NaTHNaC | Hajj_Umrah, Health Professionals

Health Information Sheets

Advice for Pilgrims: Hajj and Umrah

Hajj, the annual pilgrimage to Makkah (Mecca), in the Kingdom of Saudi Arabia (KSA), is the largest gathering of its kind in the world. Each year over two million Muslims from around the world gather in Makkah.

Each year, the KSA Ministry of Health (MOH) issues specific requirements for entry to the Hajj and Umrah, usually during the summer months before the Hajj and Umrah season commences. The Hajj pilgrimage occurs between the 8th and 12th day of the twelfth month of the Islamic calendar. The 1434 H season is estimated to fall between 13 and 15 October 2013 [1]. Umrah is a shorter, non-compulsory pilgrimage for Muslims that can be performed at any time.

The following general advice is available and will be updated when the MOH announce their requirements and any additional recommendations for the 1434 H season.

Hajj and Umrah vaccination requirements

Meningococcal meningitis: All pilgrims aged two years and older, who intend to undertake Hajj or Umrah, are required to provide proof of vaccination against meningococcal meningitis ACW135Y in order to obtain a visa for entry into KSA [2, 3].

Meningococcal ACW135Y vaccine should have been received not more than three years, and not less than ten days, before arrival in KSA, and should be recorded in a vaccination book showing the traveller’s full name. If a traveller is in possession of an International Certificate of Vaccination or Prophylaxis (ICVP) booklet, meningococcal meningitis ACW135Y vaccine can be recorded in the ‘Other Vaccinations’ pages.

Meningococcal meningitis has occurred during previous Hajj pilgrimages and has spread to other countries in association with returning pilgrims [4]. Therefore, vaccination is also advised for personal protection of all pilgrims, including those under the age of two years.

A conjugated ACWY vaccine is the preferred vaccine for all travellers. Full details of vaccines and schedules can be found in the meningococcal chapter of Immunisation against infectious diseases (the ‘Green Book’) and the manufacturer’s Summary of Product Characteristics [5].

Polio: For infants and children up to 15 years of age, a vaccination report is also required for polio [3]. Additional requirements relating to polio vaccination for the 1434 H season may be stipulated by the MOH.

(All pilgrims to Hajj and Umrah are recommended 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).

Yellow fever: All pilgrims to Hajj and Umrah arriving from countries or areas at risk for transmission of yellow fever must present a valid ICVP documenting yellow fever vaccination completed in accordance with International Health Regulations (2005) [6]. These countries are listed by the WHO in International Travel and Health 2012, Annex 1 [7].

Hajj and Umrah recommendations

Vaccination advice

General vaccination advice for travellers to KSA can be found on the NaTHNaC Country Information Page. All pilgrims should ensure that they are up-to-date with routine immunisations including measles, mumps and rubella (MMR).

The following vaccine-preventable diseases have particular relevance to Hajj and Umrah pilgrims.

Seasonal influenza: It is recommended that all pilgrims are vaccinated against seasonal influenza.

Influenza is transmitted via the respiratory route and is easily transmitted in crowded conditions. Certain groups are at particular risk of complications from influenza including those aged 65 years and older, pregnant women and those with pre-existing medical conditions such as chest, heart, liver or kidney conditions, a history of splenectomy, or diabetes [8]. Travellers who fall into any relevant risk categories should receive influenza vaccine annually from their usual healthcare provider. For those who do not fall into any of these risk categories, vaccine can be purchased and administered at some high street pharmacies, other retailers, or private travel clinics.

Viral respiratory infection (known as Hajj cough) experienced by many pilgrims at the Hajj, can range from a mild inconvenience to a severe illness, and can interfere with performing the rites. Advice about the prevention of influenza can be found on the NaTHNaC Health Information Sheet on seasonal influenza.

Severe respiratory illness - novel coronavirus

Between September 2012 and 13 May 2013 a global total of 33 confirmed cases of a a respiratory illness caused by a novel coronavirus infection (nCoV), have been identified in six countries (Jordan, KSA, France , Qatar, United Arab Emirates and UK);18 of these 33 cases have died. There are no travel restrictions and no specific advice for travellers to the Middle East [9-11]. Health Professionals are are advised to consult NaTHNaC clinical updates (nCoV) for up to date information.

Pilgrims are recommended to practise ‘cough hygiene’: sneezing or coughing into a tissue and promptly discarding it safely, and frequent hand washing, to reduce the risk of respiratory infection including influenza.

Travellers returning from the Middle East with mild respiratory symptoms are most likely to have a common respiratory illness such as a cold.

However, if symptoms worsen considerably with breathlessness, medical advice should be sought from the GP or NHS Direct. Returning travellers should mention which countries of the Middle East they have visited.

