Home Diagnosing and managing heat exhaustion: insights from a systematic review of cases in the desert climate of Mecca
Article
Licensed
Unlicensed Requires Authentication

Diagnosing and managing heat exhaustion: insights from a systematic review of cases in the desert climate of Mecca

  • Saber Yezli ORCID logo EMAIL logo , Yara Yassin , Sujoud Ghallab , Mashan Abdullah , Bisher Abuyassin , Ramesh Vishwakarma and Abderrezak Bouchama
Published/Copyright: August 4, 2023
Reviews on Environmental Health
From the journal Reviews on Environmental Health Volume 39 Issue 4

Abstract

Heat exhaustion (HE) is a common, yet obscure, heat-related illness that affects millions of people yearly and its burden is projected to rise due to climate change. A comprehensive literature synthesis is lacking despite previous studies on various HE aspects. This systematic review aims to fill this gap by identifying and synthesizing available evidence on the risk factors, symptoms, biomarkers, treatment options, and outcomes for HE. The review focused on HE during the Muslim (Hajj) pilgrimage where the condition is endemic. We conducted a structured search of MEDLINE/PubMed, Embase, Web of Science Core Collection, SCOPUS, and CINAHL databases. We summarized the data from eligible studies and synthesized them in narrative form using pooled descriptive statistics. Ten studies were included between 1980 and 2019, reporting over 1,194 HE cases. HE cases presented with elevated core temperature (up to 40°C) and mainly affected older males from the Middle East and North Africa region, with overweight individuals at a higher risk. Clinical symptoms included hyperventilation, fatigue, dizziness, headaches, nausea, and vomiting, but not central nervous system disturbances. HE was associated with cardiac stress, and with water, electrolyte, and acid-base alterations. Cooling and hydration therapy were the primary management strategies, leading to a low mortality rate (pooled case fatality rate=0.11 % [95 % CI: 0.01, 0.3]). Most cases recovered within a few hours without complications. HE is associated with cardiac stress and changes in homeostasis, leading to distinct clinical symptoms. Early diagnosis and treatment of HE are crucial in reducing the risk of complications and mortality. The review provides insights into the pathophysiology and outcomes of HE, adding to the scarce literature on the subject. Prospero registration number: CRD42022325759.

Keywords: climate change; emergency medicine; heat exhaustion; heatstroke; public health; symptoms
Corresponding author: Dr. Saber Yezli, Ph.D, Biostatistics, Epidemiology and Scientific Computing Department, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; and Experimental Medicine Department, King Abdullah International Medical Research Center, King Saud bin Abdulaziz University of Health Sciences, Riyadh, Saudi Arabia, Phone: +966111 464 7272 ext. 77601, E-mail:

  1. Ethical approval: Not applicable.

  2. Informed consent: Not applicable.

  3. Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.

  4. Competing interests: Authors state no conflict of interest.

  5. Research funding: None declared.

  6. Data availability: The data supporting the findings of this review are available within the article [and/or] its supplementary materials.

References

1. Gauer, R, Meyers, BK. Heat-related illnesses. Am Fam Physician 2019;99:482–9.Search in Google Scholar

2. Bouchama, A, Abuyassin, B, Lehe, C, Laitano, O, Jay, O, O’Connor, FG, et al.. Classic and exertional heatstroke. Nat Rev Dis Prim 2022;8:8. https://doi.org/10.1038/s41572-021-00334-6.Search in Google Scholar PubMed

3. Sorensen, C, Hess, J. Treatment and prevention of heat-related illness. N Engl J Med 2022;387:1404–13. https://doi.org/10.1056/nejmcp2210623.Search in Google Scholar PubMed

4. Krau, SD. Heat-related illness: a hot topic in critical care. Crit Care Nurs Clin 2013;25:251–62. https://doi.org/10.1016/j.ccell.2013.02.012.Search in Google Scholar PubMed

5. Asplund, CA, O’Connor, FG, Noakes, TD. Exercise-associated collapse: an evidence-based review and primer for clinicians. Br J Sports Med 2011;45:1157–62. https://doi.org/10.1136/bjsports-2011-090378.Search in Google Scholar PubMed

6. Glazer, JL. Management of heatstroke and heat exhaustion. Am Fam Physician 2005;71:2133–40.Search in Google Scholar

7. Wexler, RK. Evaluation and treatment of heat-related illnesses. Am Fam Physician 2002;65:2307–14.Search in Google Scholar

