Health Professionals

Health Information Sheet

Advice for Pilgrims: Hajj and Umrah 1435 (2014)

Health Regulations and recommendations for travellers to the Kingdom of Saudi Arabia (KSA) for Umrah and Pilgrimage (Hajj) 1435 (2014).

Further updates may be added

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. Each year over two million Muslims from around the world gather in Makkah.

The Hajj pilgrimage occurs between the 8th and 12th day of the twelfth month of the Islamic calendar. The 1435 Hajj season is estimated to fall in early October 2014.  Umrah is a shorter, non-compulsory pilgrimage for Muslims that can be performed at any time.

 As of 8 August, 2014 the Ministry of Health (MOH) KSA issued revised entry requirements and recommendations for the Hajj and Umrah seasons, 2014 [1]. 

Special risk groups

In response to international outbreaks of disease, the Ministry of Health KSA recommends that elderly people, pregnant women, children, and those with chronic diseases (e.g. heart diseases, kidney diseases, respiratory diseases, nervous system disorders, diabetes, and immune deficiency) postpone the performance of the Hajj and Umrah rituals for this year for their own safety [2].

Required vaccinations

Meningococcal meningitis: 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 MOH KSA stipulate that one dose of meningitis  ACW135Y vaccine should be received not more than three years and not less than ten days, before arrival in KSA [1].

The Department of Health, United Kingdom, recommends conjugated meningococcal ACWY vaccine as the preferred vaccine in all instances.  Full details of meningococcal vaccines and schedules can be found in the  Immunisation against infectious diseases (the ‘Green Book’) [3] and the manufacturer’s Summary of Product Characteristics [4].

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 meningitis ACW135Y vaccine can be recorded in the ‘Other Vaccinations’ pages.

Adults and children aged over 12 years, 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 administered preventive medicine at the port of entry, in addition to the requirement for proof of vaccination against meningococcal meningitis ACW135Y [1].

Polio:

Visitors arriving from countries reporting endemic Wild Polio Virus (WPV) or importation of WPV within in the past 12 months [5]:

  • Afghanistan
  • Cameroon
  • Ethiopia
  • Equatorial Guinea
  • Iraq
  • Israel
  • Nigeria
  • Pakistan
  • Somalia
  • Syria

As of 16 May 2014, in order to obtain a visa for entry into KSA, all travellers arriving from any of the countries listed above are required to provide proof of polio vaccination given within the previous 12 months and at least four weeks prior to departure (from the country in which WPV is reported) [1].

Travellers from these countries will also be given a dose of Oral Polio Vaccine (OPV) at border points on arrival in Saudi Arabia [1].

 

All pilgrims to Hajj and Umrah are advised to ensure their polio vaccination is up-to-date. Travellers, who last received a dose of polio more than ten years ago, should receive a booster, using the trivalent tetanus, diphtheria and polio vaccine.

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 (including Tobago)  must present a valid International Certificate of Vaccination or Prophylaxis documenting yellow fever vaccination and completed in accordance with International Health Regulations (2005) [6].

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).

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 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 [7].  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 meningitis:

Meningococcal meningitis has occurred during previous Hajj pilgrimages and has spread to other countries in association with returning pilgrims [8]. A conjugated meningococcal ACWY vaccine is the preferred vaccine for all travellers (see ‘required vaccines ’ above).

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 pilgrims are vaccinated against seasonal influenza before arrival into KSA, especially pregnant women, children (under 5 years), obese people, and those suffering from chronic disorders (heart diseases, kidney diseases, respiratory diseases, nervous system disorders, diabetes, immune deficiency [congenital and acquired] and metabolic illnesses) [1]. (see also MOH KSA recommendations for travel for specific risk groups).

Travellers in clinical risk groups defined by the UK Department of Health should receive influenza vaccine annually from their usual healthcare provider [9]. 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

Middle East respiratory syndrome coronavirus (MERS-CoV):

Since 2012, when MERS-CoV was first identified, there have been over 800 cases reported to the World Health Organization, the majority associated with KSA  [10, 11].  Some cases associated with travel to the Middle East have been reported from European countries [12].  This infection can cause severe illness and death [13]. 

Since April 2014, there has been an increase in the number of reported cases of MERS-CoV, however, the risk to UK residents travelling to the Middle East of contracting MERS-CoV during travel remains very

low [14].

The Ministry of Health, KSA advises all pilgrims to:

  • Wash hands with soap and water or disinfectant, especially after coughing and sneezing.
  • Use disposable tissues when coughing or sneezing and dispose of them in  a waste basket.
  • Try as much as possible to avoid hand contact with the eyes, nose and mouth.
  • Avoid direct contact with infected persons (people with symptoms such as cough, sneeze, expectoration, vomiting, and diarrhoea).
  • Wear masks, especially when in crowded places.
  • Maintain good personal hygiene [1].

