Health Related Experiences among International Pilgrims Departing Through King Abdul Aziz International Airport, Jeddah, Saudi Arabia, Hajj 1431 H (201 0)

H ajj terminal at King Abdul Aziz International Airport in J eddah is the main facility for processing pilgrims visiting Makkah and Madinah for Hajj and Umrah.

This cross-sectional study aims to assess health related expe­riences of pilgr ims departing through this terminal during Hajj season of 1431 H (2010 G). Single stage stratified ran­dom cluster sampling was done, with probability propor­tionate to size. Stratification was based upon five geograph­ical groups of countries. A self administered questionnaire translated to thirteen languages was used to collect the data.

A total of 1717 pilgrims had fallen sick as a result of de­agreed to participate in the terioration of their condition. study, their mean age was The most frequent com­(46.20 ± 11.53), 63 .7% were plaint among the participants males, 54.1% had universi- was cough (72 .2% ) , which was ty education or above , 83 .7% strongly related to crowdedness were performing Hajj for first (p=O .00 1). Over half ( 51 .4%) time . Almost half of participat- had visited one or more health ing hajjis (44 .6%) had not used facilities, and a strong associa­the face mask during hajj, and tion was found between lower there was a strong association education and visiting health between fever and not using the facilities (p=O .001). face mask (p=0 .007) (Table 1) . 39.5% had shaved their heads at an authorized barber, of whom 75.7% were sure that the blade was new; 63.6% and 52.4% had been vaccinated against menin­gococcal meningitis and season­al influenza; 64% had brought a 1st aid bag for hajj .

The study showed that 42.5% and 42.9% of hajjis were fully satisfied with the availability and quality of Saudi health fa­cilities.

- Reported by: Dr. Yahya A . M. Maslamani Dr. Abdul Jamil Chaudhry

Editoria l Notes: Hajj is a long journey where pilgrims experience a lot of events. Due

to their differing demographic characteristics, their behaviors are also different. Age, gen­der, nationalities and education along with other factors play sensitive roles in changing pil­grims' actions .

The face mask was not used by a large proportion of hajjis. The efficiency of the face mask in prevention of respiratory symptoms is controversial. A previous study in Hajj season 2009 conducted among French pilgrims reported that face mask use did not significantly reduce respiratory symptoms .1

However, this study revealed a significant relationship be­tween fever and not using a face mask.

Head shaving through razor blade is a risk factor for scalp wounds, which may lead to blood borne infection if con­taminated. These wounds arise from lack of practice as in case of unauthorized barbers. In this study, nearly half the male pil­grims went to unauthorized bar­bers. A previous study reported many reasons for pilgrims go­ing to unauthorized barbers , mainly crowded and expensive authorized barber shops.2

Hajj missions and restau­rants were the main food source for 42% and 24.8% respective­ly, and there was a strong as­sociation between eating from a restaurant and development of abdominal pain (p=0.02) and diarrhea (p=0.007) (Ta­ble 2) . 21.7% reported having been trapped in an elevator dur­ing hajj, 11.3% had foot injury secondary to walking barefoot, 27.1% had chronic diseases mainly Hypertension and Dia­betes and among them 14.9%

Table 1 : Using face mask and development of cough and fever among pilgrims, Hajj season 1431 H (2010). (Weighted)

Using Face Mask Symptom Yes No p-value

No. % No. %

Yes 680 73.0 545 72.5

Cough No 252 27.0 207 27 .5 0.82

Total 932 100 752 100

Yes 193 20.7 117 15.6

Fever No 740 79.3 635 84.4 0.007

Total 933 100 752 100

42 Saudi Epidemiology Bulletin, Vol. 18 No.4, 2011

In hajj season 1431 H (2010 G), new instructions were re­leased from the Saudi Ministry of Health targeted international pilgrims from each country re­garding which vaccines to be received prior to Hajj; these are Meningococcal Meningitis, Seasonal Influenza (including H1N1) , Yellow Fever, and Po­liomyelitis vaccines. It is worth mentioning that some vaccines that are recommended for a particular country may not be recommended for others.3

A large number of hajjis come from areas endemic for Meningococcal Meningi­tis , which may result in an in­creased risk of outbreaks. In order to prevent occurrence of these outbreaks, high vacci­nation coverage rates against meningococcal meningitis have to be maintained, in addi­tion to other preventive meas­ures. Vaccination coverage rate against Meningococcal Menin­gitis was lower than expected (63.6%), in comparison with previous similar studies, that reported 90%, 88%, 89.8% and 84.4% in 1997, 1998,2002 and 2007 respectively. 2·4•

5•6

There was a reasonable in­crease of seasonal influenza vaccine coverage rate this year (52.4%), as a result of the pan­demic H1N1 virus and develop­ing of new influenza vaccine in­cluding this strain? However, the influenza vaccine remains a weak defender. A study conducted in 2009 among French pilgrims showed that seasonal influenza vaccine did not significantly re­duce respiratory symptoms .1

