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Abstract

Annually, millions of Muslims embark on a religious pilgrimage called the "Hajj" to Mecca in Saudi Arabia. The mass migration during the Hajj is unparalleled in scale, and pilgrims face numerous health hazards. The extreme congestion of people and vehicles during this time amplifies health risks, such as those from infectious diseases, that vary each year. Since the Hajj is dictated by the lunar calendar, which is shorter than the Gregorian calendar, it presents public-health policy planners with a moving target, demanding constant preparedness. We review the communicable and non-communicable hazards that pilgrims face. With the rise in global travel, preventing disease transmission has become paramount to avoid the spread of infectious diseases, including SARS (severe acute respiratory syndrome), avian influenza, and haemorrhagic fever. We examine the response of clinicians, the Saudi Ministry of Health, and Hajj authorities to these unique problems, and list health recommendations for prospective pilgrims.

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... During the expedition, it is essential to identify people with health risk. Once they are detected, it is easy to monitor them and medical help and assistant can easily be provided for them [1][2][3][4][5]. ...
... To deal with a normal (regular) medical and emergency event at any moment is much more comfortable, encouraging and less challenging than that of multiple emergency events simultaneously at WBSN coordinator level. Based on our study [1][2][3][4][5][6][7], to build a priority MAC protocol in this research, we consider heterogeneous traffic. Besides, emergency data is further classified into twelve different classes based on traffics severity level during the pilgrimage as presented in the following Table I. ...
... Fig. 11 shows the overall network throughput of the priority MAC protocol, TA-MAC protocol and TP-CAT protocol. Here, in this research, when the network has increased number of sensor nodes (in our case nodes range [1][2][3][4][5][6][7][8][9][10][11][12] or traffic load, then the throughput of all three protocols such as priority MAC, TP-CAT protocol and TA-MAC protocol also increases. Our proposed priority MAC protocol shows enhanced throughput over TA-MAC and TP-CAT protocol with the increased number of sensor nodes. ...
Article
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Every year during Hajj in Saudi Arabia and Kumbh Mela in India, many pilgrims suffering from different medical emergencies thus need real-time and fast healthcare services. Quick healthcare can be facilitated by setting up Wireless Body Sensor Network (WBSN) on pilgrims because of its suitability for a wide range of medical applications. However, higher delay, data loss and excessive energy consumption may occur in the network when multiple emergency data aggregate at the coordinator for accessing the data communication channel simultaneously. In this context, for low delay and energy-efficient data transmission, an M/M/1 preemptive queue technique is proposed and minimal backoff period is considered to develop a priority Medium Access Control (MAC) protocol for WBSN. Our proposed MAC is designed based on IEEE802.15.6 standard that supports modified MAC superframe structure for heterogeneous traffic. The proposed priority MAC protocol has been simulated using the Castalia simulator to analyze the results. In the first scenario considering varying nodes, the delay is calculated as 13 ms and 33 ms for the emergency, and the normal medical condition. Besides, for emergency and normal medical condition energy consumption per bit is calculated at around 0.12 µj and 0.19 µj. In the second scenario, we consider variation in traffic size. For 16 bytes traffic size, delay of extremely very high critical traffic is 5.8 ms and 14.5 ms for extremely low critical traffic. Similarly, extremely very high critical traffic consumes 0.035 µj energy per bit, whereas extremely low critical traffic consumes 0.37 µj. in the third scenario, the delay, data loss rate, average energy consumption and throughput for the proposed priority MAC are analyzed. Result demonstrates our proposed priority MAC protocol outperforms the state-of-the-art protocols.
... [43] Administrative managers should provide facilities such as adequate shade structures, chiller, cooling station, and sprinkler as well as methods to control the population to prevent such risks. [5,[43][44][45] Furthermore, insect and arthropod bites were reported as health-threatening risks in the World Cup 2014 in Brazil. The participants are told to wear suitable clothes and cover exposed areas, while the health-care system had to prepare itself to recognize and treat the affected people. ...
... [46] Population density is considered the main threat to health risks of the participants in MGs, which causes death and various injuries due to population pressure, trampling, and being strangled. [5,8,45,47,48] Only in the Hajj ceremony, hundreds of people lose their lives or are injured due to population density and pressure. [5,7] In addition, significant statistics of injuries due to population pressure in MGs have been reported in other areas of the world. ...
... Furthermore, a portion of injuries of Hajj participants were due to traffic accidents. [45,54] It is suggested that participants in gatherings pay more attention to warnings in the field and be trained about safety measures. [54] Public health risk domain ...
Article
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Context: Mass gatherings (MGs) are established for different religious, social, political, cultural, and sport motivations. Many risks threaten the participants' health in MGs for different reasons. One duty of health-care system is to identify the risks and manage them to reduce the participants' injuries in MGs. This study aimed to identify and classify the risks threatening the health of participants in MGs and review related articles systematically. Subjects and methods: In this study, we investigated electronic databases including Science Direct, PubMed, Ovid, ProQuest, Web of Science, Scopus, and Google Scholar. This systematic review investigated those health articles which studied MGs published after 2000. Keywords that were searched included (Mass gathering OR Crowd) AND (Assessment OR Evaluation) AND (Disaster OR Emergencies) AND (Injuries OR Stamped). The final full text articles were assessed qualitatively by STROBE article assessment checklist, and then the data extracted from the results of the articles were analyzed and reported. Results: Initially, a total of 1874 articles were found, qualitative exclusion and inclusion criteria were applied, and finally 29 full-text articles were selected for the analysis. More than forty health-related risks were recognized. In order to better understand the risks and use of the results more efficiently, the risks were classified and reported into the following five domains: environmental risks, individual risks, psychological risks, public health risks, and management risks. Conclusion: Many risks threaten the health of participants in MGs. Recognizing and managing the risks are considered the primary and basic essentials of health sector for the better management of MGs.
... Similarly to the Hajj and other mass gatherings, the Umrah entails global movement of people, gathering of crowds, and therefore an increased health challenge, including the risk of spreading infection [4]. Respiratory tract infections, overcrowding accidents, pollution, and many other medical and health issues are encountered by the host country, which requires special attention and measurable responses to mitigate these risks [4,5]. Without proper planning and preventative measures, this religious activity can overwhelm the health system of the host country and impact global health preparedness, because the majority of Umrah pilgrims come from, and return to, their different countries [5,6]. ...
... Respiratory tract infections, overcrowding accidents, pollution, and many other medical and health issues are encountered by the host country, which requires special attention and measurable responses to mitigate these risks [4,5]. Without proper planning and preventative measures, this religious activity can overwhelm the health system of the host country and impact global health preparedness, because the majority of Umrah pilgrims come from, and return to, their different countries [5,6]. ...
... There is no doubt that providing health education to pilgrims on non-communicable and infectious diseases (including the preventative measures and modes of infection transmission) is of great interest for the Hajj and health authorities in Saudi Arabia [5]. It is also critical for global public health and disease control, which is considered good practice to minimize the risks and improve compliance with preventative control measures [8][9][10]. ...
Article
Full-text available
Background: Annually, approximately 10 million pilgrims travel to the Kingdom of Saudi Arabia (KSA) for Umrah from more than 180 countries. This event presents major challenges for the Kingdom's public health sector, which strives to decrease the burden of infectious diseases and to adequately control their spread both in KSA and pilgrims home nations. The aims of the study were to assess preventative measures practice, including vaccination history and health education, among Umrah pilgrims in Saudi Arabia. Methods: A cross sectional survey was administered to pilgrims from February to April 2019 at the departure lounge at King Abdul Aziz International airport, Jeddah city. The questionnaire comprised questions on sociodemographic information (age, gender, marital status, level of education, history of vaccinations and chronic illnesses), whether the pilgrim had received any health education and orientation prior to coming to Saudi Arabia or on their arrival, and their experiences with preventative practices. Results: Pilgrims (n = 1012) of 41 nationalities completed the survey. Chronic diseases were reported among pilgrims (n = 387, 38.2%) with cardiovascular diseases being the most reported morbidity (n = 164, 42.3%). The majority of pilgrims had been immunized prior to travel to Saudi Arabia (n = 770, 76%). The most commonly reported immunizations were influenza (n = 514, 51%), meningitis (n = 418, 41%), and Hepatitis B virus vaccinations (n = 310, 31%). However, 242 (24%) had not received any vaccinations prior to travel, including meningitis vaccine and poliomyelitis vaccine, which are mandatory by Saudi Ara-bian health authorities for pilgrims coming from polio active countries. Nearly a third of pilgrims (n = 305; 30.1%) never wore a face mask in crowded areas during Umrah in 2019. In contrast, similar numbers said they always wore a face mask (n = 351, 34.6%) in crowded areas, while 63.2% reported lack of availability of face masks during Umrah. The majority of participants had received some form of health education on preventative measures, including hygiene aspects (n = 799, 78.9%), mostly in their home countries (n = 450, 44.4%). A positive association was found between receiving health education and practicing of preventative measures, such as wearing face masks in crowded areas (p = 0.04), and other health practice scores (p = 0.02). Conclusion: Although the experiences of the preventative measures among pilgrims in terms of health education, vaccinations, and hygienic practices were at times positive, this study identified several issues. These included the following preventative measures: immunizations, particularly meningitis and poliomyelitis vaccine, and using face masks in crowded areas. The recent COVID-19 pandemic highlights the need for further Citation: Tobaiqy, M.; Alhasan, A.H.; Shams, M.M.; Amer, S.A.; MacLure, K.; Alcattan, M.F.; Al-mudarra, S.S. Assessment of Preventative Measures Practice among Um
... 4,5 The prevalence of musculoskeletal pain is rising, and it has been described as an epidemic. 1,6 "Hajj" is an Arabic word meaning "pilgrimage", 7 and it is the largest annual pilgrimage in the world, undertaken by Muslims at least once in their lifetime as a religious duty [8][9][10][11] if they are financially and physically capable. 12 Every year, around two to three million pilgrims converge simultaneously on the holy city of Mecca in Saudi Arabia (SA) for the rites of the Hajj, where they perform a series of rituals 9,10,12,13 that were originally performed by the Prophet Mohammed. ...