Public Health England also advises the following measures for all travellers to the Middle East:

  • Practice 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].  

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.

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 with the onset of breathlessness or cough, medical advice should be sought from the GP or NHS 111. Returning travellers should mention which countries of the Middle East they have visited.  

Public Health England provides guidance for travellers to the Middle East, travellers returning from the Middle East and further information for health professionals.

  

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 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

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.

Fresh food cannot be brought into KSA by travellers.  Strict regulations about food materials apply [1].

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.

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 advice

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 if emergency medical care is necessary.

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.

Further information

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

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.  World Health Organization. Wkly Epid Rec. Health Conditions for travellers to Saudi Arabia for the pilgrimage to Mecca (Hajj) 2014. 8 August 2014;32/33 (89):357-368 [Accessed 29 August 2014]. Available at: http://www.who.int/wer/2014/wer8932_33.pdf?ua=1

2  Kingdom of Saudi Arabia. Ministry of Health. Hajj and Umrah e-Portal. Health Regulations for 1435H – Hajj Season. [Accessed 29 August 2014]. Available at: http://www.moh.gov.sa/en/Hajj/HealthGuidelines/Health

GuidelinesDuringHajj/Pages/HealthRegulations1435.aspx

3. Meningococcal Ch 22. In: Salisbury D, Ramsay M, Noakes K (eds). Immunisation against infectious disease. 2006. Updated 11 April 2014. Department of Health, London. [Accessed 29 August 2014]. Available at: https://www.gov.uk/government/publications/meningococcal-the-green-book-chapter-22

4. Electronic Medicines Compendium. Available at: https://www.medicines.org.uk/emc/

5. Global Polio Eradication Initiative. Polio Public Health Emergency: Temporary Recommendations to Reduce the Spread of Poliomyelitis. Accessed 29 August 2014]. Available at: http://www.polioeradication.org/Infectedcountries

/PolioEmergency.aspx

6. World Health Organization. International Health Regulations (2005). [Accessed 29 August 2014]. Available at :http://www.who.int/topics/international_health_regulations/en/

7. Memish ZA. The Hajj: Communicable and non-communicable health hazards and current guidance for pilgrims. Eurosurveillance. 15(39); 30 September 2010. [Accessed 29 August 2014]. Available at: http://www.eurosurveillance.org/ViewArticle.aspx?

ArticleId=19671

8. World Health Organization. 2001 – Meningococcal disease, serogroup W135 – update. 16 May 2001 [Accessed 29 August 2014]. Available at: http://www.who.int/csr/don/2001_05_16/en/.

9. Influenza C 19. In: Salisbury D, Ramsay M, Noakes K (eds). Immunisation against infectious disease. 2006. Updated 1 August2014. Department of Health, London. [Accessed 29 August 2014]. Available at:  https://www.gov.uk/government/uploads/system/uploads

/attachment_data/file/341076/Green_Book_Chapter_

19_v6_.pdf

10. World Health Organization.  Middle East Respiratory Syndrome Coronavirus (MERS-CoV). Update 23 July 2014  [Accessed 29 August 2014] Available at: http://www.who.int/csr/don/2014_07_23_mers/en/

a=1

11. Kingdom of Saudi Arabia. Ministry of Health. Command and Control Centre: Statistics. [Accessed 29 August 2014]. Available at: http://www.moh.gov.sa/en/CCC/PressReleases/

Pages/default.aspx

12. World Health Organization. Regional Office for Europe. Middle East Respiratory Syndrome (MERS-CoV)- situation update. European Region. [Accessed 29 August 2014]. Available at: http://bit.ly/1hE6iRG

13.World Health Organization. Frequently Asked Questions on Middle East Respiratory Syndrome Coronavirus (MERS-CoV). 9 May 2014. [Accessed 29 August 2014]. Available at: http://www.who.int/csr/disease/coronavirus_infections/faq/en/

14.  Public Health England. Risk Assessment – Middle East Respiratory Syndrome coronavirus – MERS-CoV. 2 May 2014 [Accessed 29 August 2014]. Available at:  http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_

C/1317140453299

Links

Association of British Hujjaj (Pilgrims)

Council of British Hajjis

Kingdom of Saudi Arabia Ministry of Hajj Portal

Kingdom of Saudi Arabia Ministry of Health

Muslim Council of Britain

NaTHNaC Clinical Update: Polio PHEIC – interim advice on vaccination

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

Further reading

Pilgrimage (Hajj/Umrah). In: Field VK, Ford L, Hill DR (eds). Health information for overseas travel. National Travel Health Network and Centre, London, UK, 2010.

 

Advice current at: 29 August 2014