8. Leon, LR, Bouchama, A. Heat stroke. Compr Physiol 2015;5:611–47. https://doi.org/10.1002/cphy.c140017.Search in Google Scholar PubMed

9. Kenny, GP, Wilson, TE, Flouris, AD, Fujii, N. Heat exhaustion (Chapter 31). In: Romanovsky, AA, editor. Handbook of clinical neurology. Elsevier; 2018, vol 157. 505–29 pp.10.1016/B978-0-444-64074-1.00031-8Search in Google Scholar PubMed

10. Kenny, GP, Yardley, J, Brown, C, Sigal, RJ, Jay, O. Heat stress in older individuals and patients with common chronic diseases. CMAJ (Can Med Assoc J) 2010;182:1053–60. https://doi.org/10.1503/cmaj.081050.Search in Google Scholar PubMed PubMed Central

11. Meehl, GA, Tebaldi, C. More intense, more frequent, and longer lasting heat waves in the 21st century. Science 2004;305:994–7. https://doi.org/10.1126/science.1098704.Search in Google Scholar PubMed

12. Noweir, MH, Bafail, AO, Jomoah, IM. Study of heat exposure during Hajj (pilgrimage). Environ Monit Assess 2008;147:279–95. https://doi.org/10.1007/s10661-007-0120-6.Search in Google Scholar PubMed

13. Ghaznawi, HI, Ibrahim, MA. Heatstroke and heat exhaustion in pilgrims performing the Haj (annual pilgrimage) in Saudi Arabia. Ann Saudi Med 1987;7:323–6. https://doi.org/10.5144/0256-4947.1987.323.Search in Google Scholar

14. Tagliacozzo, E, Toorawa, SM. The Hajj: pilgrimage in Islam. New York: Cambridge University Press; 2015.10.1017/CBO9781139343794Search in Google Scholar

15. Yezli, S. Risk factors for heat-related illnesses during the Hajj mass gathering: an expert review. Rev Environ Health 2023;38:33–43. https://doi.org/10.1515/reveh-2021-0097.Search in Google Scholar PubMed

16. Yezli, S, Khan, A, Bouchama, A. Summer Hajj pilgrimage in the era of global warming: a call for vigilance and better understanding of the risks. J Trav Med 2019;26. https://doi.org/10.1093/jtm/taz069.Search in Google Scholar PubMed

17. Moher, D, Liberati, A, Tetzlaff, J, Altman, DG, Group, P. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009;6:e1000097. https://doi.org/10.1136/bmj.b2535.Search in Google Scholar PubMed PubMed Central

18. Abdelmoety, DA, El-Bakri, NK, Almowalld, WO, Turkistani, ZA, Bugis, BH, Baseif, EA, et al.. Characteristics of heat illness during Hajj: a cross-sectional study. BioMed Res Int 2018;2018:1–6. https://doi.org/10.1155/2018/5629474.Search in Google Scholar PubMed PubMed Central

19. Alkassas, W, Rajab, AM, Alrashood, ST, Khan, MA, Dibas, M, Zaman, M. Heat-related illnesses in a mass gathering event and the necessity for newer diagnostic criteria: a field study. Environ Sci Pollut Res Int 2021;28:16682–9. https://doi.org/10.1007/s11356-020-12154-4.Search in Google Scholar PubMed PubMed Central

20. Almuzaini, Y, Abdulmalek, N, Ghallab, S, Mushi, A, Yassin, Y, Yezli, S, et al.. Adherence of healthcare workers to Saudi management guidelines of heat-related illnesses during Hajj pilgrimage. Int J Environ Res Publ Health 2021;18:1–11. https://doi.org/10.3390/ijerph18031156.Search in Google Scholar PubMed PubMed Central

21. Baomer, AAS, El Bushra, HE. Profile of diabetic Omani pilgrims to Mecca. East Afr Med J 1998;75:211–4.Search in Google Scholar

22. el-Bakry, AK, Channa, AB, Bakhamees, H, Turkistani, A, Seraj, MA. Heat exhaustion during mass pilgrimage – Is there a diagnostic role for pulse oximetry? Resuscitation 1996;31:121–6. https://doi.org/10.1016/0300-9572(95)00918-3.Search in Google Scholar PubMed

