The 2018 Hajj – the annual pilgrimage to Mecca, Saudi Arabia, and the largest mass gathering in the world – is expected to take place Aug. 30 to Sept. 4 (map).Officials will likely identify sporadic outbreaks of diarrheal, respiratory, or bloodborne diseases during and immediately following the Hajj. Those with pre-existing heart or respiratory conditions are more likely to experience negative health consequences when participating in Hajj events.
Large crowds present varied disease risks to individuals, particularly when groups of people congregate from many different parts of the world. Large crowds also present a significantly increased risk of physical trauma, cardiac (heart) events, dehydration and heat-related illnesses, and acute mental distress. Travelers participating in Hajj events should take special precautions to protect themselves from these risks. The Saudi Ministry of Health has also issued vaccination requirements of all pilgrims for Hajj or Umrah; these include proof of vaccination against meningococcal meningitis and yellow fever. The US CDC also maintains an “Alert-Level 2” travel health advisory for the upcoming Hajj and Umrah, as well as an “Alert-Level 2” advisory due to the ongoing risk of Middle East Respiratory Syndrome (MERS) in Saudi Arabia.
According to international health officials, cardiovascular disease is the primary cause of death among Hajj pilgrims. The Hajj is arduous even for young, healthy individuals, and many Muslims wait until they are older before making the pilgrimage. Furthermore, pilgrims who are caught up in the spiritual experience of the Hajj may forget to take their usual medications. Pilgrims with pre-existing cardiovascular (heart) conditions should consult a medical professional prior to travel; ensure they take an adequate supply of medication; adhere to their usual medication regimen; and immediately seek medical attention if they notice cardiac symptoms.
Finally, physical trauma is a major concern. Motor vehicle accidents are common. However, the most common trauma hazard is the possibility of a stampede. In the dense crowds that form during the Hajj, little can be done to avoid or escape a stampede once it has begun, and such events usually begin because of a minor incident. Deaths from stampede usually result from suffocation or head trauma, and providing prompt medical care is almost impossible in large crowds. Travelers should try to avoid the most densely crowded areas and, when possible, perform rituals at nonpeak hours.
Prevention of Food- and Waterborne Illnesses
The pressure to serve such huge numbers of people also increases the potential for transmission of food- or waterborne diseases through food and beverage vendors. Diarrheal diseases are common during the Hajj, and travelers should practice general hand, food, and water hygiene. Travelers should drink only recognized brands of sealed bottled water, or water that has been boiled or chemically treated. Pilgrims should regularly wash their hands with soap and water, or with alcohol-based hand sanitizer, especially before preparing or eating food.
Long rituals of standing and walking – in combination with heat and sweating – can contribute to the risk for skin infections. Travelers should be advised to keep skin dry, use talcum powder, and be aware of any pain or soreness caused by garments. Similarly, heat exhaustion and heatstroke are major causes of death, and temperatures in Mecca can exceed 37.8 C (100 F) in August and September. Pilgrims should stay hydrated, wear sunscreen, and seek shade when possible. Some rituals may also be performed at night to avoid daytime heat.
After the Hajj, many Muslim men shave their heads. Unclean razors can transmit bloodborne pathogens such as hepatitis B, hepatitis C, and HIV. Licensed barbers are tested for such pathogens and are required to use disposable, single-use blades. However, several unlicensed barbers using nonsterile blades on multiple customers operate along roadsides. Pilgrims should be sure to only visit officially designated barbers, whose establishments are clearly marked.
To protect the health and safety of the many travelers – as well as the health and safety of their own population – Saudi authorities have mandated several immunizations and recommended others. These include proof of vaccination against both meningococcal meningitis and yellow fever. Individuals arriving from countries within the African “Meningitis Belt” must be vaccinated against the disease prior to arrival in Saudi Arabia (map). Yellow fever vaccination is required of all travelers arriving from countries considered at risk for yellow fever transmission, which includes select countries in Africa and the Americas (map).
Nonpilgrim travelers may also encounter Hajj pilgrims en route , a fact which requires that all travelers be aware of the increased risk of infectious disease associated with international travel. Pilgrims may have been exposed to a variety of diseases, such as measles or polio, which can be avoided by ensuring a traveler is fully vaccinated against both routine and exotic diseases prior to departure.