saudi Arabia, during the 2025 Hajj season (April 15–July 4, 2025).

The Diyanet Turkey Hospital is a temporary facility activated annually by the Presidency of Religious Affairs of the Republic of Türkiye for Turkish pilgrims. The 2025 deployment served 84,942 pilgrims [ 28 ] and ran continuously for approximately three months, from pre-Hajj arrival to post-Hajj departure. The central facility housed an emergency department, outpatient clinics, inpatient wards, and an intensive care unit, supported by 14 primary healthcare centers across the pilgrim accommodation areas. Specialist physicians, most with academic appointments, staffed the outpatient and inpatient services; family medicine specialists staffed the primary care centers. The emergency department ran three eight-hour shifts, each staffed by two emergency medicine specialists (one in a supervising role) and a variable number of general practitioners.

As a temporary deployment, the hospital worked within fixed diagnostic and therapeutic limits. Imaging was confined to plain radiography and ultrasonography, the latter through both a point-of-care device used at the bedside by emergency physicians and a separate unit operated by an on-site radiologist for formal sonographic evaluation; computed tomography and magnetic resonance imaging were unavailable. Cardiac workup rested on electrocardiography (ECG) and echocardiography, with no coronary angiography on site. The laboratory ran basic biochemistry and hematology, with any advanced testing requiring external facilities. There was no blood bank or transfusion capacity and no operating theater, and neither narcotic analgesics nor thrombolytics were stocked. Together these limits forced referral to Saudi facilities whenever a case required advanced diagnostics, definitive intervention, or specialized care, most notably acute coronary syndrome, cerebrovascular events, and major trauma.

Care pathway and referral process

Pilgrims could present without restriction to the emergency department (open 24 h) or to the outpatient clinics and 14 primary healthcare centers (both 08:00–24:00). At the primary care centers, family medicine specialists managed ambulatory complaints and escalated cases to the central emergency department on clinical judgment. External referral decisions were made jointly by the on-duty emergency medicine specialists, and transfer proceeded once the receiving institution confirmed acceptance; referrals went predominantly to Saudi German Hospital (private) and Al Noor Specialist Hospital (Ministry of Health) in Makkah. Throughout this study, admission denotes inpatient admission from the emergency department to the hospital’s own wards or intensive care unit.

Data source and study population

Data were retrieved retrospectively from the hospital’s electronic medical record system, Fonet Information Systems (Fonet Bilgi Teknolojileri A.Ş., Türkiye), which records only encounters within the Diyanet Turkey Hospital and its primary healthcare centers. Each pilgrim was uniquely identified by full name combined with Turkish national identification number; this dual identifier enabled reliable linkage of repeat presentations and a clear separation of patient-level and visit-level analyses. All emergency department presentations between April 15 and July 4, 2025 were eligible; visits with incomplete registration records were excluded. No analysis variable contained missing data, so all analyses used the complete dataset.

Outcome definitions

A referral was defined as external transfer from the Diyanet Turkey Hospital emergency department to a Saudi healthcare facility. A revisit was any subsequent emergency department presentation by the same patient within the study period, and an early repeat visit was a revisit occurring within the first 3 days of the index visit. Mortality was ascertained from the Presidency of Religious Affairs centralized pilgrim registry, which captures deaths regardless of location.

Hajj period classification

Visits were stratified into four periods reflecting the ritual calendar and pilgrim density in Makkah [ 3 ]:

Pre-Hajj Period: through June 3, 2025 (preparation and early arrival). Arafat Period: June 4–5, 2025 (the standings at Arafat and Muzdalifah). Eid Period: June 6–9, 2025 (Eid al-Adha and the stoning ritual at Jamarat; pilgrims at Mina and Makkah). Post-Hajj Period: from June 10, 2025 onward (departure).

Service model transition

The study period was also split by operational service model. On May 26, 2025, inpatient admissions were discontinued, creating two phases. In the Secondary Care Period (through May 25), the hospital provided emergency evaluation, outpatient and inpatient management, intensive care, and basic laboratory and imaging, with referral reserved for advanced investigation or definitive treatment. In the Primary Care Period (from May 26 onward), services were limited to emergency evaluation and outpatient treatment, and all patients needing admission or advanced diagnostics were referred onward.

Diagnosis classification

Emergency department diagnoses were coded using the International Classification of Diseases, 10th Revision (ICD-10) and grouped into 10 organ-system categories reflecting clinical relevance and disease patterns characteristic of the Hajj setting [ 29 ] (Table 1 ).