... 12 Every year, around two to three million pilgrims converge simultaneously on the holy city of Mecca in Saudi Arabia (SA) for the rites of the Hajj, where they perform a series of rituals 9,10,12,13 that were originally performed by the Prophet Mohammed. 9 Based on the lunar Islamic year/calendar, the Hajj begins on the eighth day of Dhu al-Hijjah (the last month of the Islamic year) and ends on the twelfth day of the same month, 10,12 although some pilgrims may spend further days to complete the Hajj. 11 The date of the Hajj differs with respect to the Gregorian calendar, occurring 11 days earlier each year. ...
... 11 The date of the Hajj differs with respect to the Gregorian calendar, occurring 11 days earlier each year. 8 This mass gathering, which leads to extreme congestion in small areas, may contribute to one of the most important public health problems in the world, 9,14 resulting in high environmental and healthcare demands. The Hajj also involves high physical demands because pilgrims move, generally by foot, among a series of religious sites over 5-7 days while following a specific route, with average distances of 5-15 km/day, 8,11,15 potentially reaching a total of 63 km during the whole period of the Hajj. ...
Article
Full-text available
Background: Musculoskeletal pain is a primary burden on individuals as well as social and health care systems. Annually, 2-3 million pilgrims perform the Hajj in Mecca, Saudi Arabia. The Hajj is highly physically demanding because pilgrims generally move by foot for long distances among a series of religious sites, an effort that may exceed their typical levels of physical activity. To understand the impact of musculoskeletal pain on the completion of the Hajj, it is first necessary to evaluate the extent of the problem. Accordingly, this study aimed to estimate the prevalence of musculoskeletal pain and associated factors among pilgrims during the Hajj. Methods: A cross-sectional survey was conducted during the period of the Hajj. The participants were adult pilgrims ≥ 18 years of age. Data regarding demographics, the prevalence of falls and the point prevalence of musculoskeletal pain by anatomical site were recorded. Participants were allowed to report more than one site of pain. Prevalence, crude and adjusted risk ratios were calculated. Results: A total of 1715 pilgrims were included in the analysis. The prevalence of falls was 13.76%. The prevalence of overall musculoskeletal pain (pain at any site) was 80.46%. Musculoskeletal pain was most commonly reported in the ankle/foot (38.34%), leg (29.89%), lower back (28.47%) and knee (21.84%). In general, musculoskeletal pain at multiple sites was more common in females and in older and obese individuals. However, there were variations in the importance of sex, age and body mass index as associated factors across different pain sites. Conclusion: Musculoskeletal pain is common among pilgrims. Unlike most populations examined in other studies, ankle/foot pain was the most common in pilgrims. These data provide guidance for potential preventative programs and the allocation of resources to optimize pilgrims' experiences and ability to complete the Hajj.
... Unlike some published reports [8,[18][19][20][21][22][23], our data showed most cases were significantly associated with pilgrims over 60 years of age ( Table 1). The vulnerability of elders to infections is probably due to a less efficient immune response, which is provoked by factors such as chronic diseases, and physical and mental stress [24][25][26]. This study highlights the need for increasing attention and provision of preventive infection control strategies to this age group. ...
... Respiratory tract viral infections (RTIs) are the most common infections among pilgrims and represent the leading cause of most hospitalizations [7,8,27,28]. In both international and domestic pilgrims [24,29]. Over the last decade, several epidemiological studies have been carried out on pilgrims showing high prevalence of RTIs mostly attributed to respiratory viruses [11,[30][31][32][33]. ...
Article
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The aim of our study was to define the spectrum of viral infections in pilgrims with acute respiratory tract illnesses presenting to healthcare facilities around the holy places in Makkah, Saudi Arabia during the 2019 Hajj pilgrimage. During the five days of Hajj, a total of 185 pilgrims were enrolled in the study. Nasopharyngeal swabs (NPSs) of 126/185 patients (68.11%) tested positive for one or more respiratory viruses by PCR. Among the 126 pilgrims whose NPS were PCR positive: (a) there were 93/126 (74%) with a single virus infection, (b) 33/126 (26%) with coinfection with more than one virus (up to four viruses): of these, 25/33 cases had coinfection with two viruses; 6/33 were infected with three viruses, while the remaining 2/33 patients had infection with four viruses. Human rhinovirus (HRV) was the most common detected viruses with 53 cases (42.06%), followed by 27 (21.43%) cases of influenza A (H1N1), and 23 (18.25%) cases of influenza A other than H1N1. Twenty-five cases of CoV-229E (19.84%) were detected more than other coronavirus members (5 CoV-OC43 (3.97%), 4 CoV-HKU1 (3.17%), and 1 CoV-NL63 (0.79%)). PIV-3 was detected in 8 cases (6.35%). A single case (0.79%) of PIV-1 and PIV-4 were found. HMPV represented 5 (3.97%), RSV and influenza B 4 (3.17%) for each, and Parechovirus 1 (0.79%). Enterovirus, Bocavirus, and M. pneumoniae were not detected. Whether identification of viral nucleic acid represents nasopharyngeal carriage or specific causal etiology of RTI remains to be defined. Large controlled cohort studies (pre-Hajj, during Hajj, and post-Hajj) are required to define the carriage rates and the specific etiology and causal roles of specific individual viruses or combination of viruses in the pathogenesis of respiratory tract infections in pilgrims participating in the annual Hajj. Studies of the specific microbial etiology of respiratory track infections (RTIs) at mass gathering religious events remain a priority, especially in light of the novel SARS-CoV-2 pandemic.
... In Saudi Arabia, pilgrims from over 160 countries gather to perform Hajj every year and in this period the risk of public health problems related to infectious diseases increase [20,21]. The Saudi government has taken a number of steps to improve the management of public health during Hajj but still outbreaks occur [22]. In 2009 there was a pandemic H1N1 influenza, the data analyses from Europe and the USA regarding the transmission dynamics of the virus estimated the basic reproduction number (R 0 ) of the virus to be 1.2-1.7, ...
... p-value <0.05 was considered statistically significant. Other health related specialties can perform the tasks of a public health professional 9 22.0 There is no needs for public health graduates in the Saudi labor market 3 7.3 ...
Article
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Background: An efficient public health workforce is necessary for improving and maintaining the health of population and such a workforce can be prepared through proper educational programs and trainings. Objectives: The present study aims to investigate the needs in the public health education programs, as well as need and availability of competent public health workforce in labour market of Saudi Arabia. Methods: A descriptive, cross-sectional survey was administered in two phases in the college of Health Sciences at the Saudi Electronic University (SEU). The first phase was carried out between September 2015 and December 2015, which involved interview with administrative heads of four health-related organizations. The second phase was performed in September 2017 and June 2018 after starting an undergraduate course in public health at the university. A total of 41 faculty and 408 students from different branches of SEU participated in the online survey. Results: According to administrative head of public health-related organization, there is a shortage of qualified workforce in public health. All the four organizations need workforce with the master degree in sub-speciality epidemiology. About 97.5% students agreed there is a shortage of public health speciality in these organizations. About 92.7% faculty had an opinion that there is a requirement to set-up educational programs in public health. To overcome the shortage of competent workforce, two organizations showed interest in updating their employees’ skill through bridging courses. The students perceiving bachelor course in public health showed interest to accomplish master’s degree in epidemiology (38.5%), public health education and promotion (36.5%) and infection control (35.5%). Conclusion: There is a shortage of expertise in the public health organizations and there is a need for development of more public health schools in the Kingdom of Saudi Arabia. The establishment of public health courses especially in the field of epidemiology at undergraduate and graduate level will help in the development of efficient and competent public health workforce.
... No studies have been conducted to investigate the transmission of AMR bacteria and ARGs in environmental samples associated with key religious mass gatherings (Kumbh Mela and Hajj) occurring in low-income settings. Kumbh Mela and Hajj are the largest and most diverse mass gathering events that have been associated with an increased risk of infectious disease emergence and transmission [100,101]. ...
... Hajj has already been associated with an increased risk of airborne, foodborne and zoonotic infections [100]. Recent studies have demonstrated that pilgrims are at high potential risk of acquiring and transmitting AMR enteric bacteria, [106][107][108][109] including carbapenemase-producing E. coli [110] and extended-spectrum cephalosporin-and colistin-resistant non-typhoidal Salmonella [111], as well as MDR Acinetobacter spp. ...
Article
Full-text available
Antimicrobial resistance (AMR) is the major issue posing a serious global health threat. Low- and middle-income countries are likely to be the most affected, both in terms of impact on public health and economic burden. Recent studies highlighted the role of resistance networks on the transmission of AMR organisms, with this network being driven by complex interactions between clinical (e.g., human health, animal husbandry and veterinary medicine) and other components, including environmental factors (e.g., persistence of AMR in wastewater). Many studies have highlighted the role of wastewater as a significant environmental reservoir of AMR as it represents an ideal environment for AMR bacteria (ARB) and antimicrobial resistant genes (ARGs) to persist. Although the treatment process can help in removing or reducing the ARB load, it has limited impact on ARGs. ARGs are not degradable; therefore, they can be spread among microbial communities in the environment through horizontal gene transfer, which is the main resistance mechanism in most Gram-negative bacteria. Here we analysed the recent literature to highlight the contribution of wastewater to the emergence, persistence and transmission of AMR under different settings, particularly those associated with mass gathering events (e.g., Hajj and Kumbh Mela).
... [32] Studies have shown that this inevitable overcrowding is mostly associated with travel-related infections. [33,34] Given all the expertise that has accrued over the years, the Saudi Arabian health authorities are familiar with the way the massing of people can result in a pandemic like COVID-19. [33,34] The concurrence of COVID-19 with the Hajj season provides an extra indication of the insights and benefits that TH could provide care delivery during such a crisis. ...
