Health Considerations for Hajj Travelers
Abstract & Commentary
By Sarah Kureshi and Philip R. Fischer, MD, DTM&H
Sarah Kureshi is a Student, Mayo Medical School, Rochester, MN, and Philip R. Fischer is Professor of Pediatrics, Division of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
Sarah Kureshi and Dr. Fischer report no financial relationships relevant to this field of study.
Synopsis: Pilgrims attending the yearly Hajj in Saudi Arabia face numerable communicable and non-communicable health hazards which, unanticipated, can lead to illness and death. Constant preparedness is essential, as the time of Hajj varies each year, as do the risks from infectious diseases and severe overcrowding. Travel medicine practitioners should be aware of these health risks and the current recommendations so that traveling pilgrims can benefit from appropriate pre-travel care both during and after their trips.
Source: Ahmed QA, et al. Health Risks at the Hajj. Lancet. 2006;367:1008-1015.
Ahmed and colleagues performed an extensive search on publications related to the Hajj pilgrimage from the past 40 years. They described the major communicable and non-communicable diseases present at Hajj, examined the response of clinicians, the Saudi Ministry of Health, and Hajj authorities to these health issues, and also listed recommendations for future pilgrims. Ahmed et al found that the major communicable diseases at Hajj include meningococcal disease, respiratory tract infections, diarrheal disease, skin infections, blood-borne disease, and emerging infectious diseases.
N. meningitidis carrier rates have been as high as 80% in congested areas of Mecca, and outbreaks affecting over 1000 pilgrims in 1987, 2000, and 2001 prompted compulsory vaccination for all pilgrims. Respiratory disease, primarily pneumonia, is the most common cause of hospital admissions during the Hajj. Influenza and other viral respiratory tract infections remain widespread during the Hajj, and use of influenza vaccine has shown benefit. The annual influx of pilgrims from areas endemic for tuberculosis, along with documented increases in immune response to tuberculosis antigens during the Hajj, should provoke physicians to keep a high index of suspicion for tuberculosis. Traveler's diarrhea also quite commonly occurs during the Hajj. Cholera outbreaks are no longer of concern; however, food poisoning remains a significant cause of diarrhea and vomiting during the Hajj, and prevention education is crucial. Skin infections, primarily pyoderma, carbuncles, and folliculitis, occur frequently during Hajj associated with lengthy rituals of standing and walking. Pilgrims should be educated on skin protection. Head shaving of males, which takes place towards the completion of the Hajj, is one route through which blood-borne diseases can be transmitted, especially Hepatitis B and C, and HIV; therefore, the HBV vaccine is recommended. The threat of emerging infectious diseases, even including rare viral hemorrhagic fever syndromes (Rift Valley fever, Alkhurma virus, Ebola virus) during Hajj, cannot be overlooked. In the past years, there was worry that the Hajj could turn SARS and Avian influenza (H5N1) into enormous epidemics. Saudi authorities took appropriate preventive measures and, to date, neither is considered a health concern for Hajj pilgrims.
Ahmed et al concluded that the major non-communicable diseases at Hajj are cardiovascular diseases, trauma risks, fire-related injury, environmental heat injury, and occupational hazards during cattle slaughtering.
Cardiovascular disease is the most common cause of death during the Hajj due to the physical stress of the pilgrimage, the massive overcrowding, and the advanced age of many pilgrims. Hajj should be avoided in pilgrims with unstable cardiac status. Over 25 billion dollars have gone into efforts to prevent Hajj-related disasters, as trauma has been a leading cause of illness and death for over a decade. Mecca's small size, extreme congestion of vehicles, and poor compliance with seatbelt use contribute to increased motor vehicle accidents. Pilgrims are most anxious about the trauma hazards from stampedes, as they have caused a total of almost 2500 deaths over the last 16 Hajj seasons. In 2006, stampedes resulting from pilgrims tripping over fallen luggage lead to 289 pilgrim injuries and 380 pilgrim deaths.
The Jamarat bridge, where pilgrims crowd to throw stones at the pillars, has had continual structural changes, as it has been a high risk site for stampedes and accidents. After Hajj 2006, 1 billion dollars went into expanding and improving it; 80% of this project should be completed in time for the 2007 Hajj. During the 1997 Hajj, 343 deaths and 1500 casualties resulted from a fire caused by open stoves burning makeshift tents. Since then, fire hazards have decreased due to the banning of open stoves, replacement of makeshift tents with permanent fiberglass installations, additional regulations, and continuous public education. Heat exhaustion and heatstroke is a leading cause of morbidity and mortality at Hajj due to high temperatures in Mecca, especially in the summer, demanding physical rituals, and open spaces with inadequate shade. Pilgrims should be educated on prevention measures and also on the flexibility associated with the ritual timings.
Commentary
Hajj, the Islamic pilgrimage to Mecca and related holy sites, is one of the ordinances which every physically able Muslim should perform once in his lifetime. Hajj occurs during the 12th month of the Islamic lunar calendar, which is 10 days shorter than the Gregorian calendar and, as a result, Hajj falls at a different date each year. The Hajj 2006 occurred from January 8th-12th, and the next Hajj will take place December 29th 2006-January 2, 2007. Hajj rituals occur over a 5-day period starting in Mecca with 7 circumambulations (Tawaf) around the Ka'aba ('the house of God') in Masjid Al-Haram and, subsequently, include a daylong group vigil at the Plain of Arafat, collecting stones in Muzdalifah, stopping in Mina at Jamarat to stone the pillars that are representations of Satan and, lastly, returning to Mecca to perform Sa'i (walking fast seven rounds) between the hills of Safa and Marwah (a 450 m long gallery path that forms part of the Masjid), make an animal sacrifice (usually by proxy), and a farewell Tawaf (see Figure 1). Mecca also serves as the setting for a minor form of Hajj, Umrah, which can be performed any time of the year. Most Hajj and Umrah pilgrims also travel to the Prophet Muhammad's grave in Medina, a city north of Mecca, although it is not required for either pilgrimage.