Table 1 Diagnostic classification categories used in the study No Category ICD-10 Codes Example Diagnoses 1 Respiratory System Diseases J00–J06,J09–J18,J20–J22,J30–J39,J40–J47,J80–J84, J90–J96, J98–J99; I26 Upper/lower respiratory tract infections, bronchitis, pneumonia, asthma/chronic obstructive pulmonary disease (COPD) exacerbation, pulmonary thromboembolism 2 Musculoskeletal System Diseases M00–M25,M40–M54,M60–M79, M80–M99 Myalgia, arthralgia, low back/neck pain, joint disorders 3 Cardiovascular System Diseases I05–I09,I10–I16,I20–I25,I27–I28,I30–I52,I70–I79,I80–I89, I95–I99 Hypertension, ischemic heart disease, arrhythmia, heart failure, deep vein thrombosis 4 Gastrointestinal System Diseases A00–A09,K00–K14,K20–K31,K35–K38,K40–K46,K50–K67,K70–K77,K80–K87, K90–K93;R10, R11, R19 Gastritis, dyspepsia, diarrhea, nausea-vomiting, abdominal pain 5 Skin and Subcutaneous Tissue Diseases L00–L08,L20–L30,L40–L45,L50–L54,L60–L75,L80–L99; T78.3–T78.4 Dermatitis, allergic reactions, skin infections, cellulitis 6 Neurological System Diseases G00–G09,G20–G26,G30–G32,G35–G37,G40–G47,G50–G59,G60–G65,G70–G73,G80–G83,G90–G99;I60–I69; R42, R51, R55, R56 Headache, vertigo, syncope, stroke, seizure 7 Trauma and Injuries S00–S99;T00–T35,T66–T78, T79; T36–T65; W00–X59 Falls, collisions, lacerations, fractures, sprains, poisoning 8 Genitourinary System Diseases N00–N08,N10–N16,N17–N19,N20–N23,N25–N29,N30–N39,N40–N51,N60–N98; R30–R39; R10.2 Urinary tract infection, renal colic, acute urinary retention, hematuria, pelvic pain 9 Endocrine and Metabolic Disorders E10–E16,E20–E35,E40–E46,E50–E64,E70–E90; E86–E87 Hypoglycemia, diabetic ketoacidosis, electrolyte disturbances, dehydration 10 Other/Unclassified R00–R09,R20–R29,R40–R41,R43–R50,R52–R54,R57–R69,R70–R99;Z00–Z99; F00–F99 Diagnoses not fitting the above categories, symptoms not elsewhere classified

Ethical approval

Institutional permission was obtained from the Presidency of Religious Affairs and the Chief Physician’s Office of the Makkah Diyanet Turkey Hospital (June 30, 2025), and ethical approval from the Etlik City Hospital Scientific Research Ethics Committee (October 22, 2025; decision AEŞH-BADEK1-2025-545). The study followed the Declaration of Helsinki; all identifying information was coded before analysis and excluded from reporting.

Statistical analysis

Data were analyzed in SPSS 23.0 (IBM Corp., Armonk, NY, USA) and Python 3.11. Categorical variables are reported as frequency and percentage, continuous variables as mean ± standard deviation. Normality was assessed with the Kolmogorov–Smirnov test, categorical comparisons with the chi-square test, and two-group continuous comparisons with the independent-samples t-test.

Multivariable logistic regression identified independent risk factors for revisit and referral. Both outcomes were captured directly by the routine registration and discharge workflow and required no investigator-defined criteria. The revisit model included age group, sex, and diagnosis category; the referral model added revisit status. These are the standard fields recorded for every presentation and are consistently identified as relevant in the mass gathering medicine literature; no wider candidate set was screened against the data. All variables were entered together by forced entry, with no stepwise selection, backward elimination, or univariate filtering. Reference categories were age < 50 years, female sex, and respiratory disease (the most frequent diagnostic category). Results are reported as adjusted odds ratios (aOR) with 95% confidence intervals (CI).

The service model transition was assessed by comparing referral rates between phases and computing the relative risk (RR); presentation patterns and outcomes across Hajj periods are described descriptively. Significance was set at two-tailed p < 0.05.