... [33,34] Given all the expertise that has accrued over the years, the Saudi Arabian health authorities are familiar with the way the massing of people can result in a pandemic like COVID-19. [33,34] The concurrence of COVID-19 with the Hajj season provides an extra indication of the insights and benefits that TH could provide care delivery during such a crisis. TH seems to be changing the nature of care delivery in Saudi Arabia since the majority of residents and noncitizens, can access the services quickly and easily. ...
Article
Full-text available
Since the beginning of the coronavirus disease (COVID-19) pandemic, the responses of countries to emerging infectious diseases have altered dramatically, increasing the demand for health-care practitioners. Telehealth (TH) applications could have an important role in supporting public health precautions and the control of the spread of the COVID-19 pandemic. This review summarizes the existing literature on the current status of TH applications used during COVID-19 in Saudi Arabia and discusses the extent to which TH can support public health measures. TH mobile applications (e.g., Seha, Mawid, Tawakklna, Tabaud, and Tetamman) have found effective tools to facilitate delivering healthcare to persons with COVID-19, and tracking of COVID-19 patients. TH has been essential in the control of the spread of COVID-19 and has helped to flatten the growth curve in Saudi Arabia. Further research is needed to explore the impact of TH applications on the progression of COVID-19 in Saudi Arabia.
... These measures explain the patient's relatively slow rate of cooling while in the ED at 0.02 C/min. Historically, similar heat stroke incidents have occurred in Lyon, France, the U.S. states of Illinois and Texas, and the Middle East (17)(18)(19)(20)(21)(22)(23)(24). In particular, heat illness has been a common insult for centuries to those making the Islamic, Makkah Pilgrimage (''Haji''). ...
... A cross-sectional study of the 2016 Haji recruited 246 patients between 4 hospitals and reported 80 (29%) patients and 187 (67.75%) patients with the diagnosis of heat stroke and heat illness, respectively (22). However, unlike the victims of the tractor trailer incident, Haji pilgrims have variable access to food, water, and shade on their journeys, and some receive pretravel education about the importance of using umbrellas or performing rituals at night (24). In addition, the Saudi Ministry of Health, in collaboration with the Haji Committees, has made provisions for heat related illness by providing the necessary supplies and trained personnel to accommodate such heat-laden trek (22). ...
Article
Background: Immigrants crossing the Southern U.S. border are particularly susceptible to heat illness. We review 3 patients from a heat-related mass-casualty incident with variations in heat stroke presentation, course, and outcome. Case report: On July 23, 2017, emergency medical services responded to a trafficking-related mass-casualty incident in San Antonio, Texas, involving 39 migrants found inside an abandoned tractor trailer without air conditioning who had been trafficked from Laredo, Texas. Three victims exhibiting heat stroke symptoms were taken to the ED of a large academic teaching hospital. Patient 1 was a 42-year-old man who presented with seizing, vomiting, and a core temperature of 38.8°C (101.8°F). His 54-day hospital course was notable for 2 cardiac arrests, disseminated intravascular coagulation, prolonged lactic acidosis, and residual kidney disease. Patient 2 was a 32-year-old man who presented to the emergency department intubated in the field with a core temperature of 40.7°C (105.3°F). His 60-day hospital course was notable for disseminated intravascular coagulation, severely elevated troponin, prolonged lactic acidosis, and stroke. Patient 3 was a 20-year-old man who presented with seizing and decorticate posturing, with a core temperature of 40.5°C (104.9°F). His 6-day hospital course was notable for rapid clinical improvement and full recovery. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians will encounter heat stroke victims. Our patients were exposed to an identical environment, and while each patient was otherwise healthy and differed significantly only in age, they exhibited a diversity of heat stroke presentations and sequelae. Treatment prioritizes cooling, but rapid deterioration requires intensive treatment of multiorgan failure.
... Excluding the recent coronavirus disease 2019 pandemic, more than 2 million pilgrims attend this event from more than 180 countries [6]. Traveling from both hemispheres and overcrowding during Hajj rituals may expose pilgrims to several health risks [7]. These health risks can be categorized by their origin into environmental, human, and emergent [7][8][9][10][11][12]. ...
... Traveling from both hemispheres and overcrowding during Hajj rituals may expose pilgrims to several health risks [7]. These health risks can be categorized by their origin into environmental, human, and emergent [7][8][9][10][11][12]. Most of them can be avoided and mitigated by careful planning, thorough governance, and appropriate practices [13][14][15]. ...
... The incidence of IMD varies significantly across the world as does the distribution of different NM serogroups [3]. The pathogenesis of IMD is based on complex and incompletely understood host-pathogen interactions and several risk factors have been proposed such as age, specific community settings, certain medical conditions, and travel to NM endemic regions or mass gatherings such as Hajj [6,7]. ...
Article
Full-text available
Invasive meningococcal disease (IMD) remains a major cause of mortality and morbidity in children worldwide. A systemic review in PubMed and Cochrane Controlled Trials Register was performed for articles on risk factors for IMD in children and adolescents published during a 20-year period (19/09/1998 to 19/09/2018). Inclusion and exclusion criteria were established and applied. The data were meta-analyzed using random-effect model and the results were presented on forest plots separately for each risk factor. We identified 12,559 studies (duplicates removed). Titles, abstracts, and full texts were screened and finally, six studies (five case-control and one cohort study) were included in qualitative synthesis, five in meta-analysis. The median age of meningococcal disease (MD) cases was 72.2 months (0–19 years). Household crowding, smoking exposure, close relationships, and recent respiratory tract infections conferred a more than twofold risk for IMD in exposed individuals compared to controls [overcrowded living OR 2.52 (95% CI 1.75–3.63), exposure to smoke OR 2.10 (95% CI 1.00–4.39), kissing OR 2.00 (95% CI: 1.13–3.51), and recent respiratory tract infection OR 3.13 (95% CI 2.02–4.86)]. Attendance of religious events was associated with a decreased risk [0.47 (95% CI, 0.28–0.79)]. Conclusion: Our review highlights the importance of individual characteristics as risk factors for IMD in childhood and adolescence. Preventive policies may consider individual as well as social-environmental factors to target individuals at risk.What is Known: • Close relationships, household crowding, and recent respiratory tract infections are major risk factors for IMD. • Passive smoking is a major risk factor for IMD. What is New: • Intimate kissing, household crowding, and passive smoking were found to double the risk of IMD. • Recent respiratory tract infections almost tripled the risk for IMD.
... Many pilgrims are from poliomyelitis-endemic countries. Therefore, due to the concern about the potential introduction of poliomyelitis into the Hajj with subsequent international spread, the Kingdom of Saudi Arabia has introduced mandatory poliomyelitis vaccination at the point of entry for all pilgrims coming from poliomyelitis-endemic countries (Table 1) [22]. ...
Article
Vaccinations are an important component of travel medicine. Beyond protection of travelers, vaccines are administered to prevent the importation of vaccine-preventable diseases at home and at destination. Proof of immunization to travel dates back to the first smallpox vaccine, developed by Edward Jenner in 1796. However, it took one century to generate the next vaccines against cholera, rabies, and typhoid fever. During the 20th century the armamentarium of vaccines used in travelers largely expanded with yellow fever, poliomyelitis, tetravalent meningococcal, and hepatitis A vaccines. The International Certificate of Inoculation and Vaccination was implemented in 1933. Currently there are vaccines administered to travelers following risk assessment, but also vaccines required according to the 2005 International Health Regulations and vaccines required at certain countries. Finally, within less than one year after the declaration of the coronavirus disease 2019 (COVID-19) pandemic, the first COVID-19 vaccines were launched and approved for emergency use to control the pandemic. Despite practical and ethical challenges, COVID-19 vaccine verifications have been widely used since spring 2021 in many activities, including international travel. In this article, we review the course of development of travel vaccines focusing on those for which a proof of vaccination has been or is required.
... All overseas pilgrims travelling to Saudi Arabia require a visa which can only be acquired through approved Hajj travel agents [12]. These tour operators play a pivotal role in pilgrims' preparation leading up to Hajj, relaying important travel instructions prior to departure through 'pre-Hajj seminars' which almost all prospective pilgrims attend [13]. ...
Article
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This study assessed Australian Hajj pilgrims’ knowledge, attitude and practices throughout their Hajj journey to understand their health behaviors, use of preventative measures and development of illness symptoms. A prospective cohort study with data collection at three phases (before, during and after Hajj) was conducted among Australian pilgrims between August and December 2015. Baseline data were collected from 421 pilgrims before Hajj, with 391 providing follow-up data during Hajj and 300 after their home return. Most participants (78% [329/421]) received one or more recommended vaccines; travel agents’ advice was the main factor affecting vaccination uptake. Most participants (69% [270/391]) practiced hand hygiene with soap and sanitizers frequently, followed by disposable handkerchief use (36% [139/391]) and washing hands with water only (28% [111/391]). During Hajj 74% (288/391) of participants reported one or more illness symptoms, 86% (248/288) of these symptoms were respiratory. Cough was less often reported among pilgrims who received vaccinations, cleaned their hands with soap or alcoholic hand rubs, while a runny nose was less common among those who frequently washed their hands with plain water but was more common among those who used facemasks. This study reveals that most Australian Hajj pilgrims complied with key preventative measures, and that tour group operators’ advice played an important role in compliance. Pilgrims who were vaccinated and practiced hand hygiene were less likely to report infection symptoms.
... To address whether mass gatherings are associated with influenza transmission, evidence was derived from the following: -A quasi-experimental study that was primarily designed to quantify vaccine efficacy in the form of a non-randomised trial -Observational studies that assessed participants before and after exposure to mass gathering events -Reports of influenza outbreaks and other respiratory illnesses at mass gathering events -Communicable disease surveillance reports from some major events A number of studies (8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20) have consistently demonstrated, over a number of years, that respiratory virus transmission occurs amongst pilgrims attending the annual Hajj in Saudi Arabia, and it is recognized as an issue of international public health significance (48)(49)(50)(51)(52) that could be particularly important in a pandemic situation. To address this concern, this update included a number of new studies that analysed influenza in pilgrims during the 2009 Hajj (which took place during the 2009 pandemic period). ...
