Health Professionals

Health Information Sheet

Advice for Pilgrims: Hajj and Umrah 1436 (2015)

This update replaces previous versions. The Ministry of Health of Saudi Arabia has issued their requirements and recommendations for those willing to perform Hajj and Umrah in 2015 (1436H) [1].

 

Key messages:

Hajj, the annual pilgrimage to Makkah (Mecca), in the Kingdom of Saudi Arabia (KSA) is one of the largest gatherings of its kind in the world


Comprehensive general information on pilgrimage to KSA is available at the KSA Ministry of Hajj Portal


Performing the rituals of the Hajj and Umrah is demanding and often involves walking long distances in hot weather. Pilgrims must ensure that they are as physically fit as possible


All pilgrims who intend to undertake Hajj or Umrah and seasonal workers, are required to provide proof of vaccination against meningococcal meningitis ACW135Y in order to obtain a visa for entry into KSA


The Ministry of Health KSA currently recommends that as a precautionary measure, elderly people, those suffering from chronic diseases, those with immune deficiency, pregnant women and children should postpone the performance of the Hajj and Umrah this year.

 

Introduction

Hajj, the annual pilgrimage to Makkah (Mecca), in the Kingdom of Saudi Arabia (KSA) occurs between the 8th and 12th day of the twelfth month of the Islamic calendar and is one of the largest mass gatherings in the world. Every year, approximately three million Muslims from around the world gather in Makkah. Due to the large crowds, mass gatherings such as Hajj and Umrah are associated with unique health risks [2].

In 2015, the Hajj season is due to fall approximately between 20 and 25 September 2015 [2]. Umrah is a shorter, non-compulsory pilgrimage for Muslims, which is performed as part of the Hajj ritual, but can also be undertaken at any time. Saudi Arabia is likely to be more crowded during the month of Ramadan, which is due to fall approximately between 17 June and 17 July this year [2, 3].

Risk management advice should follow that of the general traveller and be tailored as described below.

Destination-specific risk management advice can be found on the NaTHNaC Country Information Pages.

 

Pre-travel preparation

Pilgrims should research their trip well in advance of travel by checking the information on pilgrimage to KSA at the KSA Ministry of Hajj Portal, the KSA Ministry of Health: Your Health – Your Hajj and also 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.

Pilgrims should ensure they are up to date with all routine immunisations, and ideally see their healthcare provider at least 4-6 weeks before travel for  advice on vaccinations, malaria chemoprophylaxis (if appropriate), food and water precautions, risks from insect bites, and injury prevention.

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, and pilgrims with pre-existing medical conditions should discuss the suitability of travel with their doctor. If on prescribed medications, they should ensure they have a sufficient supply to cover their time abroad and carry a copy of their prescription.

In some situations deferment of travel should be considered when the risks to the pilgrim are assessed to be high. 

In response to international outbreaks of disease, the Ministry of Health (MOH) KSA recommends that elderly people, pregnant women, children, and those suffering from chronic diseases (e.g. heart diseases, kidney diseases, respiratory diseases, neurodegenerative diseases, diabetes, and immune deficiency) postpone the performance of the Hajj and Umrah rituals for this year for their own safety [1].

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.

Pilgrims should identify in-country healthcare resources in advance of their trip, and ensure they have adequate travel insurance should they fall ill.  Comprehensive travel insurance is essential for all aspects of the journey, and Sharia compliant travel insurance is available.

 

Vaccination

Pilgrims should be up-to-date with immunisations routinely administered in the UK, including measles, mumps and rubella (MMR). Information on specific health risks, including recommended vaccinations, for pilgrims to KSA can be found on the NaTHNaC Country Information page.

 

Required vaccinations

Meningococcal disease:

Meningococcal disease may result in meningitis (infection of the lining of the brain), septicaemia (blood poisoning) and pneumonia (chest infections).

