Published Date: 2012-10-11 17:24:30
This year [2012] the Hajj will take place during [24-29 Oct 2012].
Recent outbreaks of Ebola haemorrhagic fever in Uganda and the
Democratic Republic of the Congo, cholera in Sierra Leone, and
infections associated with a novel coronavirus in Saudi Arabia and Qatar
required review of the health recommendations of the 2012 Hajj. Current
guidelines foresee mandatory vaccination with quadrivalent
meningococcal vaccine for all pilgrims and yellow fever and
poliomyelitis vaccine for pilgrims from high-risk countries. Influenza
vaccine is strongly recommended.
The annual Hajj is one
of the greatest assemblies of humankind on earth. Each year, 3 million
Muslims attend the Hajj in Mecca, Saudi Arabia. Of these, 1.8 million
non-Saudi Arabians usually come from overseas countries, and 89 per cent
(1.6 millions) of them arrive by air [1]. Pilgrims come from more than
180 countries worldwide, and about 45 000 pilgrims each year arrive to
Saudi Arabia from the European Union [2].
Preventive measures during the Hajj:
Saudi
Arabia provides free health care to all pilgrims during the Hajj. For
the 2012 Hajj, which will take place on [24-29 Oct 2012], the country
has prepared 25 hospitals, 4427 beds including 500 critical care beds
and 550 emergency care beds. In addition, there are 141 health care
centres in the vicinity of the Hajj area with 20 000 specialised health
care workers. The planning for the Hajj relies on the coordinated
efforts of 24 supervisory committees [2]. The Hajj preventive medicine
committee oversees all public health and preventative matters during the
Hajj. A large number of public health officers regulate ports of entry
for all pilgrims to ensure compliance with the requirements of the Saudi
Arabian Ministry of Health. Public health teams are located in various
areas of the Hajj, including 21 mobile teams. At each of the 18 hubs at
King Abdulaziz International Airport Hajj terminal in Jeddah, 2 clinical
examination rooms and a large holding area are dedicated to assess
arriving pilgrims, check their immunisation status, and administer the
recommended prophylactic medicines [2]. The public health teams and
teams at the ports of entry report back to the command centre on 9
communicable diseases using electronic and manual surveillance systems.
These diseases are influenza, influenza-like illness, meningococcal
disease, food poisoning, viral haemorrhagic fevers, yellow fever,
cholera, poliomyelitis, and plague [2].
Pre- and post-Hajj travel advice:
The
Hajj is a unique event with possible impact on international public
health. Health care practitioners around the world must be attentive to
the potential risks of disease transmission during the Hajj. They must
recommend appropriate strategies for the prevention and control of
communicable diseases before, during, and after the completion of the
Hajj. The current international collaboration in planning vaccination
campaigns, developing visa quotas, arranging rapid repatriation, and
managing health hazards at the Hajj are crucial steps in this process.
The Saudi Arabian Ministry of Health publishes the Hajj requirements for
each Hajj season. This year's [2012] Hajj recommendations have recently
been published [3].
Recent outbreaks of Ebola
haemorrhagic fever in Uganda and the Democratic Republic of the Congo
(DRC), cholera in Sierra Leone, and infections associated with a novel
coronavirus in Saudi Arabia and Qatar required review of the health
recommendations of the 2012 Hajj. We present here the changes and
additions made in the recommendations for these diseases. For
completeness, we also summarise the existing recommendations [3,4].
Meningococcal disease
The
risk of the occurrence of meningococcal outbreaks is a real concern
during the Hajj seasons. This risk is related to the high carriage
rates, with one study from Mecca reporting carriage rate as high as 80
per cent [5]. Due to the previous occurrence of meningococcal outbreaks,
the bivalent A and C meningococcal vaccine became a requirement for the
attendance of the Hajj in 1986. Two large outbreaks caused by
meningococcal serogroup W135 in 2000 and 2001 [6-8] resulted in an
extension of the previous requirement to include serogroups Y and W135,
and the quadrivalent (A, C, Y, W135) meningococcal polysaccharide
vaccine was included as a requirement for a Hajj visa in May 2001 [9].
In addition, visitors arriving from countries in the African meningitis
belt receive chemoprophylaxis with ciprofloxacin tablets (500 mg) at the
port of entry to lower the rate of meningococcal carriage. It is
estimated that about 400 000 to 460 000 pilgrims receive the recommended
doses at the port of entry in Saudi Arabia. Compliance with
meningococcal vaccination among arriving international pilgrims exceeded
97 per cent in 2011 [1].