Technical Report
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In light of the large number of publications and the operational experience that have emerged since the 2009 pandemic (H1N1 pdm09), the Department of Health commissioned the HPA to update this review and several other pandemic influenza topic areas. Summary of findings: The evidence to help address important public health questions around mass gatherings and influenza transmission is sparse, especially in the context of an influenza pandemic. This remains the case following the recent update. However, it is possible to draw three principal conclusions from the review. Firstly, mass gatherings are very varied and the type, size, duration and setting of such events may play a role in the risk of influenza transmission. Secondly, there is some evidence that influenza may be transmitted at certain kinds of mass gatherings. Thirdly, limited - and mainly historical - evidence indicates that restrictions of mass gatherings can reduce transmission when part of a package of other public health interventions including isolation and school closures. In terms of policy implications, it is clear that mass gatherings should not be considered as a homogenous group of events; the adoption of a common terminology for describing mass gatherings and the development of a hierarchy based on factors such as event size, duration, and crowd density may be helpful towards risk assessment and policy decision making. While there is little, if any direct evidence, to support banning mass gatherings, voluntary rather than legislated restrictions may, if implemented as part of a package of other public health measures, be a pragmatic and beneficial approach should the severity of a future pandemic warrant extraordinary measures. Link: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/316200/Mass_Gatherings_evidence_Review.pdf
... Muslims can also go to Mecca/Makkah to perform Umrah, a minor pilgrimage, at any time of the year. In both Hajj and Umrah, the huge mass gatherings in a small area, fluctuating weather, and the hostile desert of Saudi Arabia expose pilgrims to health risks [4][5][6]. ...
Article
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Objective Mass gatherings medicine is an emerging and important field at the national and international health security levels. The objective of the current study was to analyze research publications on religious mass gatherings of Muslims using bibliometric tools. Methods Keywords related to religious mass gatherings of Muslims were used in Scopus database. The duration of the study was from January 01, 1980 to December 31, 2020. Examples of keywords used include hajj, Umrah, mass gatherings/Mecca or Makkah, mass gatherings/Karbala, pilgrim/Makkah or Mecca, and others. Bibliometric indicators and mapping were presented. Results In total, 509 documents were retrieved. The average number of citations per article was 16.7 per document. Analysis of the retrieved documents indicated that (1) more than 90% of the retrieved documents were about the mass gatherings in Mecca/Makkah; (2) two-thirds of the retrieved documents were research articles; (3) a take-off phase in the number of publications was observed after 2008; (4) the retrieved documents were disseminated in a wide range of journals but specifically the ones in the fields of infectious diseases, public health, and travel medicine; (5) the retrieved documents were mainly published by scholars from Saudi Arabia with collaborative research ties with scholars in the US, France, the UK, and Australia; (6) Saudi Arabia contributed to more than half of the retrieved documents; and (7) four research themes were found: knowledge, attitude, and practices of pilgrims to Mecca/Makkah, vaccination, etiology of hospital admission among pilgrims, and epidemiology of various types of infectious diseases. Conclusions Research on mass gatherings, specifically the Hajj, is emerging. Researchers from the Saudi Arabia dominated the field. Research collaboration between scholars in Saudi Arabia and scholars in low- and middle-income countries is needed and must be encouraged since these countries have weaker health systems to screen, monitor, and control the spread of infectious diseases because of the Hajj season.
... Hajj is an annual religious mass gathering where over 2 million pilgrims assemble for around one week within a confined area measuring around 40 km 2 , where the risk of transmission of infectious diseases is amplified [6]. Hajj has already been associated with an increased risk of airborne, foodborne and zoonotic infections [7]. Recent studies have demonstrated that pilgrims are at high potential risk of acquiring and transmitting AMR enteric bacteria [8,9], including multidrug resistant Acinetobacter spp., carbapenemase-producing Escherichia coli [10] and extended-spectrum cephalosporin-and colistin-resistant non-typhoidal Salmonella [11]. ...
Article
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Antimicrobial resistance (AMR) is a global public health issue. Upper respiratory tract infections (URTIs) are common illnesses during Hajj, for which antibiotics are often inappropriately prescribed. Hajj healthcare workers’ (HCW) knowledge, attitudes and perceptions (KAP) about AMR and antibiotic use for URTIs are not known. We conducted a survey among HCWs during Hajj to explore their KAP regarding antibiotic use for URTIs in pilgrims. Electronic or paper-based surveys were distributed to HCWs during the Hajj in 2016 and 2017. A total of 85 respondents aged 25 to 63 (median 40) years completed the surveys. Most participants were male (78.8%) and were physicians by profession (95.3%). Around 85% and 19% of respondents claimed to have heard about AMR and antimicrobial stewardship programs, respectively, among whom most had obtained their knowledge during their qualification. Implementation of URTI treatment guidelines was very low. In conclusion, HCWs at Hajj have significant knowledge gaps regarding AMR, often do not use standard clinical criteria to diagnose URTIs and display a tendency to prescribe antibiotics for URTIs.
... tents, using shared toilets, eating food that may be prepared to low hygienic standards, 625 and potential contact with asymptomatic carriers of infectious agents, may facilitate the 626 transmission of infectious agents within susceptible populations. This could 627 subsequently increase the emergence and dissemination of airborne, foodborne and 628 zoonotic infectious diseases within the host country and globally [145]. for all pilgrims against meningococcal disease [146]. ...
Chapter
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Antimicrobial resistance (AMR) is a major issue that poses a serious threat to global health. Recent reports from the World Health Organization (WHO) highlighted the increased threat from continuously emerging AMR organisms, accompanied by the paucity of development of new antimicrobial drugs. Low- and middle-income countries are likely to be the most affected, both in terms of the impact on public health and economic burden. Recently there has been increased evidence that the global transmission of AMR pathogens is fueled by AMR carriage associated with human movement, including international travel and forcible displacement. This is alarming, with the United Nations World Tourism Organization (UNWTO) reporting that 1.4 billion people, accounting for 19% of the world’s population, traveled across international borders in 2018. The number of tourists traveling to different destinations across the globe is predicted to increase to 1.8 billion by 2025. However, traveler population is not entirely formed of tourists, but it comprises different categories including forcibly displaced people and participants of mass gathering events. In this chapter, we will discuss the contribution of traveler populations to the emergence and global dissemination of AMR bacteria. Specifically, we will highlight the contribution of special traveler populations, such as forcibly displaced refugees and attendees of mass gathering events, on the dissemination of AMR globally.
... However, although general vaccination for Hajj pilgrims has been discussed and acknowledged in the literature and by some countries [53,54], it is not specifically recommended by the Saudi Ministry of Health [55,56] or WHO [57]. In fact, very few High-risk groups Hajj pilgrims ≥65 years or younger adults who have chronic disease or weakened immune system data are available regarding pneumococcal disease in relation to the Hajj, and more studies are needed before an official recommendation can be made. ...
Article
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Pneumococcal disease has substantial incidence, morbidity and mortality in older adults. Decreased birth rates and longer lifespans indicate that the global population is aging, although rates of aging differ between countries [1]. In 2010, the proportion of the population aged >60 years in the general Arab Region was 7%, and this proportion is expected to rise to 19% by 2050 for the region as a whole [2]; the United Nations estimates for the individual countries of the Arabian Gulf by 2050 are 25.7%, 24.9%, 20.7%, 26.7% and 10.5% in the Kuwait, Bahrain, Qatar, United Arab Emirates (UAE) and Oman, respectively, which are comparable to the 26.9% predicted for the USA and lower than that predicted in European countries,
... 16 This is relevant as the behaviour of reusing blades from other pilgrims and using the services of unlicensed barbers who may use nonsterile blades can put pilgrims at risk of spreading blood-borne infections such as hepatitis B and C as well as HIV. 1 Hepatitis B vaccine is not among the Hajj travel vaccines recommended by the Saudi authorities as it is difficult for many pilgrims to take due to the cost and time required to complete the vaccination course. 1 The risk of hepatitis B and C and HIV transmission using laboratory testing in pilgrims using unlicensed barbers was not investigated in our study. This is an important knowledge gap that needs to be investigated in further research based on laboratory confirmed results of blood samples from pilgrims before and after the Hajj. ...
Article
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Background: The Hajj is one of the world's largest pilgrimage and gathers millions of Muslims from different nationalities every year. Communicable diseases have been reported frequently, during and following the Hajj and these have been linked to individual behavioural measures. This study aimed to measure the effect of personal preventive measures, such as facemask use, hand hygiene and others, adopted by pilgrims in reducing the acquisition of infectious diseases. Methods: We conducted a cross-sectional study at the Hajj terminal in King Abdulaziz International Airport in Jeddah, Saudi Arabia. Pilgrims were approached in the airport lounges after the 2017 Hajj season and prior to the departure of their flights from Jeddah to their home countries. An electronic data collection tool ('Open Data Kit' (ODK)), was used to gather survey data in regards to health problems and preventive measures during the Hajj. Results: 2973 Hajj pilgrims were surveyed. 38.7% reported symptoms of upper respiratory tract infections (URTI) and 5.4% reported symptoms of travel diarrhoea. Compliance with facemask use was 50.2%. Changing a facemask every 4 hours was found to be significantly associated with lower prevalence of URTIs (adjusted OR 0.56; (95% CI; 0.34-0.92), P = 0.02). There was no statistical difference between overall facemask use and URTI acquisition. The main sources of food, eating raw vegetables/food, frequency of hand washing or use of hand sanitisers were not found to be significantly associated with reported travellers' diarrhoea. Unlicensed barbers were used by 12% of pilgrims and 9.2% of pilgrims reported using blades that were re-used by other pilgrims. Conclusion: Preventive measures are the most effective way to prevent infections Pilgrims can benefit from facemasks by changing them frequently. There is still limited information on the effect of the use of facemask in decreasing the risk of URTI in mass gatherings.
... Mass-gathering events, by virtue of people congregating together in a common place, may result in an increased transmission of communicable diseases, particularly respiratory tract infections. 7,8 Transmission of respiratory viruses such as human coronavirus, seasonal influenza virus, and rhinovirus has been reported in various MGE contexts with varying rates of transmission. 9 However, novel respiratory viruses pose a unique public health threat due to a lack of treatment options and preventative measures, such as vaccines, as well as unknown modes of transmission and virulence of the pathogen involved. ...