23. Abudahish, AA, Elbushra, HE. The utilization of primary health care services at Mina during Hajj, 1998. Saudi Epidemiol Bull 1999;6:4–5.Search in Google Scholar

24. Kashmeery, A. Physiological studies on heat exhaustion victims among Mecca pilgrims. Acta Med Austriaca 1995;22:16–22.Search in Google Scholar

25. Khan, ID, Hussaini, SB, Shazia, K, Ahmad, FMH, Faisal, FA, Salim, MA, et al.. Emergency response of Indian Hajj Medical Mission to heat illness among Indian pilgrims in tent-clinics at Mina and Arafat during Hajj, 2016. Int J Travel Med Global Health 2017;5:135–9. https://doi.org/10.15171/ijtmgh.2017.26.Search in Google Scholar

26. Khogali, M. Epidemiology of heat illnesses during the Makkah pilgrimages in Saudi Arabia. Int J Epidemiol 1983;12:267–73. https://doi.org/10.1093/ije/12.3.267.Search in Google Scholar PubMed

27. Mimish, L. Electrocardiographic findings in heat stroke and exhaustion: a study on Makkah pilgrims. J Saudi Heart Assoc 2012;24:35–9. https://doi.org/10.1016/j.jsha.2011.08.003.Search in Google Scholar PubMed PubMed Central

28. Alkassas, W, Rajab, AM, Alrashood, ST, Khan, MA, Dibas, M, Zaman, M. Heat-related illnesses in a mass gathering event and the necessity for newer diagnostic criteria: a field study. Environ Sci Pollut Res Int 2021;28:16682–9. https://doi.org/10.1007/s11356-020-12154-4.Search in Google Scholar PubMed PubMed Central

29. Memish, ZA, Assiri, A, Almasri, M, Alhakeem, RF, Turkestani, A, Al Rabeeah, AA, et al.. Prevalence of MERS-CoV nasal carriage and compliance with the Saudi health recommendations among pilgrims attending the 2013 Hajj. JID (J Infect Dis) 2014;210:1067–72. https://doi.org/10.1093/infdis/jiu150.Search in Google Scholar PubMed PubMed Central

30. Bouchama, A, Knochel, JP. Heat stroke. N Engl J Med 2002;346:1978–88. https://doi.org/10.1056/nejmra011089.Search in Google Scholar

31. Saudi Ministry of Health. Guidelines for management of heat illnesses during Hajj; 2019.Search in Google Scholar

32. Yezli, S, Yassin, Y, Ghallab, S, Abdullah, M, Abuyassin, B, Vishwakarma, R, et al.. Classic heat stroke in a desert climate: a systematic review of 2632 cases. J Intern Med 2023. https://doi.org/10.1111/joim.13633.Search in Google Scholar PubMed

33. Al-Faify, SK, El Bushra, HE, AI-Wahaibi, SS, AlSalman, SA, BaOmer, AA, Khawajah, AA, et al.. Behavioral risk factors for pilgrims to Makkah, 1997. Saudi Epidemiol Bull 1998;5:3–7.Search in Google Scholar

34. Yezli, S, Mushi, A, Yassin, Y, Maashi, F, Khan, A. Knowledge, attitude and practice of pilgrims regarding heat-related illnesses during the 2017 Hajj mass gathering. Int J Environ Res Publ Health 2019;16. https://doi.org/10.3390/ijerph16173215.Search in Google Scholar PubMed PubMed Central

35. AI-Rabeah, AM, EI-Bushra, HE, AI-Sayed, MO, Al-Saigul, AM, AI-Rasheedi, AA, AI-Mazam, AA, et al.. Behavioral risk factors for disease during Hajj: the second survey. Saudi Epidemiol Bull 1998;5:19–20.Search in Google Scholar

36. Kenney, WL, Craighead, DH, Alexander, LM. Heat waves, aging, and human cardiovascular health. Med Sci Sports Exerc 2014;46:1891–9. https://doi.org/10.1249/mss.0000000000000325.Search in Google Scholar

37. Alele, F, Malau-Aduli, B, Malau-Aduli, A, Crowe, M. Systematic review of gender differences in the epidemiology and risk factors of exertional heat illness and heat tolerance in the armed forces. BMJ Open 2020;10:e031825. https://doi.org/10.1136/bmjopen-2019-031825.Search in Google Scholar PubMed PubMed Central