Results

Fig. 1 Flow diagram of patient enrollment and clinical outcomes

Of the 84,942 Turkish pilgrims served, 9,902 (11.7%) reached the emergency department and generated 13,360 visits (1.35 per patient; 219 per day) (Fig. 1 ). The cohort was older, with a slight male predominance (mean age 61.3 ± 11.5 years; median 63, interquartile range [IQR] 54–70; 54.1% male), with visits concentrated in the seventh decade of life. Children rarely presented: 31 patients under 18 accounted for just 42 visits. Overall, 273 patients (2.76%) and 2.04% of visits ended in referral. Table 2 details the full demographic and clinical profile.

Table 2 Demographic and clinical characteristics of patients presenting to the emergency department Variable n % General Characteristics Total patients 9,902 11.7 Total visits 13,360 - Age (years), mean ± SD 61.3 ± 11.5 - Age range 6–97 - Mean daily visits 219 - Sex Male 5,355 54.1 Female 4,547 45.9 Age Group < 50 years 1,515 15.3 50–64 years 4,013 40.5 65–74 years 3,375 34.1 ≥ 75 years 999 10.1 SD Standard Deviation. Percentage of total patients represents the emergency service utilization rate (9,902/84,942 = 11.7%)

Visits clustered before the rituals began: 61.4% fell in the pre-Hajj period and 28.2% in the post-Hajj period, with the Arafat and Eid periods accounting for the remainder (Fig. 2 ). The daily pattern was the reverse: intensity peaked during Eid (283.2/day) and was lowest during Arafat (122.5/day), when pilgrims had moved to Arafat and Muzdalifah.

Fig. 2 Temporal distribution of emergency department visits across the 2025 Hajj periods

Respiratory disease was the most common presentation at 49.4%, well above the other/unclassifiable, musculoskeletal, and cardiovascular categories that followed. Table 3 breaks down visits and referrals by category.

Table 3 Distribution of patients and referrals by diagnosis category at the patient level Diagnosis Category n % Referral n Referral Distribution % Respiratory System Diseases 4,890 49.4 49 17.9 Musculoskeletal System Diseases 1,521 15.4 4 1.5 Cardiovascular System Diseases 702 7.1 61 22.3 Gastrointestinal System Diseases 545 5.5 45 16.5 Skin and Subcutaneous Tissue Diseases 192 1.9 0 0 Genitourinary System Diseases 151 1.5 17 6.2 Trauma and Injuries 142 1.4 38 13.9 Endocrine and Metabolic Diseases 130 1.3 7 2.6 Neurological System Diseases § 21 0.2 37 13.6 Other/Unclassified 1,608 16.2 15 5.5 Total 9 , 902 100 273 2.76 ‡ n: Number of patients; %: Percentage of patients; Referral n: Number of referred patients; Referral %: Distribution of referred patients by diagnosis category ‡The value shown in the Total row (2.76%) represents the patient-based referral rate (273/9,902). The visit-based referral rate is 2.04% (273/13,360) § Sixteen patients initially classified under non-neurological categories were reassigned a neurological diagnosis following clinical evaluation. Consequently, “n” reflects the presenting diagnosis, whereas “Referral n” reflects the final referral diagnosis

The 273 referred patients were older than the cohort as a whole (mean age 67.0 ± 10.2 years; 61.2% aged ≥ 65). Referral rate climbed steeply with age, reaching roughly eight-fold in the ≥ 75 group relative to the < 50 group ( p < 0.001), but did not differ by sex ( p = 0.634; Table 4 ). A further 72 patients required inpatient admission, again older on average (mean age 68.6 years).

Cardiovascular disease was the leading reason for referral, and the referral mix diverged sharply from the presentation mix (Table 3 ). Respiratory complaints accounted for half the visits but only 17.9% of transfers, whereas cardiovascular and neurological diagnoses, both uncommon among presentations, were referred far more often than their volume would suggest.

Trauma made up 13.9% of referrals ( n = 38); women were referred for trauma at roughly 2.7 times the male rate (21.5% vs. 7.9%). Imaging, ordered for 99 referred patients (36.3%), revealed pathology in 42 (42.4%).

During the study period, 54 patients were referred from primary healthcare centers to the emergency department, and 75 patients were referred from outpatient clinics to higher-level facilities.