Article
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Background Mass-gathering events (MGEs) occur regularly throughout the world. As people congregate at MGEs, there is an increased risk of transmission of communicable diseases. Novel respiratory viruses, such as Severe Acute Respiratory Syndrome Coronavirus-1 (SARS-CoV-1), Influenza A Virus Subtype H1N1 Strain 2009 (H1N1pdm09), Middle East Respiratory Syndrome Coronavirus (MERS-CoV), and Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), or Coronavirus Disease 2019 (COVID-19), may require specific infection prevention and control strategies to minimize the risk of transmission when planning MGEs. This literature review aimed to identify and analyze papers relating to novel respiratory viruses with pandemic potential and to inform MGE planning. Method This paper used a systematic literature review method. Various health care databases were searched using keywords relating to MGEs and novel respiratory viruses. Information was extracted from identified papers into various tables for analysis. The analysis identified infection prevention and control strategies used at MGEs to inform planning before, during, and following events. Results In total, 27 papers met the criteria for inclusion. No papers were identified regarding SARS-CoV-1, while the remainder reported on H1N1pdm09 (n = 9), MERS-CoV (n = 15), and SARS-CoV-2 (n = 3). Various before, during, and after event mitigation strategies were identified that can be implemented for future events. Conclusions This literature review provided an overview of the novel respiratory virus epidemiology at MGEs alongside related public health mitigation strategies that have been implemented at these events. This paper also discusses the health security of event participants and host communities in the context of cancelling, postponing, and modifying events due to a novel respiratory virus. In particular, ways to recommence events incorporating various mitigation strategies are outlined.
... Saudi Arabia is the cornerstone of pilgrimage for Muslims from all over the world for Hajj/Umrah, with these religious rites centered on the holy city of Makkah. The extreme congestion of Saudi and non-Saudi populations results in the occurrence and spread of various infectious diseases, specifically when the healthcare system is not wellestablished [9,10]. A national point prevalence survey (PPS) carried out in 26 hospitals in Saudi Arabia reported that 45.7% of antimicrobials are used in surgical departments, and 59.6% of patients received at least one antimicrobial in Makkah hospital, representing the fourth highest antimicrobial usage nationally [11]. ...
Article
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(1) Background: Inappropriate use of antimicrobials and subsequently rise of antimicrobial resistance (AMR) remains a major public health priority. Over-prescribing of broad-spectrum antibiotics is one of the main contributing factors for the emergence of AMR. We sought to describe antimicrobial prescribing trends among patients in public hospitals in Makkah hospitals. (2) Method: We undertook a point prevalence survey (PPS) in six hospitals in Makkah, Saudi Arabia, from January 2019 to July 2019. The survey included all the inpatients receiving antimicrobials on the day of PPS. Data was collected using the Global point prevalence survey (PPS) tool developed by the University of Antwerp, Belgium. (3) Results: Of 710 hospitalized patients, 447 patients (61.9%) were treated with one or more antimicrobials during the study period. The average bed occupancy among six hospitals was 74.4%. The majority of patients received antimicrobials parenterally (90.3%). Of the total prescribed antimicrobials, 415 (53.7%) antimicrobials were used in medical departments, 183 (23.7%) in surgical departments, and 175 (22.6%) in ICUs. Pneumonia (17.3%), skin and soft tissue infections (10.9%), and sepsis (6.6.%) were three common clinical indications. Ceftriaxones were the most commonly used antibiotics that were prescribed in 116 (15%) of patients, followed by piperacillin, with an enzyme inhibitor in 84 (10.9%). (4) Conclusion: There was a high prevalence of antibiotic use in the hospitals of Makkah, which could be a potential risk factor for the incidence of resistant strains, particularly MRSA infection. Public health decision-makers should take these findings into consideration to update national policies for antibiotic use in order to reduce the risks of further increases of AMR.
... Approximately, 100,000 pilgrims go to Mecca from Iran (2). The 35-45-day course of Hajj has its specific complexities and features regarding health aspects (3). Health problems in days of the Hajj can generally be divided into two groups. ...
Article
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Background: Chronic renal failure (CRF) and end-stage renal disease (ESRD) are among the underlying reasons for the hospitalization of expeditionary pilgrims to Mecca. This study aimed to evaluate the reasons and consequences of sending the patients with CRF and ESRD to Mecca to perform rites of pilgrimage. Methods: This retrospective cross-sectional study assessed the profiles of all pilgrims in 2012 and 2013. The independent variables were awareness and unawareness of the patients with CRF and patients on dialysis; moreover, the dependent variables were reasons for referral and hospitalization in hospital, probable death rate, and indications of dialysis in an emergency. Results: Out of all Pilgrims, 2416 (1.76% of the total pilgrims’ population) cases had CRF, out of whom 1.15%, 10.47%, and 88.36% of the patients were on dialysis, aware, and unaware of their disease, respectively. Furthermore, 93 (3.9%) patients with CRF were hospitalized during Hajj. Cardiovascular disease (41%) and respiratory diseases (20%) were the most common reasons for patients’ hospitalization. Conclusion: It is suggested that the glomerular filtration rate of the pilgrims be calculated before sending them to Hajj; moreover, the patients with CRF should be screened accurately. Proper vaccination and cardio check-up are necessary before the Hajj expedition. Considering low-salt diet and adequate fluid intake in patients with CRF during Hajj can minimize patients' referral to hospitals.
... This study is focused on expanding understanding of health information, attitudes and actions of Hajj pilgrims to Makkah in the Kingdom of Saudi Arabia (KSA), as it is the most crowded and complicated annual event in the world. Every year over 2 million believers, from more than 140 countries congregate over s few days to perform religious rituals and are faced with unique health and safety challenges including crowd crush, heatstroke and infectious diseases [6][7][8][9][10]. Despite huge built infrastructure investments year in and year out by the Saudi government, to reduce overcrowding and crowd crush accidents and technological enhancements for crowd monitoring and management, pilgrims continue to be wary. ...
Article
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Mass gatherings for sporting events, music shows, and religious needs continue to grow in our urban areas, requiring local authorities to develop safety procedures to mitigate the challenges of keeping the attendees safe. These challenges are even more pronounced at pilgrimage venues where social distancing and contact avoidance are difficult as pilgrims are required to perform various rituals in close proximity with others, in a sequential manner, either daily or weekly, as per their religious tenets. Over two million pilgrims attend the Hajj pilgrimage in Saudi Arabia annually. Keeping the local and visiting pilgrims safe from crowd crush, sunstroke, skin infections, recurrence of prior medical issues, and contagious diseases requires the Saudi government to allocate huge investments for health communication and prevention programs every year. However, there is no evidence to date that has empirically tested whether Hajj pilgrims’ are able to receive such information and are subsequently adopting various health promoting behaviors. This study aims to do that by framing it within the Health Belief Model. Data collected and analyzed from 245 pilgrims in Makkah between September 9th-19th, 2017 suggests that roughly 48% of the pilgrims adopted all five protective measures. However, language barriers, limited health care facilities, and difficulties in purchasing prescription mediciens were cited as impediments to adopting healthy measures.The study concludes with recommendations for the KSA government agencies, Hajj authorities, Mission authorities and pilgrims, during various phases of travel-- i.e. pre-travel, during the pilgrimage and post-travel, in light of new emerging health threats.
... Matters around congestion, crowd management and the movement of people over the 6 days have also been addressed (Koshak, 2006;Al-Kodmany, 2009;Fayoumi et al., 2011;Al-Kodmany, 2013;Haase et al., 2018). Studies dealing with services are more limited; although see Ahmed et al. (2006) and in relation to health issues. Halabi (2012), Mitchell, Rashid et al. (2013), used a combined approach (navigation systems, people tracking and location-based systems) to aid pilgrim movements at the Hajj by providing an ability to locate family and friends and important places within Mina. ...
... Every year more than two million Muslims travel to one of the largest and most geographically and ethnically diverse mass gatherings in the world-Hajj (Ahmed, Arabi, and Memish, 2006;Memish, 2010). Hajj, the annual Islamic pilgrimage to Mecca, Kingdom of Saudi Arabia, spans over a few days in the 12th month of the Islamic lunar calendar (Yezli et al., 2016). ...
Preprint
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Epidemics can negatively affect economic development except mitigated by global governance institutions. We examine the effects of sudden exposure to epidemic disease on human capital outcomes using evidence from the African meningitis belt. Meningitis shocks reduce child health outcomes, especially in periods when the World Health Organization (WHO) does not declare an epidemic year. These effects are reversed when the WHO declares an epidemic. Children born in meningitis shock areas during a year when an epidemic is announced are 10 percentage points (pp) less stunted and 8.2 pp less underweight than their peers born in non-epidemic years. We find suggestive evidence for the crowd-out of routine vaccination during epidemic years. We analyze data from World Bank projects and find evidence that an influx of health aid in response to WHO declarations may partly explain these reversals.
... A combination of the hot desert climate, physical fatigue, and crowded conditions makes pilgrims much more susceptible to contracting an infectious disease, especially acute respiratory infections [44]. Moreover, the fact that the Hajj is based on a lunar calendar means that it moves forward by 10 to 11 days each year, causing extra challenges based on whether it coincides in the hot summer months [45]. ...
Article
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Emerging infectious diseases are of great concern to public health, as highlighted by the ongoing coronavirus disease 2019 (COVID-19) pandemic. Such diseases are of particular danger during mass gathering and mass influx events, as large crowds of people in close proximity to each other creates optimal opportunities for disease transmission. The Hashemite Kingdom of Jordan and the Kingdom of Saudi Arabia are two countries that have witnessed mass gatherings due to the arrival of Syrian refugees and the annual Hajj season. The mass migration of people not only brings exotic diseases to these regions, but also takes new diseases back to their own countries, e.g. outbreak of MERS in South Korea. Many emerging pathogens originate in bats, more than 30 bat species have been identified in these two countries. Some of those bat species are known to carry viruses that cause deadly diseases in other parts of the world, such as rabies virus and coronaviruses. However, little is known about bats and the pathogens they carry in Jordan and Saudi Arabia. Here, the importance of an enhanced surveillance of bat-borne infections in Jordan and Saudi Arabia is emphasized, promoting the awareness of bat-borne diseases among the general public and building up infrastructure and capability to fill the gaps in public health preparedness in order to prevent future pandemics.