38. Gifford, RM, Todisco, T, Stacey, M, Fujisawa, T, Allerhand, M, Woods, DR, et al.. Risk of heat illness in men and women: a systematic review and meta-analysis. Environ Res 2019;171:24–35. https://doi.org/10.1016/j.envres.2018.10.020.Search in Google Scholar PubMed

39. Ahmed, A, Sadaniantz, A. Metabolic and electrolyte abnormalities during heat exhaustion. Postgrad Med 1996;72:505–6. https://doi.org/10.1136/pgmj.72.850.505.Search in Google Scholar PubMed PubMed Central

40. Chung, NK, Pin, CH. Obesity and the occurrence of heat disorders. Mil Med 1996;161:739–42. https://doi.org/10.1093/milmed/161.12.739.Search in Google Scholar

41. Bedno, SA, Urban, N, Boivin, MR, Cowan, DN. Fitness, obesity and risk of heat illness among army trainees. Occup Med (Lond) 2014;64:461–7. https://doi.org/10.1093/occmed/kqu062.Search in Google Scholar PubMed

42. Carberry, PA, Shepherd, AM, Johnson, JM. Resting and maximal forearm skin blood flows are reduced in hypertension. Hypertension 1992;20:349–55. https://doi.org/10.1161/01.hyp.20.3.349.Search in Google Scholar PubMed

43. Yezli, S, Mushi, A, Almuzaini, Y, Balkhi, B, Yassin, Y, Khan, A. Prevalence of diabetes and hypertension among Hajj pilgrims: a systematic review. Int J Environ Res Publ Health 2021;18. https://doi.org/10.3390/ijerph18031155.Search in Google Scholar PubMed PubMed Central

44. Wilson, TE, Crandall, CG. Effect of thermal stress on cardiac function. Exerc Sport Sci Rev 2011;39:12–7. https://doi.org/10.1097/jes.0b013e318201eed6.Search in Google Scholar

45. Hostler, D, Suyama, J, Guyette, FX, Moore, CG, Pryor, RR, Khorana, P, et al.. A randomized controlled trial of aspirin and exertional heat stress activation of platelets in firefighters during exertion in thermal protective clothing. Prehosp Emerg Care 2014;18:359–67. https://doi.org/10.3109/10903127.2013.869644.Search in Google Scholar PubMed

46. Donoghue, AM, Sinclair, MJ, Bates, GP. Heat exhaustion in a deep underground metalliferous mine. Occup Environ Med 2000;57:165–74. https://doi.org/10.1136/oem.57.3.165.Search in Google Scholar PubMed PubMed Central

47. Keatinge, WR, Coleshaw, SR, Easton, JC, Cotter, F, Mattock, MB, Chelliah, R. Increased platelet and red cell counts, blood viscosity, and plasma cholesterol levels during heat stress, and mortality from coronary and cerebral thrombosis. Am J Med 1986;81:795–800. https://doi.org/10.1016/0002-9343(86)90348-7.Search in Google Scholar PubMed

48. Brandenberger, G, Candas, V, Follenius, M, Libert, JP, Kahn, JM. Vascular fluid shifts and endocrine responses to exercise in the heat. Effect of rehydration. Eur J Appl Physiol Occup Physiol 1986;55:123–9. https://doi.org/10.1007/bf00714993.Search in Google Scholar

49. Montain, SJ, Laird, JE, Latzka, WA, Sawka, MN. Aldosterone and vasopressin responses in the heat: hydration level and exercise intensity effects. Med Sci Sports Exerc 1997;29:661–8. https://doi.org/10.1097/00005768-199705000-00012.Search in Google Scholar PubMed

50. Richards, R, Richards, D. Exertion-induced heat exhaustion and other medical aspects of the City-to-Surf fun runs, 1978–1984. Med J Aust 1984;141:799–805. https://doi.org/10.5694/j.1326-5377.1984.tb132954.x.Search in Google Scholar PubMed

51. Hess, JJ, Saha, S, Luber, G. Summertime acute heat illness in U.S. emergency departments from 2006 through 2010: analysis of a nationally representative sample. Environ Health Perspect 2014;122:1209–15. https://doi.org/10.1289/ehp.1306796.Search in Google Scholar PubMed PubMed Central

Supplementary Material

This article contains supplementary material (https://doi.org/10.1515/reveh-2023-0059).