Table 4 Distribution of referrals by age group, sex, and revisit status Variable Total n Referral n Referral Rate ** % Referral Distribution *** % p value Sex Male 5,355 152 2.84 55.7 0.634 Female 4,547 121 2.66 44.3 Age Group < 50 years 1,515 12 0.79 4.4 < 0.001 * 50–64 years 4,013 94 2.34 34.4 65–74 years 3,375 102 3.02 37.4 ≥ 75 years 999 65 6.51 23.8 Revisit No 7,625 129 1.69 47.3 < 0.001 * Yes 2,277 144 6.32 52.7 * Chi-square test ** Referral Rate: Percentage of patients referred within each category (Referral n / Total n × 100) *** Referral Distribution: Proportion of referred patients within each category (Referral n / Total Referral × 100)

Most patients came once; 23.0% returned at least once more (Table 4 ). Among repeat visitors, 1,577 came back twice and 700 three or more times; one patient returned 13 times. The 118 frequent visitors (≥ 5 visits) were predominantly male (66.1%) and most often had a respiratory diagnosis (32.8%).

Repeat visitors were referred far more often than single-visit patients ( p < 0.001; Table 4 ). Men returned more than women (24.1% vs. 21.7%; χ² = 8.29, p = 0.004), and the revisit rate rose with age to a peak of 26.0% in the ≥ 75 group.

Most repeat visitors (70.0%) returned on just two separate days, and only 4.8% (104 patients) attended on five or more separate days. Early repeat visits, defined as those within three days of the index presentation, made up 27.0% of all revisits.

In multivariable analysis, three factors independently predicted revisit: male sex, age ≥ 75, and a musculoskeletal diagnosis, the last carrying the largest effect (Table 5 ). Neither the younger age bands nor the remaining diagnostic categories showed an independent association.

Table 5 Risk factors for revisit: multivariable logistic regression analysis Variable aOR 95% CI p value Sex Female (Reference) 1.00 - - Male 1.16 1.05–1.27 0.002 * Age Group < 50 years (Reference) 1.00 - - 50–64 years 1.02 0.88–1.17 0.818 65–74 years 1.09 0.94–1.27 0.238 ≥ 75 years 1.23 1.02–1.48 0.032 * Diagnosis Category Respiratory System (Reference) 1.00 - - Musculoskeletal System 1.74 1.53–1.98 < 0.001 * Gastrointestinal System 1.15 0.93–1.42 0.208 Cardiovascular System 0.97 0.79–1.19 0.773 Trauma 1.34 0.91–1.98 0.139 Other 1.48 1.31–1.66 < 0.001 * aOR Adjusted odds ratio, CI Confidence interval. * p < 0.05. Reference categories: female sex, age < 50 years, respiratory system diseases

Age was the dominant predictor of referral: risk climbed across every band to roughly 14-fold in the ≥ 75 group against those under 50 (Table 6 ). Among diagnoses, trauma carried the steepest referral risk, with cardiovascular, gastrointestinal, and other/unclassifiable categories also elevating it; sex made no difference.

Table 6 Risk factors for referral: multivariable logistic regression analysis Variable aOR 95% CI p value Sex Female (Reference) 1.00 - - Male 1.01 0.78–1.31 0.934 Age Group < 50 years (Reference) 1.00 - - 50–64 years 4.36 2.00–9.48 < 0.001 * 65–74 years 5.58 2.57–12.10 < 0.001 * ≥ 75 years 13.64 6.22–29.93 < 0.001 * Revisit No (Reference) 1.00 - - Yes 3.74 2.91–4.79 < 0.001 * Diagnosis Category Respiratory System (Reference) 1.00 - - Musculoskeletal System 1.38 0.86–2.23 0.184 Gastrointestinal System 3.45 2.02–5.89 < 0.001 * Cardiovascular System 3.85 2.44–6.05 < 0.001 * Trauma 7.85 2.30–26.76 0.001 * Other 4.89 3.52–6.80 < 0.001 * aOR Adjusted odds ratio, CI Confidence interval. * p < 0.05. Reference categories: female sex, age < 50 years, no revisit, respiratory system diseases

Twenty-nine pilgrims died, for a mortality rate of 34 per 100,000: four in the emergency department and the remaining 25 in receiving hospitals or elsewhere, including 13 in hotels or other non-clinical settings. The deceased were predominantly older and male: mean age 71.8 ± 9.5 years (median 73; range 36–85), 82.8% male, 93.1% aged ≥ 65. The four emergency-department deaths were all men (mean age 74.25 years) and all from cardiac arrest.

Deaths clustered after the rituals: 13 (44.8%) occurred in the post-Hajj period, 9 (31.0%) pre-Hajj, 5 (17.2%) during Eid, and 2 (6.9%) during Arafat. The daily mortality rate was highest during Eid (1.25/day) and lowest in the pre-Hajj period (0.28/day).