... Mass gatherings are either spontaneous, such as at train stations during rush hour or are planned, such as at sport, cultural, religious, or political events (WHO, 2015). The Hajj pilgrimage in Saudi Arabia and the Kumbh Mela in India are the biggest regular mass gatherings globally, bringing millions of pilgrims together (Ahmed et al., 2006;Illiyas et al., 2013). Mass gatherings may affect health in different ways and crowd disasters may occur, including the collapse of infrastructure, fire incidents, terrorist attacks, violence riots, and human stampedes (Soomaroo and Murray, 2012;WHO, 2015;Still, 2019). ...
Article
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With disasters increasing in intensity, severity and impacts across the globe, improving risk information across all types of hazards is critical to enhance our capacity to anticipate, prevent and respond to disaster risks from the local to the global scales. One barrier to sharing and using risk information effectively has been the lack of standardized definitions of hazards and a lack of guidance on the full range of hazards from hydrometeorological, extraterrestrial, geological, environmental, chemical, biological, technological and societal that need to be addressed in risk management. The UNDRR/ISC Hazard Information Profiles Supplement (2021) to UNDRR-ISC Hazard Definition & Classification Review: Technical Report (2020) is the first ever compilation of definitions of over 300 hazards that are relevant to the 2015 United Nations landmark agreements of the Sendai Framework for Disaster Risk Reduction, the Paris Agreement on climate change and the Sustainable Development Goals. The last two years have shone a light on the need for a more holistic approach to understanding risk with countries facing multiple and compounding disasters such as heatwaves, cold waves, wildfires, floods, locust invasion, pandemic and others. Many of these hazards are defined in multiple ways which can hinder the sharing and integration of information. Improving hazard definitions needs to be built on scientific evidence and collaboration across institutions and sectors. With 100 authors and 130 reviewers involved in the development of the hazard information profiles, this work has stimulated a process of multi-disciplinary and multi-sectoral collaboration on using science-based information to better define hazards and the data requirements to measure them effectively. This compilation of existing information provides a starting point for bringing together information on hazards that will need to be regularly reviewed and updated by the relevant international institutions in partnership with the scientific community in order to build an information ecosystem better suited to the risks of today and tomorrow.
... Similarly, most of the pilgrims are older people (>50 years) with comorbidities such as hypertension, diabetes, and liver diseases [5,6]. These scenarios could increase the risk of spread and transmission of infections, particularly respiratory tract infections (RTIs) [7]. Respiratory pathogens and symptoms are high among Malaysian Hajj pilgrims and range from 58.9% to 94.3% [8][9][10]. ...
Article
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Respiratory tract infection (RTI) is a major public health challenge during the Muslim pilgrimage to Makkah. This study aims to evaluate the knowledge, attitude, and practice of Malaysian Hajj and Umrah pilgrims towards the prevention of RTIs in 2018 and determine correlations among three domains. A cross-sectional study was conducted among 225 Umrah and Hajj pilgrims. Knowledge, attitude, and practice (KAP) towards RTI prevention was assessed by using a validated self-administered questionnaire among pilgrims attending a weekly orientation course organized by private Hajj/Umrah companies. Out of 225 participants, 65.9% of respondents were female with the mean (SD) age of 46.74 (13.38) years. The interquartile range (IQR) score for knowledge is 18.0 (6.0), the mean scores of attitude and practice are 32.65 (4.72) and 25.30 (4.9). respectively. Significant and negative linear correlations between knowledge and practice (r = −0.232, p < 0.001), and attitude and practice (r = 0.134, p = 0.045) were observed. Results from the current study showed good knowledge of RTIs among Malaysian pilgrims. However, a poor attitude was reflected in their preventive practice behaviors. This will further help in the prevention and management of RTIs during Hajj and Umrah. Therefore, an extensive educational health campaign should be provided to pilgrims to create awareness.
... Annually, millions of Muslims travel from over 180 different countries to Makkah city for Hajj; from 8 to 13 of Dhual-Hijja. The lunar calendar only has 354 days, compared with 365 days for Gregorian calendar, this means that the Hajj is held during different periods of seasonality [1]. Starting 2016 Hajj has entered into the summer months with ambient temperature between 43°C and 48.7°C, and relative humidity of 58-87%, which increases the risk of dehydration [2]. ...
Article
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Background: Performance of Hajj is physically very demanding, especially if performed during the summer season. The aim of this study is to evaluate the importance of ambient temperature and dehydration, indicated by plasma osmolarity on the clinical outcomes of cardiac patients during Hajj season in 2017. Methods: We included all patients referred to tertiary center with acute coronary syndrome during Hajj period of 2017. Plasma osmolarity was calculated using concentrations of sodium, plasma glucose, and blood urea nitrogen at admission. Patients were stratified by groups (G) of admission osmolarity, clinical outcome was compared. The primary endpoints were in-hospital mortality, length of stay, Cardiac complications (heart failure, re-infarction, arrhythmia, shock and thrombus formation), left ventricular function and readmission rate. Result: Total of 300 patients were identified with mean age 56.2 ±12.1, 84% males and 97(32%) were pilgrims. They were exposed to average heat index 61.9 ±10.6° C. Significantly longer admissions were found in the group of higher osmolarity (G2) (≥295 mos/L) as compared to patients with normal osmolarity in G1 [6.7 ±14.9 VS 4.0 ±4.5, P=0.045]. Total in-hospital death rate was 4.3% (13). Using Binary regression analysis; osmolarity Group [p=0.009], Pilrgrim [P=0.005], Heat index [ P=0.005], were independent predictor of inhospital mortality, while Heat index is the only independent predictor for MACE [P=0.001]. Conclusion: Plasma osmolarity and heat index significantly affect cardiac patient’s outcome. These finding underscore the importance of health awareness of protection from dehydration for pilgrims during summer season.
... Physical and environmental stressors encountered during Hajj, in addition to changes in sleeping and nutrition habits, can lead to exacerbation of NCDs especially if pilgrims neglect to take their regular medications. As such, NCDs, such as CVDs and diabetes and related complications, are an important health risk during Hajj and a major cause of hospitalization and mortality among pilgrims [10][11][12][13][14]. ...
Article
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The Hajj mass gathering is attended by over two million Muslims each year, many of whom are elderly and have underlying health conditions. Data on the number of pilgrims with health conditions would assist public health planning and improve health services delivery at the event. We carried out a systematic review of literature based on structured search in the MEDLINE/PubMed, SCOPUS and CINAHL databases, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, to estimate the prevalence of diabetes and hypertension among Hajj pilgrims. Twenty-six studies conducted between 1993 and 2018 with a total of 285,467 participants were included in the review. The weighted pooled prevalence rates of hypertension and diabetes among Hajj pilgrims in all included studies were 12.2% (95% CI: 12.0–12.3) and 5.0% (95% CI: 4.9–5.1), respectively. The reported prevalence of other underlying health conditions such as chronic respiratory, kidney or liver disease, cardiovascular disease, cancer and immune deficiency were generally low. Potentially a large number of pilgrims each Hajj have diabetes and/or hypertension and other underlying health conditions. Hajj could be a great opportunity to reduce the burden of these diseases within the over 180 countries participating in the event by identifying undiagnosed cases and optimizing patients’ knowledge and management of their conditions. Prospero registration number: CRD42020171082.
... Every able, practicing Muslim is duty-bound by faith to perform Hajj at least once in life (Gatrad and Sheikh 2005). Each year, in the last month of the Arabic lunar calendar, two to three million Muslims from all corners of the world gather in Makkah (Fig. 1) to perform Hajj pilgrimage that involves performing specific rituals at designated places, such as contemplating and reflecting in the valley of Mina and in the plain of Arafat while donned in a pair of unstitched sheets, and visiting various sites of historical and religious significance in Makkah and Madinah (Ahmed et al. 2006). Pilgrims stay in Makkah for variable periods; most local pilgrims stay for about a week, while many overseas pilgrims spend 2-4 weeks, but some devotees and tour organizers stay for longer periods. ...
Chapter
Hajj is the largest annual mass gathering event on the planet and usually attracts two to three million people from all over the world and is one of the most significant events in the life of a practicing Muslim. Viruses that may cause pandemic outbursts, such as influenza and COVID-19, are important public health threats at Hajj. Influenza, both seasonal and pandemic, has been reported at Hajj at variable frequencies. Preventive measures including vaccination and hand hygiene are known to be beneficial. The vaccination uptake is still suboptimal but improving, and time is ripe to consider using quadrivalent influenza vaccine that provides protection against both lineages of influenza B. In response to COVID-19, Hajj pilgrimage was essentially cancelled in 2020, downscaling to just a few thousand local pilgrims who were required to comply with strict preventive measures including maintaining optimum physical distance from fellow pilgrims, and no case of Hajj-associated COVID-19 has been reported. To combat COVID-19 in the coming years, all evidence-based preventive measures, including hand hygiene and use of personal protective equipment, should be considered for Hajj pilgrims in addition to limiting the number of attendees. The recently approved and rolled out COVID-19 vaccines would be important preventive measures for prospective Hajj pilgrims.
... In religious events such as Kumbh Mela and Hajj, the complexities are increased multifold as it attracts more people across the globe, which poses several challenges to organizers. Extreme congestion of people and vehicles in mass events poses severe health hazards [27], potentially turning into epidemics [28]. In the Indian context, there are several issues related to risk assessment, pilgrim safety, extreme weather, law and order enforcement, an outbreak of disease, failure of structures, religious riots, the mobility of pedestrians, etc. that require immediate attention and stochastic plans by event managers and planners in a mass gathering. ...