Further information is available on the Public Health England website.

Hepatitis B: Hepatitis B virus is found in body fluids and can be transmitted either percutaneously or by sexual contact. Percutaneous transmission can 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. The KSA authorities provide licensed barbers with a new blade to use for each pilgrim, however, unlicensed barbers may not conform to this standard [12]. Pilgrims should avoid shaving with a blade previously used by another, as this could result in transmission of hepatitis B, and other blood borne infections such as hepatitis C, for which there is no vaccine. Pilgrims can consider taking with them a disposable razor for personal use during this rite.

Food and water advice

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

All pilgrims are advised to take personal, food and water hygiene precautions.

Travellers should also take with them oral rehydration therapy and self-treatment for diarrhoea. An anti-motility agent such as loperamide can be carried and an antibiotic 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 antibiotic of choice for adults.

Vector-borne diseases

Malaria is not present in Medina or Makkah, but malaria is a risk in the south-western, rural region of KSA. Pilgrims planning further travel before or after Hajj or Umrah to malaria risk areas in KSA or Asia, Africa and Latin America, 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.

Heat and sun-related hazards

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

If possible, travel 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 and cooled) to avoid dehydration.

Sunscreen with a sun protection factor of at least 15 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; 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.

Cold: During the winter months the weather can be very cold overnight. Pilgrims should ensure they take appropriate bedding with them such as blankets and sleeping bags.

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

Medical kits: All pilgrims should take a basic medical kit that includes simple analgesia (pain killers), plasters, and oral rehydration treatment. An anti-motility agent (such as loperamide) can be carried to treat the symptoms of diarrhoea. Pilgrims who take regular medication should ensure they have an adequate supply and carry a copy of their prescription.

Insurance: All pilgrims to Hajj and Umrah should have adequate travel health insurance.

Pilgrims should 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 KSA can be found on the NaTHNaC Saudi Arabia Country Information Page.

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

References

1. The Council of British Hajjis. Hajj dates 2013. [Accessed 13 May, 2013]. Available at: http://dobuy.co.uk/cbhuk/?s=Hajj+dates

2. Ministry of Hajj, Kingdom of Saudi Arabia. Saudi Ministry of Health Requirements. [Accessed 13 May, 2013]. Available at: http://www.hajinformation.com/main/p3001.htm 3..Ministry of Hajj, Kingdom of Saudi Arabia. Hajj Visas. [Accessed 10 may, 2013]. Available at: http://www.hajinformation.com/main/t1510.htm

4. World Health Organization. 2001 – Meningococcal disease, serogroup W135 – update. 16 May 2001 [Accessed 13 May, 2013]. Available at: http://www.who.int/csr/don/2001_05_16/en/.

5.. Meningococcal Ch 22. In: Salisbury D, Ramsay M, Noakes K (eds). Immunisation against infectious disease. 2006 updated 7 May 2013. Department of Health, London. [Accessed 13 May, 2013]. Available at: https://www.gov.uk/government/publications/meningococcal-the-green-book-chapter-22

6. World Health Organization. International Health Regulations (2005). [Accessed 13 May. 2013]. Available at: http://www.who.int/csr/ihr/en/

7. World Health Organization. International and travel health. 2012; World Health Organization, Geneva. Available at: http://www.who.int/ith/en/

8. Influenza. Chapter 19. In: Salisbury D, Ramsay M, Noakes K (eds). Immunisation against infectious disease. 2006 updated 19 April, 2013. Department of Health, London. [Accessed 13 May 2013]. Available at: https://www.gov.uk/government/publications/influenza-the-green-book-chapter-19

9. World Health Organization. Novel coronavirus infection – update. 8 May 2013. [Accessed 13 May 2013]. Available at: http://www.who.int/csr/don/2013_05_03_ncov/en/index.html

http://www.who.int/csr/don/2013_05_09_ncov/en/index.html

10. World Health Organization. Novel coronavirus infection – update.9 May 2013. [Accessed 13 May 2013]. Available at: http://www.who.int/csr/don/2013_05_09_ncov/en/index.html

11. Ministére des Affaires cociales et de la Sante. Noveau coronavirus: Presésentation des disposif national d’investigation épidemiologique. [Accessed 13 May, 2013]. Available at : http://www.social-sante.gouv.fr/actualite-presse,42/communiques,2322/nouveau-coronavirus-presentation,15823.html

12.. Memish ZA. The Hajj: Communicable and non-communicable health hazards and current guidance for pilgrims. Eurosurveillance. 15(39); 30 September 2010. [Accessed 13 May, 2013]. Available at: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19671