Among critical cases, clinicians intubated 10 patients and evacuated 10 to Türkiye by air ambulance. Most of those who died had been managed on mechanical ventilation in Saudi intensive care units; cardiac arrest and complicated pneumonia were the leading causes of death.

When admissions stopped on May 26 and the hospital shifted from secondary to primary care, the admission rate fell to zero by definition while referrals and daily visit volume both rose (Table 7 ).

Table 7 Comparison of service model periods Parameter Secondary Care Period Primary Care Period p Value Date range ≤ 25 May ≥ 26 May - Total visits 3,989 9,371 - Mean daily visits 190 236 - Number of deaths 7 22 - Admission rate (%) 1.64 0.00 - Referral rate (%) 1.58 2.27 0.009* Relative risk (RR) - 1.44 - *Chi-square test; χ² = 6.79

The referral rate increased significantly during the primary care period, corresponding to a 44% higher referral risk (RR: 1.44; Table 7 ).

Discussion

This study analyzes the emergency department operations of a temporary healthcare facility run by an independent national health mission during the Hajj, an angle that remains scarce in the mass gathering medicine literature. To our knowledge, the 11.7% figure is among the first reported utilization rates for a national Hajj mission within its own population. We emphasize that this rate reflects care delivered within the Diyanet system: pilgrims could also reach Saudi Ministry of Health facilities, and those encounters were not captured in Fonet, so true overall utilization is necessarily somewhat higher. Read with that boundary in mind, the figure still offers a usable reference point for comparative analysis and resource planning across missions.

The advanced mean age (61.3 ± 11.5 years) and the high proportion of patients aged 65 and older (44.2%) align with the aging pilgrim profile reported in the Hajj literature [ 11 , 12 ]. Ardiana et al., in a retrospective cohort of 72,078 Indonesian pilgrims, classified 58.9% as high-risk on the basis of age over 60 and underlying conditions such as hypertension and diabetes [ 30 ]. This demographic structure raises the burden of chronic disease and the demand for care that follows from it.

Age shaped clinical outcomes as decisively as it shaped the demographic profile. Advanced age was the strongest independent risk factor for referral, with the risk rising roughly 14-fold in the ≥ 75 group relative to those under 50, consistent with the age-related increase in hospitalization reported by Kolivand et al. among Iranian pilgrims [ 31 ]. That pilgrims aged ≥ 75 accounted for 23.8% of all referrals despite representing only 10.1% of patients confirms the marked vulnerability of the oldest pilgrims to critical illness. These data argue for age-based risk assessment in pre-Hajj screening and dedicated follow-up protocols for pilgrims aged 75 and older. The 2026 Hajj regulations point in the same direction: under Saudi Ministry of Hajj and Umrah (MOHU) directives, pilgrims aged 65 and older must now be accompanied by a blood relative aged 18 to 60 [ 32 , 33 ], a policy development consistent with the age gradient we observed.

Alongside age, the temporal distribution of visits carried its own implications for resource planning. Most visits (61.4%) fell in the pre-Hajj period, consistent with pre-ritual stabilization and with Sugeng et al.‘s emphasis on monitoring pilgrims with chronic disease [ 34 ]. The daily visit mean peaked during the Eid period (283.2/day), when physical exertion was highest, and fell to 122.5 during Arafat; this variability supports adjusting resource allocation to the ritual calendar [ 18 , 19 ]. Part of the Arafat decline is geographic rather than clinical: as the rituals move pilgrims from Makkah toward Mina and Arafat, a Makkah-centered facility becomes harder to reach, and emergencies at the ritual sites may be managed by nearer health units. Distance, transit time, and crowd movement can delay or redirect presentations, so our single-center counts likely understate care delivered outside Makkah during these periods, a second route by which true utilization sits above what we report.

Respiratory disease was the most common presentation [ 4 , 8 , 15 ], unsurprising given how readily these pathogens spread through a dense, mobile crowd [ 5 , 35 ]. Al-Tawfiq et al. traced most infections to influenza, rhinovirus, and coronaviruses [ 36 , 37 ], and the COVID-19 experience reviewed by Alsaleh et al. shows how resistant they are to containment [ 38 ].