Article
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Over the last decade, activity-based travel demand modeling has proved to be a reliable tool for urban travel demand analysis. This paper aims to understand pilgrims’ travel behavior in a mass religious gathering using the activity-based approach. The focus here is the Kumbh Mela event of 2016 (22nd April to 21st May) held at Ujjain, India, considered the world’s largest human gathering and attracts pilgrims worldwide. Thus, the study’s focus is to present a detailed exploratory analysis of activity participation (episode frequency and time allocation to various activities) and activity-travel patterns (trip chain patterns) of pilgrims based on primary data collected using an activity-travel questionnaire survey. The results suggest that pilgrims follow intricate trip chain patterns while performing primary activities, such as offering prayer, holy dip, and visiting ghat, and then carrying out secondary activities, including recreation and discretionary activities. Primary and secondary activities in a religious context differ significantly from the conventional activity-based study in the transportation domain. The undertaken research is the first of its kind, and results provide insights on the understanding of crowd dynamics in mass religious gatherings at a macroscopic level.
... The engineering challenges posed by such migrations has resulted in development of new pedestrian bridges with multiple levels to manage crowds more effectively. Khan in his reflection of the 2015 disaster, emphasized the vital importance of the planning process in order to apply lessons learned and engineer out obvious pinch points where possible to avoid bottlenecking of pilgrims [10][11][12]. ...
Article
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The Hajj is a recurring annual mass gathering event with over three million attendants taking place at the same site for six days. During such events, major incidents and disasters can occur. It is crucial that Emergency Medical Services providers are sufficiently trained regarding disaster preparedness to respond appropriately. EMS-providers of the Saudi Red Crescent Authority who worked during the Hajj in 2016 were asked to complete a web-based survey, utilizing predetermined responses with 5-point Likert scale responses. Seven hundred respondents identified real disasters as the most common source of information about disaster preparedness and also indicated that a disaster management course was the most desired course for improving knowledge. The study has also highlighted a list of Life Support Courses providers feel should be offered as part of a disaster response training package. These findings highlight the importance of continuing education, which may be obtained through short, focused courses, or for small numbers of specialists through higher educational degrees, such as masters or doctorates. This study also examines the importance of media and its impact on increasing knowledge and awareness for EMS-providers. Consideration should be given to pairing novice providers with experienced personnel to disseminate knowledge and practical experience during Hajj missions. Simulated disaster drilling should be considered to introduce novices to the stress of mass casualty disaster response
... Cough is also a very symptom during the Haj [20][21][22][23][24], where it is at least twice as common (50-93%) as reported here for the Arbaeen [25]. In the current study, the prevalence of influenza-like illness (combination of fever, cough, and sore throat; 7.8%) was a tenth of that found in Haj (78.2%) [26], and sore throat (18%) less than one sixth (82%) [27]. ...
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COVID-19 poses grave challenges for mass gatherings. One of the world’s largest annual gatherings, Arbaeen, occurs in Iraq. We studied respiratory symptoms and risk and protective factors using representative sampling of Arbaeen pilgrims in 2019 to inform prevention of COVID-19 transmission. Structured sampling was used to recruit walking pilgrims. A questionnaire asked about respiratory symptoms, risk, and preventive factors, including hygiene-related resources of toilet facilities. The commonest symptom reported by the 1842 participants (63.3% male, 36.7% female) was cough (25.6%). Eating in mawkibs (rest areas) with indoor kitchens and drinking only packaged water were associated with lower risk of cough (AOR = 0.72, CI = 0.56–0.94; AOR = 0.60; CI = 0.45–0.78, p < 0.05). Facemask use was associated with increased risk of cough (AOR = 2.71, CI = 2.08–3.53, p < 0.05). Handwashing was not protective against cough, or against (one or more of) cough, fever, or breathlessness in multivariate analysis. Toilet facilities often lacked running water (32.1%) and soap (26.1%), and had shared hand towels (17%). To reduce risk of respiratory infections including COVID-19 during Arbaeen or other mass gatherings, needs include running water, soap, and hygienic hand drying options or hand sanitiser. Education on proper handwashing and facemask approaches and monitoring around food preparation and eating spaces are needed.
... In addition, Hajj involves demanding religious rites in crowded settings and often in the outside hot environment. As such, the pilgrimage is associated with several health risks include communicable and worsening or complications of non-communicable disease, injuries and heat-related illnesses [2]. These health risks do not always originate in the Kingdom, and their effects are often not confined to the Hajj period but are sometimes felt long after Hajj is completed [3,4]. ...
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The Hajj mass gathering annually attracts over two million Muslim pilgrims worldwide to the Kingdom of Saudi Arabia (KSA). We aimed to establish demographics and health profiles for the South African pilgrims performing the 2017 Hajj. Methods: This is a longitudinal survey-based study conducted on 1138 adult South African pilgrims in two phases (during and post-Hajj). Data on demographics, vaccination status, underlying health conditions, pre-Hajj training, health promotion, travel history, and health issues during and post-Hajj were collected using pre-designed questionnaires. Results: Participants had a mean age of 49.2 years (SD = 13.3; range 18–81), with a male: female ratio of 1.2:1. The majority of pilgrims were married (88.2%), of Indian/Asian background (73%), and literate (>99%). Nearly all pilgrims were vaccinated against meningococcal disease and yellow fever, but only 23.7% were vaccinated against Influenza. Hypertension, diabetes, and elevated cholesterol levels were the most common underlying health conditions reported by 22.6%, 13.2%, and 11.5% of pilgrims, respectively. One month after return to South Africa, nearly 65% of pilgrims reported illness during Hajj, while 40% reported falling ill post event upon return to South Africa. Nevertheless, only a few were admitted to hospitals (12 during Hajj and 15 post-Hajj). Among ill pilgrims, respiratory symptoms were the most commonly experienced symptoms during (70.2%) and post-Hajj (82.2%). Other symptoms such as walking-related symptoms include symptoms directly related or mainly caused by walking (e.g., leg pain, sore feet, blisters on the feet), dehydration, and gastrointestinal tract symptoms reported during Hajj. Medication to treat respiratory symptoms and antibiotics were the most commonly used medications during and post-Hajj. Having an underlying health condition was an independent predictor of falling ill during or post Hajj. Conclusion: Our study indicates that a sizable proportion of South African pilgrims are elderly with underlying health conditions and most contract respiratory tract infections during and post Hajj. Our study highlights the need for systematic collection of prospective pilgrims’ demographics and health data and more attention to post-Hajj health follow-ups of pilgrims.
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Meningococcal conjugate vaccine was administered for the first time to pilgrims in 2018 in Turkey prior to their departure to the Hajj. This study aimed to determine the effect of vaccination on the prevalence of Neisseria meningitidis carriage among the pilgrims returning to Turkey.This prospective paired (departing and arriving) cohort study includedpilgrims aged 10-80 years and compared N.meningitidis carriage before and after pilgrimage.Oropharyngeal samples were collected from 229 pilgrims before departing for Mecca, Kingdom of Saudi Arabia (KSA) and after their return to Turkey.Meningococcal carriage was detected in3.9% (n=9) at the time of departure; all positive samples were serogroup B. Upon returning to Turkey,1 (0.4%) pilgrim,who was not a carrier before pilgrimage, was positive for serogroup B.This study is the first to examine meningococcal carriage following the administration of conjugate vaccine to Hajj pilgrims from Turkey.
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The potential occurrence of disease outbreaks during the hajj season is of great concern due to extreme congestion in a confined space. This promotes the acquisition, spread and transmission of pathogenic microorganisms and pneumococcal disease are one of the most frequent infections among Hajj pilgrims. This study aimed to assess the cost-effectiveness and budget impact of introducing the PPV23 to Malaysian Hajj pilgrims. A decision tree framework with a 1-year cycle length was adapted to evaluate the cost-effectiveness of a PPV23 vaccination program with no vaccination. The cost information was retrieved from the Lembaga Tabung Haji Malaysia (LTH) database. Vaccine effectiveness was based on the locally published data and the disease incidence specifically related to Streptococcus pneumoniae was based on a literature search. Analyses were conducted from the perspective of the provider: Ministry of Health and LTH Malaysia. The incremental cost-effectiveness ratios (ICER), cases averted, and net cost savings were estimated. Findings from this study showed that PPV23 vaccination for Malaysian Hajj pilgrims was cost-effective. The PPV23 vaccination programme has an ICER of MYR -449.3 (US$-110.95) per case averted. Based on the national threshold value of US$6,200-US$8,900 per capita, the base-case result shows that introduction of the PPV23 vaccine for Malaysian Hajj pilgrims is very cost-effective. Sensitivity analysis revealed parameters related to annual incidence and hospitalised cost of septicemia and disease without vaccination as the key drivers of the model outputs. Compared with no vaccination, the inclusion of PPV23 vaccination for Malaysian Hajj pilgrims was projected to result in a net cost saving of MYR59.6 million and 109,996 cases averted over 5 years period. The PPV23 vaccination program could substantially offer additional benefits in reducing the pneumococcal disease burden and healthcare cost. This could be of help for policymakers to consider the implementation of PPV23 vaccination for Malaysian performing hajj.
