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The Hajj, a mass-gathering of over 3.5-million pilgrims, faces challenges to global health-security, housing, food, water, transportation, communication, sanitation, crowd-control and security. The Indian Medical Mission extended health-security to approximately 140,000 pilgrims, through outreach medical teams, primary-care clinics, tent-clinics, secondary-care hospitals and evacuation capabilities. Data on medical attendance, bed-occupancy, investigations, referrals, medication usage and deaths was compared. Outpatient attendance was 374,475 in static-clinics, 5135 in tent-clinics and 13,473 through task-forces. 585 (62.90%) in-patients were hospitalized amongst 930 secondary-care referrals. Secondary-care bed-days were 2106 with average bed-occupancy being 77.78%. 495 patients were institutionalized in tertiary-care Saudi-Arabian hospitals. Infectious diseases were most commonly (53.26%) encountered due to overwhelming respiratory-infections, followed by trauma (24.40%). Analgesics (66.38/100 patients) and antibacterials (48.34/100 patients) were frequently prescribed. Crude mortality amongst Indian pilgrims was 11.99/10,000. Risk-factors associated with high morbidity were old-age and pre-existing comorbidities. Overwhelming surge of patients facilitates transmission of communicable infections and leads to stress induced physical, mental and compassion fatigue amongst healthcare personnel. Respiratory infections are highly prevalent and easily transmissible during Hajj leading to significant morbidity, increased burden to existing health facilities, overwhelming costs on health systems and globalization of multiresistant pathogens. Diabetic patients should avoid heat exposure and use protective footwear during Hajj rituals. Mass-gathering medicine at Hajj can be optimized by improving patient knowledge on performing Hajj at a younger age, medicine compliance, avoiding self-medication, self-monitoring of hypertension, blood glucose, and preventive health measures; screening of pre-existing comorbidities; and resource augmentation with telemedicine networks and decision-support systems.

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Mean rates of VAP, CLABSI, and CAUTI were 14.4, 8.1, and 4.5 per 1000 device days, which are comparable with Indian and global ICUs. Patients and HCPs form important reservoirs of infection. Resolute conviction and sustained momentum in Infection Control Initiatives are an essential step toward patient safety.

Emerging organisms are likely to evade routine identification or be disregarded as non-contributory. Astute efforts directed at identification of emerging isolates, decisions by clinical microbiologists and treating physicians and containment of infection are required.

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Available online at www.sciencedirect.com jo urn al ho mep age: www .e lsev ie r. co m/ lo cate/ mj afi m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 6 9 ( 2 0 1 3 ) 2 4 6 e2 5 3

Background: Prototheca is an emerging, opportunistic, pathogenic, zoonotic achlorophyllous green alga, expanding in pathogenicity and host range, causing localized and disseminated infections. This outbreak of Prototheca wickerhamii algaemia and sepsis in a tertiary care 30bedded chemotherapy oncology unit is the first human outbreak to the best of our knowledge.Methods: P. wickerhamii algaemia was confirmed on consecutive isolation. Person to person transmission was hypothesized considering all patients in the unit at risk. Clinico-demographic, diagnostic and treatment profile were correlated. Both manual and automated systems were used for blood culture, isolation, identification and susceptibility of Prototheca.Liposomal amphotericin B was given. Outbreak surveillance of faeces, fingertips and environmental reservoirs, retrospective surveillance during past 15 years and prospective surveillance was continued for two years. Results:The outbreak affected 12 neutropenic patients over 50 days. No specific clinical features were noted. The hypothesis could not be substantiated. P. wickerhamii was isolated as yeast-like colonies revealing Gram positive yeast-like cells without budding and pseudohyphae which were confirmed by automated system. Post amphotericin B blood cultures were negative for Prototheca. Surveillance studies were not contributory.Conclusion: P. wickerhamii has no documented reservoirs or transmission. Endogenous colonization in the gut followed by translocation during chemotherapy induced immunosuppression is likely to cause algaemia and sepsis. Outbreaks are difficult to detect and control as incubation period is variable and clinical presentation is muted, emphasizing the need to strengthen hospital and laboratory based surveillance systems to ensure adequate preparedness, rapid detection and response to outbreaks.