NaTHNaC | Advice for pilgrims for the Hajj and Umrah seasons of 1430 (2009), 04 Sep 09, Travellers

Travel Health Information Sheets

September 2009

Advice for pilgrims for the Hajj and Umrah season of 1430 (2009)

Hajj, the annual pilgrimage to Makkah (Mecca), is the largest gathering of its kind in the world. Each year over two million Muslims from around the world gather in Makkah. The Hajj pilgrimage occurs from the 8th and 12th day of the twelfth month of the Islamic calendar, and is estimated to fall between 25 and 29 November 2009.

Umrah is a shorter, non-compulsory pilgrimage for Muslims that can be performed at any time.

The Ministry of Health of the Kingdom of Saudi Arabia and the World Health Organization (WHO) have advised that the elderly, children, pregnant women and patients with chronic diseases, should postpone their participation in Hajj and Umrah this year due to the risk of acquiring pandemic influenza during the pilgrimage. [1,2].

Vaccination advice

Vaccination advice for travellers to Saudi Arabia can be found on the NaTHNaC Country Information Page. The following vaccine-preventable diseases have particular relevance to Hajj and Umrah pilgrims.

Seasonal influenza: The Ministry of Health of Saudi Arabia requires all pilgrims performing Hajj to have received vaccination against the 2009-2010 seasonal influenza at least two weeks before applying for a visa. Proof of vaccination is required [3] in order to obtain a visa and no exceptions will be allowed. A written record of vaccination, authorised with the vaccinator’s official stamp, should be provided. If a traveller is in possession of an International Certificate of Vaccination or Prophylaxis (ICVP) booklet, seasonal influenza vaccine can be recorded in the ‘Other Vaccinations’ pages of the booklet. Travellers should note that vaccination against seasonal influenza is not likely to protect against pandemic 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, and those with pre-existing medical conditions such as chest, heart, liver or kidney conditions, a history of splenectomy, or diabetes [4]. Travellers who fall into any of these categories should receive influenza vaccine annually from their usual healthcare provider, but should also note the advice to postpone their pilgrimage this year [1,2 ]. For those who do not fall into any of these categories, vaccine can be purchased and administered at some high street chemists, 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. Simple precautions such as use of tissue to cover coughs and sneezes, safe disposal of the tissue, and hand washing will help reduce the spread of respiratory infection. The use of face masks during public events such as the Hajj is not recommended. Advice about the prevention of influenza including pandemic influenza can be found on the NaTHNaC Health Information Sheet: Pandemic (H1N1) 2009 influenza: Advice for travellers.

Pandemic (H1N1) 2009 influenza (swine flu): Pandemic influenza has occurred throughout the world, including Saudi Arabia [5]. Although symptoms of pandemic influenza have been mild in most people, certain groups are at an increased risk of severe disease (see above) and should note the advice to postpone their pilgrimage this year [1,2 ]. There is screening of passengers on arrival at all ports into Saudi Arabia, and if persons are suspected to have pandemic influenza, they will be temporarily quarantined and admitted to hospital for further testing.

The Ministry of Health of Saudi Arabia requires vaccination against pandemic (H1N1) 2009 influenza if the vaccine becomes universally available within the UK, but they recognise that this is unlikely to apply for this year’s pilgrimage.

Meningococcal meningitis: All pilgrims to Hajj and Umrah are required to show proof of vaccination against meningococcal meningitis ACW135Y. Vaccination is also a requirement for obtaining a visa.

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. If a traveller is in possession of an ICVP booklet, meningococcal meningitis vaccine can be recorded in the ‘Other Vaccinations’ pages of the booklet.

Meningococcal meningitis has occurred during previous Hajj pilgrimages and has spread to other countries in association with returning pilgrims [6], therefore, vaccination is also advised for personal protection.

Children older than three months and younger than two years of age may not be protected by a single dose of meningococcal meningitis ACW135Y vaccine. It is therefore recommended that, to optimise protection, two doses of vaccine are given in this age group with an interval of three months [4].

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 [7]. The Ministry of Health of Saudi Arabia regards these countries as: Benin, Burkina Faso, Cameroon, Central African Republic, Chad, Côte d’Ivoire, Eritrea, Ethiopia, Gambia, Guinea, Guinea-Bissau, Mali, Niger, Nigeria, Senegal, and Sudan.

Polio: All pilgrims to Hajj and Umrah 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.

The Ministry of Health of Saudi Arabia also 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) six weeks prior to departure for Saudi Arabia [7]. All such travellers will be required to receive a further dose of OPV upon their arrival in Saudi Arabia.