In order to obtain a visa for entry into KSA, all those arriving to perform Hajj or Umrah, or undertake seasonal work, are required to have a valid certificate of vaccination against meningococcal disease.

Health Authorities must check that the correct procedure of vaccination has been followed in which a single dose of 'quadrivalent conjugate' vaccine (against meningococcal groups A, C, W and Y) has been administered between three years and ten days before arrival in KSA [1].

The vaccine is also recommended for personal protection against groups A, C, W and Y meningococcal disease (see also recommended vaccines).

 

Details of the vaccine given should be recorded in a patient-held vaccine record showing the traveller’s full name. If a traveller is in possession of an International Certificate of Vaccination or Prophylaxis (ICVP) booklet, meningococcal ACWY vaccination can be recorded in the ‘Other Vaccinations’ pages.

In addition to being immunised in their own countries, travellers arriving from countries in the African meningitis belt (Benin, Burkina Faso, Cameroon, Chad, Central African Republic, Côte d’Ivoire, Eritrea, Ethiopia, Gambia, Guinea, Guinea-Bissau, Mali, Niger, Nigeria, Senegal, South Sudan and Sudan) will be given chemoprophylaxis at the port of entry to lower the number of individuals undertaking pilgrimage who maybe carriers of meningococcal bacteria [1].

 

Polio:

All travellers from the following countries are required to produce a certificate to show that polio vaccine (OPV or IPV) has been administered within a period no more than 12 months or less than 4 weeks prior to departure for Saudi Arabia [1]:

 

  • Afghanistan
  • Cameroon
  • Ethiopia
  • Equatorial Guinea
  • Guinea
  • Iraq
  • Madagascar
  • Nigeria
  • Palestine (Gaza Strip, West Bank and "Arab of the 48")  
  • Pakistan
  • Somalia
  • South Sudan
  • Syrian Arab Republic
  • Yemen

 

In addition, travellers from these countries will also receive a dose of OPV at border points on arrival in KSA regardless of their age or vaccination history [1].

(see also recommended vaccines).

 

Health professionals and travellers should refer to NaTHNaC Country Information Pages for country-specific polio vaccine recommendations and requirements.

 

Yellow fever:

All pilgrims to Hajj and Umrah arriving from  countries or areas at risk for transmission of yellow fever(YF)  must present a valid International Certificate of Vaccination or Prophylaxis documenting YF vaccination and completed in accordance with International Health Regulations (2005) [4].

The KSA lists the following as countries/areas at risk of YF transmission *

  • In Africa: Angola, Benin, Burkina Faso, Burundi, Cameroon, Central African Republic, Chad, Congo, Cote d’Ivoire, Democratic Republic of the Congo, Equatorial Guinea, Ethiopia, Gabon, Guinea, Guinea Bissau, Gambia, Ghana, Kenya, Liberia, Mali, Mauritania, Niger, Nigeria, Rwanda, Senegal, Sierra Leone, Sudan, South Soudan, Togo, Uganda
  • In South and Central America: Argentina, Bolivarian Republic of Venezuela, Brazil, Colombia, Ecuador, French Guyana, Guyana, Panama, Paraguay, Peru, Bolivia, Suriname, Trinidad and Tobago.

*note the KSA list differs from that of the WHO

 

Recommended vaccinations

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) and diphtheria-tetanus-polio vaccine.

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

 

Hepatitis B:

Hepatitis B virus is found in body fluids and can be transmitted either percutaneously (through the skin) or by sexual contact. Percutaneous transmission can occur through the use of contaminated medical, dental, or other instruments; all pilgrims should consider receiving hepatitis B vaccine prior to travel.

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 [5]. 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.

 

Meningococcal disease:

Large outbreaks of meningococcal disease, including meningitis and septicaemia, have occurred during previous Hajj pilgrimages and spread to other countries by returning pilgrims [6]. A conjugated meningococcal ACWY vaccine is the preferred vaccine for all travellers because it not only protects against serious infection but also prevents vaccinated individuals from carrying the meningococcal bacteria and bringing it back with them.

