NaTHNaC | Advice for Hajj pilgrims, 17 Nov 08, Travellers

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17 November 2008

Advice for Hajj pilgrims

Hajj, the annual pilgrimage to Makkah, is the largest gathering of its kind in the world. Each year over two million Muslims from around the world gather in Makkah. The next Hajj will take place between 6 and 9 December 2008 [1].

Vaccination advice

Vaccination advice for travellers to Saudi Arabia can be found on the NaTHNaC Country Information Page. The following vaccine-preventable diseases have particular relevance to Hajj pilgrims.

Meningococcal meningitis: All pilgrims to Hajj are required to show proof of vaccination against meningococcal meningitis ACW135Y. This vaccine should have been received not more than three years and not less than ten days before arrival in Saudi Arabia, and should be recorded in a vaccination book showing the traveller’s full name. Vaccination is also a requirement for obtaining a visa.

As meningococcal meningitis has occurred during previous Hajj pilgrimages, and has spread to other countries associated with returning pilgrims [2], vaccination is also advised for personal protection.

Children older than three months and younger than 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 in this age group with an interval of three months [3].

Chemoprophylaxis against meningococcal infection will also be given to all arrivals from countries in the African meningitis belt to lower the meningitis carrier rate among them [4]. The Ministry of Health of Saudi Arabia regards these countries as: Benin, Burkina Faso, Cameroon, Central African Republic, Chad, Côte d’Ivoire, Eritrea, Ethiopia, Gambia, Guinea, Guinea-Bissau, Mali, Niger, Nigeria, Senegal, and Sudan.

Polio: All travellers to Saudi Arabia should 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.

In addition, the Ministry of Health of Saudi Arabia recommends that all travellers arriving from Afghanistan, India, Nigeria, Pakistan and Sudan, regardless of age and vaccination history, receive one dose of oral polio vaccine (OPV) prior to departure for Saudi Arabia [4]. All such travellers will also be required to receive a dose of OPV upon their arrival in Saudi Arabia.

The Ministry of Health of Saudi Arabia also recommends that all travellers aged less than 15 years from countries with on-going or recent transmission of imported wild polio virus, show proof of vaccination with oral polio vaccine six weeks prior to visa application. Irrespective of vaccination history, these travellers will be required to receive a dose of OPV on arrival in Saudi Arabia. The Ministry of Health considers the following countries to have on-going transmission of wild polio virus: Angola, Benin, Burkina Faso, Central African Republic, Chad, Democratic Republic of the Congo, Eritrea, Ethiopia, Nepal, Niger, Somalia, Sudan and Yemen.

Hepatitis B: Hepatitis B virus is found in body fluids and can be transmitted either percutaneously or by close sexual contact. Percutaneous transmission 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. Avoid shaving with a previously used blade as this could carry a risk of hepatitis B and other blood borne infections such as hepatitis C for which there is no vaccine. Although the Saudi authorities provide licensed barbers with a new blade to use for each pilgrim, unlicensed barbers abound who may not conform to such standards. It is not unusual for pilgrims to help each other - pilgrims can consider taking with them a disposable razor for this purpose.

Influenza: Influenza is transmitted via the respiratory route. Certain groups are at particular risk of complications from influenza including those aged 65 years and older, and those with pre-existing medical conditions such as chest, heart, liver or kidney conditions, a history of splenectomy, or diabetes [3]. Travellers who fall into any of these categories should receive influenza vaccine annually. In addition, as influenza is readily transmitted in crowded conditions, pilgrims to the Hajj can consider vaccination against influenza. The Ministry of Health of Saudi Arabia recommends that all pilgrims receive influenza vaccine.

Viral respiratory infection (known as Hajj cough) experienced by many pilgrims at the Hajj may range from mild inconvenience to being severe and can interfere with performing the rites. Simple precautions such as use of tissue to cover coughs and sneezes, safe disposal and hand washing will help reduce their spread.

Yellow fever: All travellers arriving from countries/areas at risk of yellow fever transmission must present a valid yellow fever vaccination certificate completed in accordance with the International Health Regulations (2005) [5]. These countries are listed by WHO in International Travel and Health, annex 1 [6].

Food and water advice

Diarrhoeal illnesses are transmitted by the consumption of contaminated food or water. Dehydration can occur as a result of diarrhoea and is of particular risk in hot weather conditions. Babies, infants, the elderly and those with chronic medical conditions are vulnerable to dehydration.