The pattern that matters most clinically is a mismatch between how often a condition presented and how severe it proved once referred. We use the term morbidity–mortality paradox to describe this, not to assert an established entity. Respiratory complaints made up half the presentations but only 17.9% of referrals. Cardiovascular disease showed the reverse (7.1% of patients, 22.3% of referrals), and neurological disease more sharply still (0.2% versus 13.6%), in line with its high acuity and need for advanced intervention. Status epilepticus and cerebrovascular events can deteriorate rapidly, and acute severe headache may signal subarachnoid hemorrhage, meningitis, or cerebral venous thrombosis, conditions especially dangerous under Hajj field conditions. Gastrointestinal diseases carried a similarly elevated referral risk, with dehydration, foodborne infection, and acute abdominal conditions proving difficult to manage in a facility with limited diagnostics.

The same severity gradient appears in other Hajj series. Gaddoury et al. attributed 31% of Hajj mortality to cardiovascular causes, and Altebainawi et al. tied cardiovascular disease to 64% of intensive care admissions and up to 66% of deaths [ 6 , 39 ]. All four of our emergency department deaths followed cardiac arrest. Triage may therefore do better to weight cardiovascular and neurological severity than to track respiratory volume, though the observational design keeps this a hypothesis for prospective testing. That we performed 10 intubations and arranged 10 air-ambulance transfers to Türkiye shows advanced life support is not optional for a temporary facility.

The sex-based analysis exposed another dimension of the same paradox. Among referred patients, trauma accounted for 21.5% of referrals in women versus 7.9% in men. This 2.7-fold gap appears to contradict Al-Hayani et al., who found 73% of trauma patients to be male during the 2022 Hajj [ 40 ], but the difference is methodological: they measured overall trauma frequency, whereas we examined serious trauma requiring referral. Women in our cohort thus sustained less frequent but more severe injury. Given the cohort’s age structure, most female pilgrims were likely postmenopausal and therefore at elevated risk of osteoporotic fracture. Two other series echo this female predominance. Among 130 pilgrims with musculoskeletal injuries during the 2024 Hajj, Ahmad et al. reported 58.5% to be women and identified wheelchair use in the Haram and Al-Jamarat areas as a key contributor [ 41 ]. In a French cohort, Sridhar et al. found foot pathologies five times more common in women than men, largely attributable to obesity [ 42 ]. Still, the pattern supports gender-aware injury prevention in future missions.

Trauma and musculoskeletal complaints generate demand well beyond the acute encounter, through recurrent visits. The 23.0% revisit rate is an original finding that the Hajj literature has not systematically examined. Repeat visitors were referred more often than single-visit patients (6.32% versus 1.69%), which points to more complex or unresolved problems [ 34 ]. In multivariable analysis, musculoskeletal disease independently raised revisit risk. This follows directly from complaints that persist while pilgrims continue physically demanding rituals, and it is consistent with Khan et al.‘s three-year Indian experience [ 15 ]. The frequent-visitor group (≥ 5 visits, n = 118) was predominantly male (66.1%), with a high share of respiratory disease (32.8%). This marks male pilgrims with chronic respiratory illness as a group to monitor closely, given how readily the crowded, climatically variable Hajj environment spreads respiratory pathogens [ 36 , 37 ]. Early repeat visits (27% within the first three days) may reflect treatment inadequacy or emerging complications, while Makkah’s hot, arid climate, construction dust, and abrupt indoor temperature shifts help explain the broader pattern of recurrence.

These individual-level patterns gain meaning against the hospital’s operational capacity. That 96.5% of patients were assessed and discharged for outpatient treatment is a high rate for a temporary facility without computed tomography, magnetic resonance imaging, surgical capacity, or a blood bank. Imaging revealed pathology in 42.4% of the 99 referred patients who underwent radiological evaluation, though confirming referral appropriateness would require follow-up of final diagnoses and outcomes, which lay beyond our scope. The service model transition adds a second dimension. After inpatient admissions ended on May 26, the referral rate rose and the daily mortality rate climbed from 0.30 to 0.58 per day. This shift is confounded by calendar overlap: the primary-care period coincided with the most intense Hajj phases (Arafat, Eid, and the immediate aftermath), when pilgrim volume, exertion, heat exposure, and case acuity all climb independently of service capacity. The differences therefore reflect reduced on-site inpatient capacity and rising disease burden together, not the model change alone. The implication is nonetheless clear: demand for advanced care peaked exactly when on-site inpatient capacity was withdrawn, confirming the need for integrated coordination with the host country’s health system [ 43 , 44 ], a requirement echoed in qualitative accounts of nursing during Hajj missions [ 45 ].

