For many muslims around the world their prayers are met if they get to visit Makkah before they die. Makkah is the Utopia of muslims and is one of the most holiest cities in Saudi Arabia as well as the world. For those not familiar, only muslims may visit Makkah and boundaries identifying the protective or muslim-only area surround the city.
Makkah is home to the Ka’aba Shrine and the Grand Mosque (Haram). Approximately three million pilgrims from all corners of the world come to Makkah each year to perform Hajj, which is one of the five pillars of Islam. The rest of the year Makkah remains active with visitors as well who come to perform Umrah (like a shortened or lesser version of Hajj).
Hajj is carefully controlled by the Kingdom of Saudi Arabia and a resident from a country outside of the Kingdom cannot just randomly decided “Oh, Hajj starts next week, I think I’ll go to Mecca.” Instead the pilgrims (hajjis) need to apply and register to perform Hajj through an Agency which in turn makes the arrangements for the pilgrims to have accommodation in Meena which is a fiberglass tent city where the majority of all pilgrims stay. On the other hand, there are indeed others from both outside the Kingdom and from within who do come to Makkah during Hajj time and perform Hajj independently and not as part of an organized group.
The Government of Saudi Arabia wishes to control Hajj and the influx of pilgrims for a variety of reasons. Security is naturally a top concern. During Hajj the population of Makkah expands by approximately 3 million people which makes an impact on multiple levels for the area. In addition to the pilgrims, there are additional security forces and paramedics dispatched to Makkah.
The congregation of so many people from different parts of the world in unavoidably overcrowded conditions within a confined area for a short period of time presents many public health challenges. The combination of physical exertion, overcrowding and any pre-existing health conditions such as diabetes, heart disease, chronic chest conditions, renal and liver disease favor local and possibly international spread of communicable diseases, including meningococcal infections, influenza, tuberculosis and gastrointestinal infections.
So what do the Saudi authorities do towards preventing spread of disease and infections? To begin with, pilgrims must go through a series of requisite inoculations before arriving in the Kingdom. The Eurosurveillance web site provides excellent detail as follows:
The Saudi authorities take these challenges very seriously and continually review arrangements to improve the pilgrims’ environment. Pilgrims also need practical pre-travel advice and appropriate immunisations in their home countries. Vaccination requirements and advice have been issued by the Saudi Ministry of Hajj for the most serious communicable disease risks :
All Hajj pilgrims are now required to submit proof of vaccination with the quadrivalent vaccine against meningococcal meningitis types A, C and W135Y as part of the Hajj visa application to Saudi Arabia. This vaccine should have been received not more than three years and not less than ten days before travel to Saudi Arabia, and should be recorded in a vaccination book showing the traveller’s full name .
Children over three months and under two years of age may not be adequately protected by a single dose of meningococcal meningitis ACW135Y vaccine. It is therefore recommended that two doses of vaccine are given to this age group with an interval of three months.
Chemoprophylaxis against meningococcal infection will also be given to all people arriving into Saudi Arabia from countries in the African meningitis belt in order to lower the meningitis carrier rate among them. These countries are listed by the World Health Organization . Ciprofloxacin tablets (500mg) will be given to adults, rifampicin to children, and a ceftriaxone injection to pregnant women .
All travellers to Saudi Arabia are advised to ensure their polio vaccination is up to date. Travellers whose last dose of polio was more than ten years ago should receive a booster, using the trivalent tetanus, diphtheria and polio vaccine. For infants and children up to 15 years of age, a polio vaccination certificate is required as part of the visa application for Saudi Arabia, regardless of whether this is for Hajj or not. The certificate of vaccination should have been issued not more than three years and not less than 10 days before the planned arrival date in Saudi Arabia .
Children over 15 years of age should present proof of the same vaccinations requested for adults.
Additionally, irrespective of previous vaccination history, all travellers under 15 years of age, arriving from polio-affected countries, will also receive oral polio vaccine on entry to Saudi Arabia. The WHO considers the following countries to be polio-affected (as of 4 October 2006):
• Countries with ongoing transmission wild poliovirus: Afghanistan, India,
• Countries with ongoing transmission poliovirus: Angola, Bangladesh, the Democratic Republic of the Congo, Ethiopia, Namibia, Nepal,
• Countries with recent circulation poliovirus: Indonesia, Sudan, Yemen.
The Ministry of Health of Saudi Arabia advises that all travellers from Afghanistan, India, Pakistan and Nigeria, regardless of age and vaccination status, should receive at least one dose of oral polio vaccine before departure for Saudi Arabia. All travellers from these countries, regardless of age and previous immunization history, will also be required to receive an additional dose of oral polio vaccine upon arrival in Saudi Arabia [4,5].