All pilgrims to the Hajj are advised to take food and water hygiene precautions.

In addition travellers should be advised to carry oral rehydration treatment and an anti-motility agent such as loperamide. Antibiotic treatment can be considered, especially for those travellers who have an underlying medical condition. Ciprofloxacin (500mg twice daily for up to three days) in the absence of contraindications is generally the drug of choice.

Vector-borne diseases

Malaria is not normally present in Medina or Makkah, but malaria 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, Africa and Latin America, and should seek advice about malaria prevention.

Pilgrims are advised to practise insect bite avoidance measures that will reduce the risk of other vector-borne diseases, such as dengue fever.

Other health risks

Heat-related hazards

Daytime temperatures in Saudi Arabia, even during the winter months, can reach over 30°C. Associated risks include sunburn, heat exhaustion, and heat stroke.

If at all possible, travel to Mecca before the start of Hajj should be considered in order to allow a period of acclimatisation to the heat. Pilgrims should ensure that they drink plenty of clean water (preferably bottled or boiled) to avoid dehydration.

Sunscreen with a sun protection factor of at least 15 to 30 should be applied liberally to exposed skin every two to three hours. Male pilgrims are not allowed to cover their heads; however an umbrella will provide shade from the sun.

Desert sand can reach very high temperatures; good quality footwear should be worn to avoid burning the feet. Footwear must be removed during times of prayer, and to avoid losing them, pilgrims are advised to carry their footwear in a bag.

Accidents and injuries

Minor injuries are relatively common, particularly to the feet. More serious injuries can occur as a result of stampedes as pilgrims undertake the stoning rite or other mass activities. Pilgrims are advised to avoid peak times, while elderly and infirm persons may wish to consider appointing a proxy for the performance of this rite.

Other health advice

Physical fitness

Performing the rituals of Hajj is demanding and involves walking great distances usually in hot weather. Pilgrims should ensure that they are physically fit before travelling.

Menstruation

Women who anticipate their periods falling during the Hajj period may wish to delay menstruation, which is possible to achieve using hormonal treatment. Women are advised to discuss this with their GP or family planning clinic well before departure.

Medical kits

All pilgrims should take a basic medical kit with them, which should include simple analgesia (pain killers), plasters, anti-motility medication such as loperamide, and oral rehydration treatment. Pilgrims who take regular medication should ensure they have an adequate supply and carry a copy of their prescription.

Insurance

All pilgrims to Hajj should ensure that they have adequate travel health insurance.

Pilgrims should carry with them their GP's details which may be required should emergency medical care be necessary.

Saudi Arabia will undertake screening for selected communicable diseases at points of entry [4].

Further information on health risks for travellers to Saudi Arabia can be found on the NaTHNaC Country Information Page.

Pilgrims should also seek advice about the health risks for any travel that may be undertaken either before or following Hajj. Information on health risks for other destinations throughout the world can be found on the NaTHNaC Country Information Pages.

References

1. Public Health Agency of Canada. Hajj pilgrims – requirements and recommendations for travel. 7 November 2008. [Accessed 12 November 2008]. Available at http://www.phac-aspc.gc.ca/tmp-pmv/2008/hadj-piligrim081107-eng.php

2. World Health Organization. 2001 – Meningococcal disease, serogroup W135 – update. 16 May 2001 [accessed 13 November 2007]. Available at: http://www.who.int/csr/don/2001_05_16/en/.

3. Salisbury D, Ramsay M, Noakes K (eds). Immunisation against infectious disease. 2006. Department of Health, London. Available online at http://www.dh.gov.uk/en/Policyandguidance/Healthandsocial

caretopics/Greenbook/DH_4097254

4. World Health Organization. Health conditions for travellers to Saudi Arabia for the pilgrimage to Mecca (Hajj). Wkly Epidemiol Rec. 2008; 83: 413-5. Available at http://www.who.int/wer/2008/wer8346/en/index.html

5. World Health Organization. International Health Regulations (2005). [Accessed 17 November 2007]. Available at http://www.who.int/csr/ihr/en/

6. World Health Organization. International and travel health. 2008; World Health Organization, Geneva. Available online at http://www.who.int/ith/en