Every year more than 2 million Muslims from all over the world, including 10,000 American Muslims, come together for Hajj, with numbers continuing to grow. Given that Hajj is the oldest and largest annual gathering of its kind in the world, it remains surprisingly structured and peaceful. However, as each Hajj ritual must be completed in a specific manner at or within a prescribed time in a congested setting, the environmental and physical hazards it poses are considerable. Ahmed et al have very thoroughly and extensively covered these hazards and outlined applicable preventive recommendations.
It is important to note that the Hajj setting can provide an avenue for many emerging infectious diseases to transform into international outbreaks. In the 2001 Hajj, WHO reported an outbreak of W135 serogroup of meningococcal meningitis among people traveling to Saudi Arabia and, after Hajj, there were 109 cases and 35 deaths among those from all different countries returning from Hajj. The resulting stringent requirements for all pilgrims to show proof of meningococcal vaccination have resulted in less concern for spread of meningitis in more recent years. Avian influenza could become a risk to Hajj participants due to crowded conditions and also because of Saudi Arabia's location on the pathway of migratory birds. Surveillance and control systems are being strengthened. Respiratory infections remain the most common diseases during Hajj, with the incidence increasing over the years. Education, prevention, and regulation remain crucial to decreasing the risk of emerging infectious diseases during Hajj.
One of us (Sarah Kureshi) found great benefit from a Hajj pilgrimage that extended far beyond the fulfillment of a religious obligation. The Hajj journey is both powerful and transformative, as the purpose is to purify the pilgrim from sin and provide a 'clean slate' in life. The experience of being surrounded by millions of people from over 150 different countries all in one place for one purpose is indescribable. While performing Tawaf among the masses, there is a surreal feeling as if one is not even walking but being lifted from the ground and pushed along by the crowd. For disabled and elderly pilgrims, there are special ramps for wheelchairs for the Tawaf and Sai walking rituals. At Mina, one of the most congested placed during Hajj, one can see nothing but thousands of tents and people for miles and miles. Trying to walk one quarter mile from a tent to a fruit shop can take up to 30 minutes due of the crowds.
The Hajj is a profound spiritual journey but, at the same time, it is also extremely tiring and stressful. There is little time for sleep, and pilgrims should be well rested before their trip. The rituals themselves require a lot of walking and physical exertion that can even fatigue young adults in good health. Pilgrims, especially the elderly, should prepare for Hajj by working towards good physical health, well in advance. Pilgrims who have sickness or weakness can perform many rituals by proxy, including entrusting someone else to throw stones on their behalf. Additionally, pilgrims should be informed of the flexibility around timings of the rituals so that they can make safe and sensible decisions. Many prominent Islamic scholars have declared a wide margin of hours allowable for different rituals, but many pilgrims are uninformed and believe their Hajj is unaccepted if their ritual is not performed during the limited sunnah hours (preferred practice by the Prophet). Therefore, the sunnah hours for rituals are often the most crowded and dangerous. At Hajj 2006, a tragic stampede occurred during a sunnah hour of the stoning at Jamarat.
While spiritual enrichment and completion of rituals are first and foremost on a pilgrim's mind, being cautious throughout Hajj must not be forgotten. Shoving and stepping on pilgrims without consideration, unfortunately, occurs throughout Hajj. Some tour groups employ the dangerous practice of banding together in horizontal lines during Tawaf and stoning. If a pilgrim is caught in this it can be very unsafe, and cautious pilgrims should especially avoid these groups. During Tawaf and while at the tents in Arafat and Mina, pilgrims are encircling each other with barely any breathing room. When one person coughs, it effortlessly sprays over all others within arms reach. Appropriate vaccination is the mainstay of prevention for these situations. One ritual marking the ending of Hajj is the head shaving or hair clipping. Although Saudi authorities have continually enforced regulations for barbers at Hajj, there still remain unlicensed barbers who reuse non-sterile blades for shaving hair on the roadsides. Along the roadsides, one will see hundreds of pilgrims and barbers shaving heads with one bloody razor, moving directly from one scalp to another. Cautious pilgrims should go to licensed barbers and also be vaccinated for Hepatitis B.
Hajj can be an enriching experience of a lifetime. By being aware of specific activities and appropriate preparation (as summarized in Table 1), travel medicine practitioners can help pilgrims maximize the value of their journey while minimizing the risks.
Sources
- www.usahajjmission.com/newsupdate.html#saudiembassy
- Phrom-in S. Surveillance for Meningococcal Carriage by Muslims Returning from the Hajj to Hat Yai Airport, Thailand. Southeast Asian J Trop Med Public Health. 2002;33:127-130.
- Balkhy H, Al-Hajjar S. Avian Influenza: Are Our Feathers Ruffled? Ann Saudi Med. 2006;26:175-182.
- Meysamie A, et al. Comparison of Mortality and Morbidity Rates Among Iranian Pilgrims in Hajj 2004 and 2005. Saudi Med J. 2006;27:1049-1053.
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