Public Health England (PHE) recommends conjugated meningococcal ACWY vaccine as the preferred vaccine in all instances. The vaccines currently available in the UK are Menveo® and Nimenrix®  Full details of meningococcal vaccines and schedules can be found in Immunisation against infectious disease (the ‘Green Book’) [7] and the manufacturer’s Summary of Product Characteristics [8].

 

These vaccines do not protect against all causes of meningitis and septicaemia; any pilgrim who becomes unwell after returning from the Hajj or Umrah should contact their GP, NHS 111 or local hospital.   

 

Rabies:

There is a risk of rabies in KSA. Pilgrims should be advised of the importance of avoiding contact with wild or domestic animals and to seek urgent emergency medical treatment if any potential exposure (animal bite, lick or scratch) occurs.  

Pre-exposure vaccination can be considered. However, rabies vaccination prior to travel does not eliminate the need for post-exposure medical evaluation and additional doses of rabies vaccine. A three dose course of rabies vaccine given pre-exposure simplifies post exposure rabies treatment and removes the need for post exposure rabies immunoglobulin, which is in short supply worldwide.

 

Seasonal influenza:

Influenza is transmitted via the respiratory route and through contact (direct or indirect) with surfaces on which the virus has been deposited by sneezing or coughing.  It is easily transmitted in crowded conditions. Certain groups are considered at particular risk of complications from influenza.

The MOH KSA recommends that all domestic and international pilgrims be vaccinated against seasonal influenza before arrival in the Kingdom, especially those at increased risk of influenza disease including those with chronic medical conditions such as heart disease, kidney disease, respiratory disease, neurodegenerative disease, diabetes, HIV, acquired congenital metabolic diseases, pregnant women, children under five years and obese people [1].

 

Pilgrims in clinical risk groups should receive influenza vaccine annually from their usual healthcare provider [9]. Those who do not fall into any of these risk categories can still pay and be vaccinated 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 influenza prevention can be found on the NaTHNaC Health Information Sheet on seasonal influenza.

 

Other health risks

Middle East respiratory syndrome coronavirus (MERS-CoV):

Middle East respiratory syndrome coronavirus (MERS-CoV), which can cause severe illness and death, was first identified in KSA in 2012; the majority of cases to date have occurred in KSA, but cases have also been reported from countries outside the Middle East  [10, 11]. A small number of cases associated with travel to the Middle East have been reported from European countries [12]; during 2015 the largest outbreak outside the Middle East has occurred in the Republic of Korea.  This outbreak was associated with one traveller who had returned from countries in the Middle East [13].

   

The annual Muslim pilgrimage to Mecca in Saudi Arabia last year, took place in October 2014 with no reported increase in travel-related cases of MERS-CoV. Intensive surveillance during the 2013 Hajj did not identify any cases of MERS-CoV among an estimated two million pilgrims. However, several cases of MERS-CoV imported to countries outside of Saudi Arabia in 2014 had returned from Umrah [14].

The risk to UK residents travelling to the Middle East of contracting MERS-CoV during travel remains very low. PHE remains vigilant and closely monitors developments in the Middle East and in the rest of the world where new cases have emerged, and continues to liaise with international colleagues to assess whether their recommendations (see below) need to change [14].

The MOH KSA recommends that those over 65 years of age, those with chronic diseases (heart, kidney or respiratory disease, diabetes or immune deficiency), malignancy and terminal illness, pregnant women and children to postpone their pilgrimage for their own safety [1].