Yellow fever
In
accordance with the International Health Regulations 2005, all
travellers arriving from countries identified by the World Health
Organization (WHO) as areas at risk of yellow fever must present a valid
yellow fever vaccination certificate showing that the person was
vaccinated at least 10 days previously and not more than 10 years before
arrival at the border. In the absence of such a certificate, the
individual will be placed under strict surveillance for 6 days from the
date of vaccination or the last date of potential exposure to infection,
whichever is earlier. Health offices at entry points will be
responsible for notifying the appropriate director general of health
affairs in the region or governorate about the temporary place of
residence of the visitor. Aircraft, ships, and other means of
transportation arriving from countries affected by yellow fever are
requested to submit a certificate indicating that it applied
disinfection in accordance with methods recommended by WHO.
Risks of respiratory tract infections
Acute
upper respiratory tract infections (URTIs) are the most common disease
during Hajj. There are many factors promoting the spread of respiratory
pathogens, including close contact among pilgrims, shared sleeping
tents, and dense air pollution [2]. The pathogens causing URTIs among
pilgrims are respiratory syncytial virus (RSV), parainfluenza virus,
influenza virus and adenovirus [10]. The rates of different types of
respiratory virus infections are as follows: influenza (9.8 per cent),
parainfluenza (7.4 per cent), adenovirus (5.4 per cent) and RSV (1.4 per
cent) [11]. Because of overcrowding and the fact that many Muslims come
from countries where tuberculosis (TB) is endemic, pulmonary
tuberculosis was a leading cause of hospitalisation in patients with
community-acquired pneumonia [12]. The estimated risk of tuberculosis
acquisition during the Hajj is thought to be around 10 per cent, based
on the use of pre-visit and post-visit QuantiFERON TB assay test [13].
In another community-based survey of the epidemiology of tuberculosis in
Saudi Arabia, positive tests using purified tuberculin antigens were
more frequent in Saudi Arabians living in the Holy cities hosting
pilgrims compared to other cities in Saudi Arabia [14]. The development
of strategies to reduce the transmission of TB during the Hajj is a
challenge for which no evidence-based approved measures are available to
date. The Saudi Arabian Ministry of Health continues to recommend
wearing face masks in crowded places and changing them frequently to
minimise transmission of respiratory infections. Controlling
tuberculosis transmission in mass gatherings is an area that needs
urgent research studies. [14].
Novel coronavirus infection
Of
particular interest is the recent report of 2 cases of acute
respiratory failure associated with a novel coronavirus. Both patients
were previously healthy adults. The cases occurred a few months before
the 2012 Muslim Hajj season. The 1st case of infection with the novel
coronavirus was identified in a Saudi Arabian national, who died in June
2012 [15,16]. The 2nd case was a patient from Qatar who was transferred
to a hospital in London, United Kingdom in early September 2012 [17].
Available data to date do not support human-to-human transmission of
this novel coronavirus, and zoonotic transmission is highly suspected.
In the 2nd case of this novel coronavirus infection, none of the 64
close contacts developed severe disease, 13 of them (20 percent)
reported mild respiratory symptoms, and the novel coronavirus was not
detected in 10 symptomatic contacts who were tested [17].
WHO
does not recommend any travel restrictions to or from Saudi Arabia. The
current case definitions from WHO [18] and from the Saudi Arabian
Ministry of Health can be found on the WHO website (http://www.who.int/csr/disease/coronavirus_infections/case_definition/en/index.html)
and in Table 1, respectively. The practice of good hand hygiene and
cough etiquette was associated with less respiratory illness among
United States travellers to the 2009 Hajj [19]. It is recommended that
pilgrims continue to practice proper hand hygiene, protective behaviours
and cough etiquette to further decrease the occurrence of respiratory
diseases. [see Table 1. Severe respiratory disease associated with novel
coronavirus: case definition by the Saudi Arabian Ministry of Health at
above given URL link.]
Foodborne diseases and cholera
Diarrhoeal
illnesses during mass gathering including Hajj are a potential health
hazard. Many factors may contribute to this problem including:
inadequate standards of food hygiene, shortage of water, the presence
asymptomatic carriers of pathogenic bacteria, and the preparation of
large numbers of meals poorly stored by pilgrims. There are only few
studies describing the incidence and aetiology of traveller's diarrhoea
during the Hajj. In one study, diarrhoea was the 3rd most common cause
(6.7 per cent) of hospitalisation [20]. Another study describes an
outbreak of diarrhoeal illness in a small number of soldiers during the
Hajj season [21]. As a precautionary measure, the Saudi Arabian Ministry
of Health strongly enforces that pilgrims are not allowed to bring
fresh food into Saudi Arabia. Only properly canned or sealed food or
food stored in containers with easy access for inspection is allowed in
small quantities, sufficient for one person for the duration of their
trip.