Mortality followed its own temporal pattern. Nearly half of deaths (44.8%) occurred in the post-Hajj period, suggesting that the cumulative physical and physiological stress of the pilgrimage can manifest with a delay; chronic-disease decompensation and the added burden of travel preparation likely contributed, though confirming these mechanisms would require prospective physiological measurement. The daily mortality rate peaked during the Eid period (1.25/day), when exertion and environmental stress were highest, marking it as the most critical window for acute mortality. It fell to its lowest (0.28/day) in the pre-Hajj period, when visit volume was at its highest, a temporal echo of the morbidity–mortality paradox. Care intensity should therefore be sustained through the post-Hajj period, not only during the rituals themselves.

The overall mortality rate of 34 per 100,000 is far lower than the 216 and 240 reported among Iranian and Indonesian pilgrims, respectively [ 30 , 31 ]. Part of this gap is probably real. Systematic pre-Hajj screening and risk-based referral catch high-risk pilgrims early, and Indonesia recorded a similar multi-year fall after it began excluding candidates who failed health criteria during the pandemic [ 46 ]. This accords with the Islamic principle of rukhsah, which lifts religious obligation in illness or incapacity [ 10 , 47 , 48 ]. Infrastructure likely helped too. One central hospital and 14 primary care centers eased access and enabled early intervention, and air-ambulance evacuation to Türkiye gave critically ill pilgrims access to primary percutaneous coronary intervention and thrombectomy. Part of the gap, however, may be one of ascertainment. Deaths after referral to Saudi facilities went unrecorded in Fonet, so the figure reflects within-Diyanet mortality and may modestly understate the true rate. The comparison therefore turns on age structure, screening, and case capture as much as on mission performance.

The broader 2026 regulatory package aligns with our findings beyond the age criterion alone. The morbidity–mortality paradox, in which respiratory disease generates volume while cardiovascular and neurological pathology drives the critical burden, has a direct policy counterpart in the designation of major organ failure and advanced neurological disorders as disqualifying criteria [ 32 ]. Pre-arrival health screening, which our data support, is now formalized through a mandatory Health Approval Certificate issued via Nusuk Masar, the Saudi Ministry of Hajj and Umrah’s official platform for integrating pilgrim procedures including health approvals and vaccination records [ 32 , 49 ]. Meningococcal, COVID-19, and seasonal influenza vaccination has been reinforced as mandatory, with all records integrated digitally into the same platform [ 49 ]. Because these measures postdate our data, they lend prospective weight to a retrospective study.

Direct comparison across cohorts is constrained by structural differences. Kolivand et al.‘s Iranian series (2013–2022) had a mean age of 55.5 years, with only 10.8% over 70 [ 31 ]; our Turkish cohort sits above both Iranian and Indonesian series [ 30 , 31 ] at 61.3 years, with 44.2% aged 65 or older. Screening also diverges: the Iranian Red Crescent Society mandates clinical and paraclinical evaluation, influenza and pneumococcal vaccination, and syndromic surveillance throughout the pilgrimage [ 31 ], whereas the Turkish system offered screenings without mandating participation in 2025, a framework now formalized for 2026 [ 32 , 49 ].

This study has several limitations. First, the retrospective, observational design risks uncontrolled variables and incomplete records and precludes causal inference; the clinical and operational implications should be read as hypothesis-generating. Turkish pilgrims could also access Saudi facilities outside the Diyanet system, though close monitoring and ambulance dispatch from accommodations made direct bypass uncommon; these encounters went unrecorded in Fonet, so the 11.7% rate and the outcomes derived from it reflect within-Diyanet care, with true utilization necessarily higher. Second, the single-center design and exclusively Turkish population limit generalizability. Third, the diagnoses and outcomes of referred patients could not be tracked, constraining any assessment of referral accuracy; referral is not a clean proxy for severity, since clinician judgment, prevailing transfer thresholds, and the facility’s own diagnostic limits all shape the decision. The referral mix is therefore better read as a marker of operational load than as a direct index of case acuity. Fourth, the mechanisms behind the high female trauma rate (fall location, trauma type, effect of clothing) could not be examined. Fifth, field conditions during the Arafat standing may have degraded recording in field tents, so visit counts for that period likely understate the true figures. Sixth, the May 26 service-model transition coincided with peak Hajj activity, so its effect on referral and mortality cannot be separated from the concurrent rise in volume and acuity.