The MOH KSA advises all pilgrims to comply with the following health guidelines to prevent the spread of MERS-CoV and other respiratory diseases:

  • Always wash hands with soap and water or a disinfectant, especially after coughing and sneezing.
  • Use a tissue when coughing or sneezing and dispose of it in the dustbin.
  • Try as much as possible to avoid touching the eyes, nose and mouth by hand.
  • Avoid direct contact with infected people and do not share their personal belongings.
  • Wear a mask, especially in crowded places.
  • Maintain good personal hygiene.
  • Stay away from places where camels groups together and avoid direct contact with them.
  • Do not drink raw camels' milk or pasteurised or eat uncooked camel meat [1].

 

PHE also advises the following measures for all travellers to the Middle East:

  • Practise good hand and general hygiene at all times, especially after visiting farms, barns or market areas.
  • Avoid close contact with sick people and sick animals.
  • Avoid unnecessary contact with camels.
  • Avoid the consumption of raw camel milk or camel products.
  • Avoid the consumption of any type of raw milk, raw milk products and any food that may be contaminated with animal secretions unless peeled/cleaned/thoroughly cooked [14].  

Travellers returning from the Middle East with severe respiratory symptoms should seek medical advice and must mention their travel history so that appropriate measures and testing can be undertaken. People who are acutely ill with an infectious disease are advised not to travel [14].

Travellers returning from the Middle East with mild respiratory symptoms are most likely to have a common viral respiratory illness rather than MERS-CoV. However, if symptoms worsen with the onset of breathlessness, medical advice should be sought from the GP or NHS 111. Returning travellers should mention which countries of the Middle East they have visited. There are currently no travel restrictions in place relating to MERS-CoV. The situation continues to be monitored and travel advice will be reviewed as information becomes available. Health Professionals are advised to consult NaTHNaC clinical updates on MERS-CoV for up to date information.

PHE provides guidance for travellers to, and returning from the Middle East, alongside further information for health professionals.

 

Ebola virus disease (EVD):

Due to the Ebola outbreak in West Africa, KSA have announced that they will not be issuing visas to people travelling from Guinea, Liberia and Sierra Leone to perform Hajj, Umrah or for any other purpose. All KSA embassies and consulates have been advised to make sure that all applicants for entry visas to KSA have not travelled or lived in EVD affected countries within the last three weeks before their visa applications [1].

In addition, all visitors to KSA will be required to complete an Ebola screening card before entering the KSA [1].

 

Travellers’ diarrhoea:

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 [Mecca] (or in the cities of Jeddah, Riyadh and Ta’if or areas of Asir province above 2,000m), but malaria is a risk in the south-western provinces of Saudi Arabia. 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.

 

Other health considerations

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 people, who have decided to make their pilgrimage, may wish to consider appointing a proxy for the performance of this rite. All pilgrims to Hajj and Umrah should have adequate travel health insurance.

 

Environmental hazards (cold, heat and sun):

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.

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 (SPF) 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.

 

Food and water advice:

Fresh food cannot be brought into KSA by travellers and strict regulations about food apply [15].

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

 

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.

 

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.

 

General advice including advice for those who get ill abroad

Pilgrims should pack a first aid kit that will also help them manage relevant, common issues. Pilgrims should identify in-country healthcare resources in advance of their trip, and carry the emergency contact numbers for their insurance company.

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. Ministry of Health. Kingdom of Saudi Arabia. Health requirements and recommendations for Hajj and Umrah performers and those working in Hajj areas - 2015. [Accessed 15 July 2015]. Available at: http://www.moh.gov.sa/en/Hajj/HealthGuidelines/Health

GuidelinesDuringHajj/Pages/HealthRegulations1436.aspx

2.  US Centers for Disease Control and Prevention. Hajj and Umrah in Saudi Arabia. 14 May 2015. [Accessed 15 July 2015]. Available at:

http://wwwnc.cdc.gov/travel/notices/alert/hajj-umrah-saudi-arabia-2015

3.  Her Majesty’s Nautical Almanac Office. Crescent Moon Visibility for Ramadan and Eid al-Fitr 2015. 27 May 2015. [Accessed 15 July 2015]. Available at:

https://www.gov.uk/government/news/crescent-moon-visibility-for-ramadan-and-eid-al-fitr-2015

4.  World Health Organization. International Health Regulations (2005). [Accessed 15 July 2015]. Available at:

http://www.who.int/topics/international_health_regulations/en/

5. Memish ZA. The Hajj: Communicable and non-communicable health hazards and current guidance for pilgrims. Eurosurveillance. 15(39); 30 September 2010. [Accessed 15 July 2015]. Available at:http://www.eurosurveillance.org/ViewArticle.aspx?