Cholera is another risk during the Hajj, especially
in light of the continued occurrence of outbreaks in different
countries. As of 20 Sep 2012, a total of 19 283 cases, including 276
(1.4 per cent) deaths have been reported in the ongoing cholera outbreak
in Sierra Leone since the beginning of the year [2012] [22]. The
highest numbers of cases occurred in the western area of the country,
where the capital city of Freetown is located. In addition, the WHO
reported a sharp increase in the number of cholera cases in July [2012]
in the DRC and many other countries [23]. The Ministry of Health of
Saudi Arabia has updated its public health staff at all ports of entry
for pilgrims, to be observant of all pilgrims coming from areas where
cholera has been reported by WHO, and to maintain a high level of
vigilance for any signs and symptoms of diarrhoea, and to continue
surveillance at their camps and initiate quarantine and contact tracing
once a case is suspected. Emphasis is being placed on early detection of
cases and timely provision of treatment at all Hajj premises, once
pilgrims have passed the ports of entry while incubating the disease.
Poliomyelitis
Poliomyelitis
is still predominant in certain countries around the world. The
attendance of visitors from these countries to the Hajj may pose a
health risk for other visitors. All travellers arriving from
polio-endemic countries and re-established transmission countries,
namely Afghanistan, Angola, Chad, the DRC, Nigeria and Pakistan,
regardless of age and vaccination status, should receive one dose of
oral poliovirus vaccine (OPV). Proof of OPV vaccination at least 6 weeks
prior departure is required to apply for entry visa for Saudi Arabia.
These travellers will also receive one dose of OPV at border points on
arrival in Saudi Arabia. The same requirements are valid for travellers
from recently endemic countries at high risk of reimportation of
poliovirus, i.e. India (Table 2).
Polio cases secondary
to wild poliovirus importation or to circulating vaccine-derived
poliovirus in the past 12 months have been reported in the following
countries: China, Central African Republic, Cote d'Ivoire, Kenya, Mali,
Niger, Somalia and Yemen [4]. All visitors aged under 15 years
travelling to Saudi Arabia from these countries should be vaccinated
against poliomyelitis with the OPV or inactivated poliovirus vaccine
(IPV). Proof of OPV or IPV vaccination 6 weeks prior to application is
required for entry visa. Irrespective of previous immunisation history,
all visitors under 15 years arriving in Saudi Arabia will also receive
one dose of OPV at border points (Table 2).
Table 2. Saudi Arabian health requirements and recommendations for entry visas for the Hajj seasons in 2012
Ebola outbreaks
Two
large outbreaks of Ebola have been reported by the Ministries of Health
of Uganda and the DRC. In Uganda, a total of 24 probable and confirmed
cases were reported during the outbreak. Eleven of these 24 cases have
been laboratory-confirmed by the Uganda Virus Research Institute in
Entebbe. A total of 17 deaths were reported in this outbreak. The last
confirmed case was admitted on [3 Aug 2012] and discharged from hospital
on [24 Aug 2012] [24,25]. This is twice the maximum incubation period
(21 days) for Ebola proposed by the WHO during Ebola outbreak response
operations. In the DRC, 46 cases (14 laboratory-confirmed, 32 probable)
of Ebola haemorrhagic fever were reported until [15 Sep 2012]. Of these,
19 have been fatal (6 confirmed, 13 probable). The cases occurred in 2
health zones of Isiro and Viadana in Haut-Uele district in Province
Orientale. In addition, 26 suspected cases have been reported and are
being investigated.
The 2 Ebola outbreaks are not
epidemiologically linked and have been caused by 2 different Ebola
subtypes: Ebola subtype Sudan in Uganda, and Ebola subtype Bundibugyo in
DRC. To avoid global spread of the disease, the Saudi Arabian Ministry
of Health decided to exclude pilgrims from these 2 countries for this
Hajj season. This restriction is based on the careful review and
deliberation of the national committee on communicable disease
prevention who felt that it cannot be excluded that new cases may
emerge, and on the fact that the risk of disease transmission is thought
to be high with potential catastrophic consequences if occurring during
the Hajj, as the disease has a high mortality rate, and no therapeutic
interventions are available.
[Reported by: J A Al-Tawfiq /1, Z A Memish /2
1. Saudi Aramco Medical Services Organization, Dhahran, Kingdom of Saudi Arabia
2.
Public Health Directorate, Ministry of Health, Riyadh, Director WHO
Collaborating Center for Mass Gathering Medicine, Professor, College of
Medicine, Alfaisal University, Riyadh, Kingdom of Saudi Arabia]
References follow: http://www.promedmail.org/direct.php?id=20121011.1338172
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