Received: 2023-05-02
Accepted: 2023-06-14
Published Online: 2023-08-04
Published in Print: 2024-12-17

© 2023 Walter de Gruyter GmbH, Berlin/Boston

Articles in the same Issue

  1. Frontmatter
  2. Reviews
  3. A systematic review on the association between exposure to air particulate matter during pregnancy and the development of hypertensive disorders of pregnancy and gestational diabetes mellitus
  4. Screen time and childhood attention deficit hyperactivity disorder: a meta-analysis
  5. The association between polycystic ovary syndrome and environmental pollutants based on animal and human study; a systematic review
  6. Residues of carcinogenic pesticides in food: a systematic review
  7. The concentration of Lithium in water resources: A systematic review, meta-analysis and health risk assessment
  8. Polychlorinated biphenyls and thyroid function: a scoping review
  9. The European Union assessments of radiofrequency radiation health risks – another hard nut to crack (Review)
  10. Research progresses on the effects of heavy metals on the circadian clock system
  11. Diagnosing and managing heat exhaustion: insights from a systematic review of cases in the desert climate of Mecca
  12. Para-occupational exposure to chemical substances: a systematic review
  13. Association of the ACE2-Angiotensin1-7–Mas axis with lung damage caused by cigarette smoke exposure: a systematic review
  14. Impacts and mechanisms of PM2.5 on bone
  15. Impacts and potential mechanisms of fine particulate matter (PM2.5) on male testosterone biosynthesis disruption
  16. Exposure to perfluoroalkyl and polyfluoroalkyl substances and risk of stroke in adults: a meta-analysis
  17. Prevalence and concentration of aflatoxin M1 and ochratoxin A in cheese: a global systematic review and meta-analysis and probabilistic risk assessment
  18. The effect of polycyclic aromatic hydrocarbon biomarkers on cardiovascular diseases
  19. Biological effects of electromagnetic fields on insects: a systematic review and meta-analysis
  20. Letter to the Editor
  21. Monkeypox and drug repurposing: seven potential antivirals to combat the viral disease
https://doi.org/10.1515/reveh-2023-0059
Keywords for this article
climate change; emergency medicine; heat exhaustion; heatstroke; public health; symptoms

Articles in the same Issue

  1. Frontmatter
  2. Reviews
  3. A systematic review on the association between exposure to air particulate matter during pregnancy and the development of hypertensive disorders of pregnancy and gestational diabetes mellitus
  4. Screen time and childhood attention deficit hyperactivity disorder: a meta-analysis
  5. The association between polycystic ovary syndrome and environmental pollutants based on animal and human study; a systematic review
  6. Residues of carcinogenic pesticides in food: a systematic review
  7. The concentration of Lithium in water resources: A systematic review, meta-analysis and health risk assessment
  8. Polychlorinated biphenyls and thyroid function: a scoping review
  9. The European Union assessments of radiofrequency radiation health risks – another hard nut to crack (Review)
  10. Research progresses on the effects of heavy metals on the circadian clock system
  11. Diagnosing and managing heat exhaustion: insights from a systematic review of cases in the desert climate of Mecca
  12. Para-occupational exposure to chemical substances: a systematic review
  13. Association of the ACE2-Angiotensin1-7–Mas axis with lung damage caused by cigarette smoke exposure: a systematic review
  14. Impacts and mechanisms of PM2.5 on bone
  15. Impacts and potential mechanisms of fine particulate matter (PM2.5) on male testosterone biosynthesis disruption
  16. Exposure to perfluoroalkyl and polyfluoroalkyl substances and risk of stroke in adults: a meta-analysis
  17. Prevalence and concentration of aflatoxin M1 and ochratoxin A in cheese: a global systematic review and meta-analysis and probabilistic risk assessment
  18. The effect of polycyclic aromatic hydrocarbon biomarkers on cardiovascular diseases
  19. Biological effects of electromagnetic fields on insects: a systematic review and meta-analysis
  20. Letter to the Editor
  21. Monkeypox and drug repurposing: seven potential antivirals to combat the viral disease
Sign up now to receive a 20% welcome discount
Institutional Access
How does access work?
Have an idea on how to improve our website?
Please write us.
© 2025 De Gruyter Brill
Downloaded on 6.11.2025 from https://www.degruyterbrill.com/document/doi/10.1515/reveh-2023-0059/html
Scroll to top button