Hepatitis B virus is found in body fluids and can be transmitted either through skin breakages or by close sexual contact. Transmission through the skin may occur through the use of contaminated medical, dental, or other instruments; all pilgrims should consider hepatitis B vaccine. One of the rites of Hajj is for men to have their head shaved. Although the Saudi authorities provide licensed barbers who use a new blade for each pilgrim, other barbers may not conform to such standards. Shaving with a previously used blade could carry a risk of hepatitis B and other bloodborne infections, and so communal use of a razor or blade to shave each other should be avoided. Pilgrims should consider taking with them a disposable razor for this purpose. This will also help to protect against hepatitis C virus infection .
Recent studies have shown a high incidence of influenza infections during the Hajj [6,7,8], and so it would seem prudent to regard all Hajj pilgrims as at risk. The Ministry of Health of Saudi Arabia recommends that pilgrims be vaccinated against influenza before arrival, particularly those with pre-existing conditions (e.g. the elderly, people with chronic chest or heart diseases or those with cardiac, hepatic or renal failure) .
All travellers arriving from countries endemic for yellow fever must present a valid yellow fever vaccination certificate in accordance with the International Health Regulations (http://www.who.int/csr/ihr/en/). These countries are listed by WHO . In the absence of such a certificate, the person will be vaccinated upon arrival and placed under strict surveillance for 6 days from the day of vaccination or the last date of potential exposure to infection, whichever is earlier .
Saudi authorities also require that aircraft and other means of transportation arriving from areas infected with yellow fever are requested to submit a certificate indicating disinsection in accordance with the International Health Regulations.
Malaria is not normally present in Medina or Mecca, but is a risk in other areas of Saudi Arabia including the south-western region and rural areas of the western region. Pilgrims may also plan further travel before or after Hajj to countries in Asia and Africa, and should seek advice about malaria prevention. Pilgrims are advised to practice insect bite avoidance measures that also protects against other vectorborne diseases .
<!–[if !supportLists]–>1. <!–[endif]–>Kingdom of Saudi Arabia. Ministry of Hajj. Hajj Visas. (http://www.hajinformation.com/main/t1510.htm)
<!–[if !supportLists]–>2. <!–[endif]–>Shafi S, Memish Z, Gatrad A, Sheikh A. Hajj 2006: communicable disease and other health risks and current official guidance for pilgrims. Euro Surveill 2005;10(12):E051215.2. (http://www.eurosurveillance.org/ew/2005/051215.asp#2)
<!–[if !supportLists]–>3. <!–[endif]–>Kingdom of Saudi Arabia. Ministry of Hajj. Saudi Ministry of Health Requirements. (http://www.hajinformation.com/main/p3001.htm)
<!–[if !supportLists]–>4. <!–[endif]–>WHO. Health conditions for travellers to Saudi Arabia for the pilgrimage to Mecca (Hajj). Weekly Epidemiological Record 2006, 81(44), 417–424 (http://www.who.int/wer/2006/wer8144.pdf)
<!–[if !supportLists]–>5. <!–[endif]–>WHO. Health conditions for travellers to Saudi Arabia pilgrimage to Mecca (Hajj) III. Poliomyelitis. Weekly Epidemiological Record 2006; 81(46): 444 (http://www.who.int/wer/2006/wer8146.pdf)
<!–[if !supportLists]–>6. <!–[endif]–>Balkhy HH, Memish ZA, Bafaqeer S, Almuneef MA. Influenza a common viral infection among Hajj pilgrims: time for routine surveillance and vaccination. J Travel Med. 2004 Mar-Apr;11(2):82-6.
<!–[if !supportLists]–>7. <!–[endif]–>Shafi S, Rashid H, Ali K, El Bashir H, Zambon M, Haworth E, et al. Enhanced Surveillance of Influenza and other respiratory viruses among UK pilgrims to Hajj 2005. Presented at HPA Annual Conference; September 2005, Warwick, United Kingdom (Abstract available at http://www.iccuk.org/media/articles/misc/study_of_influenza.htm)
<!–[if !supportLists]–>8. <!–[endif]–>Haitham El Bashir, Elizabeth Haworth, Maria Zambon, Shuja Shafi, Jane Zuckerman, and Robert Booy.Influenza among U.K. Pilgrims to Hajj, 2003, Emerging Infectious diseases, 2004, 10, (10) 1883
<!–[if !supportLists]–>9. <!–[endif]–>NaTHNaC. Guidelines for Hajj Pilgrims. 24 November 2006. (http://www.nathnac.org/pro/clinical_updates/hajj241106.htm)
The influx of visitors from all over the world coupled with the crowded conditions during Hajj make the Hajj and Makkah an ideal environment to fuel an epidemic that pilgrims in turn could carry back to their own countries. Even the healthiest pilgrim may be susceptible to disease. It is also not uncommon for someone who has a life threatening condition or illness to purposely try to make it to Makkah (whether during Hajj or not) so he or she can have that last breath take place in Makkah. As a result, pilgrims should take precautions when visiting Makkah and the Haram. Wearing a face mask is recommended as well as ensuring all those inoculations are up-to-date.