The Ministry of Health of Saudi Arabia 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 be required to receive a further dose of OPV on arrival in Saudi Arabia. The Ministry of Health considers the following countries to have on-going transmission of wild polio virus: Angola, Benin, Burkina Faso, Central African Republic, Chad, Côte d’Ivoire, Democratic Republic of the Congo, Ethiopia, Ghana, Kenya, Mali, Nepal, Niger, Togo, and Uganda.

Hepatitis B: Hepatitis B virus is found in body fluids and can be transmitted either percutaneously or by sexual contact. Percutaneous transmission occurs 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 Saudi authorities provide licensed barbers with a new blade to use for each pilgrim, however, unlicensed barbers may not conform to such standards. Pilgrims should avoid shaving with a blade previously used by another, as this could carry a risk 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.

Yellow fever: All pilgrims to Hajj and Umrah arriving from countries or areas at risk of yellow fever transmission must present a valid ICVP documenting yellow fever vaccination completed in accordance with International Health Regulations (2005) [8]. These countries are listed by the WHO in International Travel and Health, annex 1 [9].

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. Babies, infants, the elderly and those with chronic medical conditions are vulnerable to dehydration.

All pilgrims to Hajj and Umrah are advised to take food and water hygiene precautions.

In addition travellers should be advised to carry 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 drug of choice.

Vector-borne diseases

Malaria is not present in Medina or Makkah, but malaria is a risk in the south-western region and rural areas of Saudi Arabia. Pilgrims planning further travel before or after Hajj or Umrah to malaria risk countries in 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 Saudi Arabia, even during the winter months, can reach over 30°C. Associated risks include sunburn, dehydration, heat exhaustion, and heat stroke.

If at all 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) to avoid dehydration.

Sunscreen with a sun protection factor of at least 15 to 30 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, 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 usually in hot weather. Pilgrims should ensure that they are physically fit before travelling.

Menstruation: Women who anticipate their periods falling during the Hajj may wish to delay menstruation, which is possible to achieve using hormonal treatment. 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 and Umrah should ensure that they have adequate travel health insurance.

Pilgrims should carry with them their GP's details which may be required should emergency medical care be necessary.

Saudi Arabia will undertake screening for selected communicable diseases at points of entry and may take additional precautionary measures [10].

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 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 Regional Office for the Eastern Mediterranean. A special session of the Regional Committee for the Eastern Mediterranean on Pandemic (H1N1) 2009 held in WHO Regional Office. 27 July 2009. [Accessed 4 September 2009]. Available at: http://www.emro.who.int/CSR/h1n1/pdf/RC_Resolution26-7-09.pdf

2. World Health Organization Regional Office for the Eastern Mediterranean. International consultative workshop on preventive measures against infectious disease for Hajj and Umra: A(H1N1) influenza is of moderate severity so far. Press release. 1 July 2009. [Accessed 4 September 2009]. Available at: http://www.emro.who.int/pressreleases/2009/no15.htm

3. World Health Organization. Health conditions for tarvellers to Saudi Arabia for the pilgrimage to Mecca (Hajj). Wkly Epi REc. 2009; 84: 27. (262KB PDF)

4. Salisbury D, Ramsay M, Noakes K (eds). Immunisation against infectious disease. 2006. Department of Health, London. Available at: http://www.dh.gov.uk/en/Policyandguidance/Healthandsocial

caretopics/Greenbook/DH_4097254

5. World Health Organization. Pandemic (H1N1) 2009 laboratory confirmed cases and number of deaths reported to WHO; as of 30 August 2009. [Accessed 4 September 2009]. Available at: http://gamapserver.who.int/h1n1/cases-deaths/h1n1_casesdeaths.html

6. World Health Organization. 2001 – Meningococcal disease, serogroup W135 – update. 16 May 2001 [Accessed 4 September 2009]. Available at: http://www.who.int/csr/don/2001_05_16/en/.

7. Ministry of Health, Kingdom of Saudi Arabia. Health requirements for Hajj and Omrah performers, 1430. 3 June 2009 [Accessed 4 September 2009]. Available at: http://www.moh.gov.sa/en/haj.htm

8. World Health Organization. International Health Regulations (2005). [Accessed 4 September 2009]. Available at: http://www.who.int/csr/ihr/en/

9. World Health Organization. International and travel health. 2009; World Health Organization, Geneva. Available at: http://www.who.int/ith/en

10. The Foreign and Commonwealth Office. Travel Summary: Saudi Arabia Updated 2 September 2009. [Accessed 4 September 2009]. Available at http://www.fco.gov.uk/en/travelling-and-living-overseas/travel-advice-by-country/middle-east-north-africa/saudi-arabia

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