The findings nonetheless point to several clinical priorities. The prominence of cardiovascular emergencies among referrals argues for strengthening advanced life support and building rapid diagnosis-and-referral algorithms for neurological emergencies. The severity of trauma in female pilgrims supports targeted prevention training, and the link between musculoskeletal complaints and revisits favors structured rehabilitation programs. The respiratory burden gives priority to mask use, isolation where feasible, air-conditioning maintenance, and vaccination [ 50 – 52 ], while the gastrointestinal referral risk points to food-safety inspection, hand hygiene, and adequate hydration in elderly pilgrims. Pre-Hajj care should incorporate age-based risk assessment, clinical evaluation of candidates with chronic disease one to two months before departure, medication optimization, and standardized medication lists [ 10 ].

The operational implications are equally concrete. A utilization rate of 11.7% implies planning for roughly 12,000 unique patients (approximately 15,700 visits) per 100,000 pilgrims, with personnel, equipment, and drug stocks scaled accordingly. The Eid-period daily mean of 283.2 visits, 29% above the overall mean, calls for reinforced shift teams during that window. Given the association between the service model transition and referrals, coordination and resource-sharing agreements with the host health system should be a strategic priority. Plain radiography, ultrasonography, ECG, echocardiography, and basic biochemistry handled most visits, but the referral profile suggests that computed tomography for trauma and stroke, a coronary angiography unit for acute coronary syndrome, and intensive care capacity for sepsis and pneumonia would meaningfully reduce the burden transferred to the host system.

Several research directions follow. Prospective follow-up of referred patients’ diagnoses and outcomes in Saudi hospitals would allow direct evaluation of referral accuracy. Observational and qualitative work should clarify the mechanisms behind severe trauma in female pilgrims, including fall location, trauma type, and the effects of clothing and wheelchair use. Cross-country comparison using standardized data collection would help identify best-practice models. Complete electronic recording during the Hajj, linked to pilgrims’ home-country medical records through an integrated system, would improve diagnostic accuracy and treatment in the emergency setting. Prospective assessment of how the 2026 regulations affect pilgrim demographics, disease burden, and mortality is a further priority.

This study fills a knowledge gap in mass gathering medicine by documenting the emergency department experience of a national Hajj health mission in detail. Age-based risk stratification, stronger advanced life support for cardiovascular and neurological emergencies, and planned coordination with the host health system during service model transitions may improve future missions, though prospective evaluation is needed to confirm their impact.

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Acknowledgements

The authors are deeply grateful to the healthcare personnel of the Makkah Diyanet Turkey Hospital, whose selfless dedication and tireless efforts under challenging conditions ensured the well-being of Turkish pilgrims throughout the 2025 Hajj season. Their meticulous commitment to patient care and data recording was indispensable to this study. We also thank the Presidency of Religious Affairs of the Republic of Türkiye for its continued institutional support.

Author contributions

ÖFT conceptualized and designed the study, collected the data, interpreted the results, drafted the manuscript, and was involved in all stages of the research. MFB contributed to the statistical analysis. MRY critically reviewed the entire manuscript and provided editorial recommendations. ZK contributed to the study methodology design and manuscript editing. All authors read and approved the final manuscript.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request. The data were obtained from the electronic medical record system (Fonet Information Systems) of the Makkah Diyanet Turkey Hospital and contain sensitive patient information; therefore, public sharing is restricted in accordance with institutional data governance policies.

Declarations

Ethics approval and consent to participate

This study was conducted in accordance with the Declaration of Helsinki. Institutional permission was first obtained from the Presidency of Religious Affairs of the Republic of Türkiye and the Chief Physician’s Office of the Makkah Diyanet Turkey Hospital on June 30, 2025. Ethical approval was granted by the Etlik City Hospital Scientific Research Ethics Committee on October 22, 2025 (Decision No: AEŞH-BADEK1-2025-545). As this was a retrospective study involving anonymized data, informed consent was not required. All patient identifying information, including names, national identification numbers, and other identifiers, was coded prior to analysis and was not used in reporting.

Consent for publication

Not applicable. This study does not contain any individual person’s data in any form.

Competing interests

The authors declare no competing interests.

Abbreviations

Adjusted odds ratio

Confidence interval

Chronic obstructive pulmonary disease

Coronavirus disease 2019

Electrocardiography

International Classification of Diseases 10th Revision

Interquartile range

Ministry of Hajj and Umrah

Relative risk

Standard deviation

Statistical Package for the Social Sciences

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