13 November 2007

Guidelines for Hajj Pilgrims

Hajj, the annual pilgrimage to Mecca, is the largest gathering of its kind in the world. Each year over two million Muslims from around the world gather in Mecca. The Hajj takes place between the eighth and thirteenth day of the last month of the Islamic calendar; the next Hajj will take place between the 18 and 23 December 2007.

Vaccination advice

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 contact with returning pilgrims [1], vaccination is also advised for personal protection.

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 in this age group with an interval of three months [2].

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 [3]. These countries are: Benin, Burkina Faso, Cameroon, Chad, Central African Republic, Côte d’Ivoire, Eritrea, Ethiopia, Gambia, Guinea, Guinea-Bissau, Mali, Niger, Nigeria, Senegal and Sudan. Ciprofloxacin tablets (500mg) will be given to adults, rifampicin to children, and ceftriaxone injection to pregnant women.

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 [3]. 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 also be required to receive a dose of OPV on arrival in Saudi Arabia.

The World Health Organization (WHO) considers the following countries to have on-going transmission of wild polio virus (as of October 2007):

•  Countries endemic for polio: Afghanistan, India, Nigeria, Pakistan
• Countries with on-going transmission of imported wild poliovirus: Angola, Chad, Democratic Republic of the Congo, Niger, Myanmar, Somalia, and Sudan.
• Countries with recent transmission of imported poliovirus: Eritrea, Ethiopia, Indonesia, and Yemen.

Tetanus: A booster is recommended if not received within the last ten years. In the UK, when a tetanus booster is recommended, the trivalent tetanus, diphtheria and polio vaccine is the vaccine of choice.

Diphtheria: A booster is recommended if not received within the last ten years. In the UK, when a diphtheria booster is recommended, the trivalent tetanus, diphtheria and polio vaccine is the vaccine of choice.

Typhoid: Vaccination is recommended for all pilgrims to the Hajj.

Hepatitis A: Vaccination is recommended for all pilgrims to the Hajj.

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. Although the Saudi authorities provide licensed barbers with a new blade to use for each pilgrim, other barbers may not conform to such standards. Therefore, shaving with a previously used blade could carry a risk of hepatitis B and other blood-borne infections.  Pilgrims can consider taking with them a disposable razor for this purpose. This will also help to protect against hepatitis C virus infection for which there is no vaccine.

Influenza: Influenza is transmitted via the respiratory route. Certain groups are at particular risk of complications from influenza including those aged 65 years and over, and those with pre-existing medical conditions such as chest, heart, liver or kidney conditions, a history of splenectomy, or diabetes [2]. All 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.

Rabies: Those exposed to potentially rabid animals should seek urgent post-exposure prophylaxis vaccination.

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) [4]. These countries are listed by WHO in International Travel and Health, annex 1 [5].

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 especially 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 Mecca, 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 and Africa, and should seek advice about malaria prevention.

Pilgrims are advised to practise insect bite avoidance measures that also protects against 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 30 should be applied regularly and liberally to exposed skin. Male pilgrims are not allowed to cover their heads; however an umbrella, preferably white in colour, 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 and other 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 often 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 by using the contraceptive pill. 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 are also advised to carry with them their GP's details which may be required should emergency medical care be necessary.

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 also be found on the NaTHNaC Country Information Page.

References

1. 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/.

2. 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

3. World Health Organization. Health conditions for travellers to Saudi Arabia pilgrimage to Mecca (Hajj). Wkly Epid Record. 2007; 82: 385-8. Available at: http://www.who.int/wer/2007/wer8244.pdf

4. World Health Organization. International Health Regulations (2005) [accessed 13 November 2007]. Available at http://www.who.int/csr/ihr/en/

5. World Health Organization. International and travel health. 2007; World Health Organization, Geneva. Available online at http://www.who.int/ith/en

Links and further information

Department of Health advice for travellers to Hajj or Umrah

http://www.dh.gov.uk/en/Policyandguidance/Healthadvicefor

travellers/DH_4114831

Foreign and Commonwealth Office advice to British Hajjis

http://www.fco.gov.uk/en/travelling-and-living-overseas/ta-relevant-to-you/hajj-pilgrims

Royal Embassy of Saudi Arabia London. http://www.ukemb.mofa.gov.sa

The Muslim Council of Britain. http://www.mcb.org.uk/

Ahmed QA, Arabi YM, Memish ZA. Health risks at the Hajj. Lancet. 367:1008, 2006.

NaTHNaC. Country Information Page. http://www.nathnac.org/ds/map_world.aspx