ArticleId=19671

6. World Health Organization. 2001 – Meningococcal disease, serogroup W135 – update. 16 May 2001 [Accessed 15 July 2015]. Available at:

http://www.who.int/csr/don/2001_05_16/en/

7. Public Health England. Meningococcal, Ch. 22. Immunisation against infectious disease. Updated 11 April 2014. [Accessed 15 July]. Available at:

https://www.gov.uk/government/publications/meningococcal-the-green-book-chapter-22

8. Electronic Medicines Compendium. Available at:

 https://www.medicines.org.uk/emc/

9. Public Health England. Influenza, Ch. 19. Immunisation against infectious disease. Updated 21 May 2015. [Accessed 15 July2015]. Available at:

https://www.gov.uk/government/publications/influenza-the-green-book-chapter-19

10. Kingdom of Saudi Arabia. Ministry of Health. Command and Control Centre: Statistics. [Accessed 15 July 2015]. Available at: http://www.moh.gov.sa/en/CCC/PressReleases/Pages/

default.aspx

11. World Health Organization. Frequently asked questions on Middle East respiratory syndrome (MERS-CoV). 10 July 2015). [Accessed 15 July 2015]. Available at: http://www.who.int/csr/disease/coronavirus_infections/faq/en/

12. World Health Organization. Regional Office for Europe. Update on cases of Middle East respiratory syndrome coronavirus (MERS-CoV) in the WHO European Region. 9 February 2015. [Accessed 15 July 2015]. Available at:http://www.euro.who.int/en/health-topics/communicable-diseases/influenza/news/news/2015/02/update-on-cases-of-middle-east-respiratory-syndrome-coronavirus-mers-cov-in-the-who-european-region

13. World Health Organization. Global Alert and Response. Middle East Respiratory Syndrome coronavirus (MERS-CoV) – Republic of Korea. Disease outbreak news. 10 July 2015. [Accessed 15 July 2015]. Available at:http://www.who.int/csr/don/10-july-2015-mers-korea/en/

14. Public Health England. Risk Assessment of Middle East Respiratory Syndrome coronavirus (MERS- CoV).  Update 9 June 2015. [Accessed 15 July 2015]. Available at: https://www.gov.uk/government/uploads/system/uploads/

attachment_data/file/434106/MERS-COV_RA_June2015.pdf

15. Ministry of Health. Kingdom of Saudi Arabia. Your Health Your Hajj: Hajj 1436 – Foodstuffs. [Accessed 15 July 2015]. Available at: http://www.moh.gov.sa/en/Hajj/HealthGuidelines/

HealthGuidelinesDuringHajj/Pages/FoodMaterial.aspx

 

 

Links

Association of British Hujjaj (Pilgrims)

Council of British Hajjis

Kingdom of Saudi Arabia Ministry of Health

Kingdom of Saudi Arabia: Your Health – Your Hajj

Muslim Council of Britain Health Advice for Pilgrims to Hajj and Umrah

NaTHNaC Saudi Arabia Country Information Page

Public Health England: MERS-CoV or Avian Influenza Primary Care Algorithm

Public Health England: Travelling to the Middle East – Important information for travellers

Public Health England: Returning from the Middle East – Important information for travellers

Public Health England: Hajj and Umrah Pilgrims _ latest health and travel advice

 

Advice current at: 15 July 2015