Eating from restaurants was significantly associated with food poisoning symptoms (ab­dominal pain and diarrhea) among pilgrims. The small

number of restaurants in the area that provide food to a huge number of pilgrims within a limited area may cause food handlers to neglect hygiene and cook food inadequately. How­ever, it has been noticed that throughout the last couple of hajj seasons, a big decline in food poisoning outbreaks oc­curred.2 This decline coincides with the start of Hamlas (Hajj companies), which receive fees from pilgrims for food-provi­sion, that are monitored by the Saudi health authorities. Nearly half of the pilgrims in this study depended on Harnlas as a main source of food.

Nearly one third of the pil­grims had one or more chronic diseases , mainly hypertension and diabetes . It is worth not­ing that in 2010, the prevalence of chronic diseases among pil­grims (27 .1 %) was higher than that reported in 2007 (25%), and double that of 2002 (13.2%). This dramatic increase reflects the global situation of rising chronic diseases .

Cough and fever were the leading causes of morbidity

among pilgrims, similar to the 2002 study.2

For a healthy Hajj environ­ment in the future it was rec­ommended to coordinate with health and hajj ministries of oth­er countries in order to initiate/ enhance the health education and hajj orientation programs for hajjis before they leave their home countries. The Saudi min­istry of health should also coor­dinate with other national min­istries of health to strengthen the weakening vaccination pro­gram against meningococcal meningitis, and ensure vaccina­tion of all hajjis at least 10 days before hajjis departure from their home countries.

References: 1 . Gautret P, Vu Hai V, Sani

S , Doutchi M, Parola P, Brouqui P. Protective meas­ures against acute respira­tory symptoms in French pilgrims participating in the Hajj of 2009 . J Travel Med 2011 ; 18(1): 53-5.

2. Almaghderi Y, Aljoudi A, Chaudhry A, Al-Rabeah A. Behavioral Risk Factors

Table 2 : Relationship between food source and development of abdominal pain, diarrhea, and vomiting among pilgrims, Hajj season 1431 H (2010G). (Weighted}

SYMPTOM p-value Main Food Source Yes No Total

No. % No. % 02 p-value

Cooked own food 19 4.9 372 95.1 391 Reference Hajj Mission 52 7.7 621 92.3 673 3.26 0.07

ABDOMINAL Restaurants 36 9.1 360 90.9 396 5.42 0 .0<. PAIN Street Vendors 6 7.2 77 92.8 83 0.77 0 .38

Canned Food 1.8 55 98.2 56 FE* 0.49 Cooked own food 25 6.4 366 93.6 391 Reference

Hajj Mission 66 9.8 607 90 .2 673 3.68 0.05 DIARRHEA Restaurants 47 11.9 349 88.1 396 7.09 0.007

Street Vendors 9 10.8 74 89.2 83 2.04 0 .15 Canned Food 5 8.9 51 91.1 56 0.50 0.48 Cooked own food 11 2.8 380 97.2 391 Reference

Hajj Mission 22 3.3 651 96 .7 673 0.17 0 .68

VOMITING Restaurants 11 2.8 385 97 .2 396 o.bo 0.91

Street Vendors 3 3.6 80 96.4 83 FE* 0.72

Canned Food 0 0.0 56 1.0 56 FE':' 0.37

Saudi Epidemiology Bulletin, Vol. 18 No.4, 2011 43

for Diseases during the Pil­grimage to Makkah 1422 H/2002 G. Saudi Epidemiol Bull2002; 9(3): 19,20.

3. Saudi Ministry of Health; Health conditions for travel­ers to Saudi Arabia for Hajj for the year 143 1H/2010; available at: http://www. moh .gov .sa/en/HealthAware­ness/Hajj/Pages/002.aspx; accessed on: 18 July 2011.

4. Alfaraj N, Alhayani 0, Choudhry A. Behavioral Risk Factors for Diseases during Hajj 1428 H/2007 G. Saudi Epidemiol Bul12008; 15(4): 28,29,31.

5. Al-Fefy S, EI-Bushra H, Al­Wehebi S, Al-Salman S. Be­havioral risk factors for pil­grims to Makkah, 1997. Saudi Epidemiol Bull1998; 5(1).

6. Al-Rabeah A, Al-Segal A, Al-Saied M, Al-Rasheedy A. Behavioral risk factors for disease during Hajj: the second survey. Saudi Epi­demiol Bul11998; 5(3) .

7. New seasonal flu vaccine to contain H1N1 strain; avail­able at: http://www.reuters. com/article/20 10/02118/ us-fiu-who-id­USWLB737620100218; accessed on: 23/08/2011.

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44 Saudi Epidemiology Bulletin, Vol. 18 No.4, 2011