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Background: Arbaeenia is the largest religious mass gathering in Iraq. The conditions associated with mass gatherings result in high rates of injury. There have been no prior studies on injuries during the Arbaeenia mass gathering. Objective: This study describes the injuries observed during the Arbaeenia mass gathering in Babel Governorate in Iraq between November 24 and December 14, 2014. Methods: The study was conducted in Babel Governorate at the emergency departments of six public hospitals and two major temporary medical units that were located along the three roads connecting the Middle and Southern Iraqi governorates. We used the Iraq Injury Surveillance System modified form to collect information on injured patients treated in the selected facilities. Data on fatal injuries was obtained from the coroner's office. The following data were collected from the patients: demographics, outcome of injury, place and time of occurrence, mode of evacuation and medical care before arriving at the hospital, duration of travel from place of occurrence to hospital, disposition of non-fatal injury, cause and mode of injury, and whether the injury occurred in connection with the Arbaeenia mass gathering. Results: Information was collected on 1564 injury cases, of which 73 were fatal. About half of the reported nonfatal injuries, 687/1404 (48.9%), and a quarter of fatalities, 18/73 (25%) were related to the Arbaeenia mass gathering (P<.001). Most of the reported injuries were unintentional, 1341/1404 (95.51%), occurred on the street, 864/1323 (65.6%), occurred during the daytime 1103/1174 (93.95 %). Most of those injured were evacuated by means other than ambulance 1107/1206 (91.79%) and did not receive pre-hospital medical care 788/1163 (67.7%). Minor injuries 400/1546 (25.9%) and traffic accidents 394/1546 (25.5%) were the most common types of injuries, followed by falls 270/1546 (17.5%). Among fatal injuries, traffic accidents 38/73 (52%) and violence 18/73 (25%) were the leading causes of death. Mass gathering injuries were more likely to occur among individuals aged 21-40 years (odds ratio [OR] 3.5; 95% CI 2.7-4.5) and >41 years (OR 7.6; 95% CI 5.4-10.6) versus those <21 years; more likely to be unintentional than assault (OR 5.3; 95% CI 1.8-15.5); more likely to happen on the street versus at home (OR 37.7; 95% CI 22.4-63.6); less likely to happen at night than during the day (OR 0.2; 95% CI 0.1-0.4); and less likely to result in hospital admission (OR 0.5; 95% CI 0.3-0.7). Conclusions: The study shows that most injuries were minor, unintentional, and nonfatal, and most people with injuries had limited access to ambulance transportation and did not require hospitalization.
Article
Background Intense congestion during the Hajj pilgrimage amplifies the risk of meningococcal carriage and disease, and there have been many meningococcal outbreaks reported amongst pilgrims. Thus, a strict vaccination policy is enforced by the host country and either polysaccharide or conjugate quadrivalent meningococcal vaccines are mandatory. However, unlike conjugate vaccines, the polysaccharide vaccine is not thought to reduce pharyngeal carriage of meningococci. Methods A single-blinded, randomised, controlled trial amongst pilgrims from Saudi Arabia and Australia during the Hajj seasons of 2016–2017 was conducted to compare MenACWY-Conjugate vaccine with MenACWY-Polysaccharide vaccine, to determine if the conjugate vaccine is more effective in reducing asymptomatic carriage of meningococci, and whether the effect may be long-standing. Oropharyngeal swabs were obtained pre-, immediately post-, and 6–11 months following completion of Hajj and tested for the presence of meningococci. Results Among 2000 individuals approached, only 1146 participants aged 18–91 (mean 37.6) years agreed to participate and were randomised to receive either the polysaccharide (n = 561) or conjugate (n = 561) vaccine, 60.8% were male, and 93.5% were from Saudi Arabia. Among oropharyngeal swabs obtained before Hajj, only two (0.2%) tested positive for Neisseria meningitidis. Similarly, meningococci were identified in only one sample at each of the post-Hajj and late follow-up visits. None of the carriage isolates were among the serogroups covered by the vaccines. A post hoc analysis of the third swabs revealed that 22.4% of all participants (50/223) were positive for Streptococcus pneumoniae nucleic acid. Conclusion The low overall carriage rate of meningococci found among Hajj pilgrims in 2016 and 2017 demonstrates a successful vaccination policy, but neither supports nor refutes the superiority of meningococcal conjugate ACWY vaccine over the polysaccharide vaccine against carriage. Although an association could not be established in this study, molecular epidemiology would help establish the role of Hajj in facilitating transmission of pneumococci and inform vaccination policy.
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Controversies surrounding the handling of corpses have been amplified during the present COVID-19 pandemic. According to Indonesian scholars, certain perspectives driving these controversies inhibit the implementation of health protocols issued by the government. This study comprehensively explores the diverse perceptions and responses of religious leaders regarding COVID-19 funeral management. Participants comprised six scholars from major Islamic religious organizations, two community leaders, and two families representing COVID-19 patients. Furthermore, content analysis was used to analyze the data. The results showed that the religious leaders, all men aged over 50 years, supported the health directives designed to reduce high transmission risk. However, there were substantial disparities in corpse preparation processes, potentially due to organizational beliefs around burial rites. Some religious leaders aligned their protocols with their religious beliefs. Conversely, families of the deceased insisted that the approved protocol for handling corpses went against their religious and cultural values. Therefore, promotion of protocols and coordination among the government, religious leaders, and the community are needed to decrease the misperceptions and misinformation surrounding the new COVID-19 funeral protocols.
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Respiratory viruses, including coronaviruses, are known to have a high incidence of infection during winter, especially in temperate regions. Dry and cold conditions during winter are the major drivers for increased respiratory tract infections as they increase virus stability and transmission and weaken the host immune system. The novel severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) emerged in China in December 2019 and swiftly spread across the globe causing substantial health and economic burdens. Several countries are battling with the second wave of the virus after a devastating first wave of spread, while some are still in the midst of their first wave. It remains unclear whether SARS-CoV-2 will eventually become seasonal or will continue to circulate year-round. In an attempt to address this question, we review the current knowledge regarding the seasonality of respiratory viruses including coronaviruses and the viral and host factors that govern their seasonal pattern. Moreover, we discuss the properties of SARS-CoV-2 and the potential impact of meteorological factors on its spread.
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Background: Hajj is a religious obligation for the Muslims who can afford and about three million people around the world come to Saudi Arabia to perform Hajj. Hospital admissions are due to acute diseases and trauma or exacerbation of comorbid conditions. Hajj Caravan, a unique experience, is a program of patients' movement under supervision. Objective: To determine the disease pattern and their status of suitability to go with Hajj caravan in the patients admitted during Hajj-time. Methodology: This was an observational and descriptive study and data of five big hospitals of Makkah, for the year 2013/ 1434H, was collected to see the disease patterns of all the patients, their status regarding permission or refusal to go with Hajj Caravan and whether the matter was discussed with the patients. Resources used for this movement, were also observed. Data was entered and analyzed by using SPSS version 16. Results: Two hundred and seventeen patients were included in the study, majority from Middle East, African and South Asian countries. Disease patterns was: trauma, 18%, GIT infection 17% and CVS disease 15%. One hundred and ninety seven patients got permission to go with Hajj Caravan and 20 patients were refused. This decision was taken by 2 consultants and mostly it was found to be subjective. Conclusion: Most common disease during Hajj were trauma, gastrointestinal infections and cardio vascular disease. Although Hajj-Caravan is a well-organized movement of patients for a compulsory ritual of Hajj, more structured policies are required related to this unique movement of inpatients from hospitals.
Chapter
Hajj pilgrimage, a form of mass gathering (MG), may facilitate rapid multinational spread of antimicrobial resistance (AMR). Hajj has traditionally been linked as an event, which favors the dissemination of various infectious outbreaks. Despite best effort in minimizing such outbreaks through longtime investment in education and medical care, respiratory infection and gastrointestinal diseases still see high occurrences during Hajj. Such diseases have to be treated by antibiotics, and improper use of antibiotics can result in secondary concerns such as that of AMR dissemination. In this chapter, we identify factors that promote AMR dissemination within the Hajj context. This includes socioeconomic and demographic factors of pilgrims, their general health status including vaccine coverage, high antibiotic use, and/or misuse in the home countries of those pilgrims. Using Hajj as a local example, we exemplified strategy plans to mitigate AMR transmission. First, medical services should be coupled with elements of AMR control strategies. Clinicians can be encouraged to use decision tools to rationally prescribe antibiotics. Second, vaccination requirements for Hajj participation can also help reduce the burden of relevant vaccine-preventable disease symptomatology and related antibiotic prescriptions. Third, priority antibiotic-resistant bacteria can be added to the surveillance agenda to facilitate AMR control. Standardized diagnostic and surveillance systems can help institutionalize these efforts. However, due to inadequate or nonexistent surveillance during MGs on AMR, resistance prevalence and trends are largely understudied, and baseline data for evaluation of potential interventions need more development.
Article
Hajj is associated with an increased risk of the transmission of infectious diseases including upper respiratory tract infections (URTIs). It can be a focal point for the emergence, persistence and dissemination of antimicrobial-resistant (AMR) bacteria. The overuse of antibiotics during Hajj can promote the development of antimicrobial resistance. Little information is known regarding the true appropriateness of prescribing antibiotics for treating URTIs during Hajj. Here we studied the rate, patterns and appropriateness of antibiotic prescription among a cohort of pilgrims who were treated for URTIs during the 2018 Hajj season. Adult pilgrims who sought medical services for URTIs [presenting with coryza, runny nose, nasal irritation, nasal congestion, cough, sore throat, headache or fever (even if subjective)] within the Holy sites were enrolled in this study and consented to provide swabs and medical information. A total of 121 pilgrims were enrolled, with the majority (60.3 %) originating from North African Arab countries. Most were male (89.3 %) with a median age of 45 years. Bacterial infections were detected in 7.3 % ( n =9) of the URTI cases. The identified bacteria included Haemophilus influenzae ( n =6, all resistant to ampicillin), Streptococcus pneumoniae ( n =2), Staphylococcus aureus ( n =1, resistant to oxacillin) and Moraxella catarrhalis ( n =1, resistant to ampicillin and trimethoprim/sulfamethoxazole). The antibiotic prescription rate was 52.1%, most of which was amoxicillin (81 %). The data demonstrated that the proportion of appropriate practices in treating bacterial URTIs in this cohort was 45.5 %. This study highlights the need for implementing laboratory identification of the aetiological agents and related AMR profiles when treating URTIs in Hajj, rather than relying on clinical assessment alone.
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Thousands of Palestinian and Arab-Israeli pilgrims travel to Mecca each year to complete their pilgrimage. To the best of our knowledge, no previous studies have characterized the infectious and noninfectious morbidity among Arab-Israeli or Palestinian Hajj pilgrims. Thus, we designed and conducted an observational questionnaire-based study to prospectively investigate the occurrence of health problems among these Hajjis who traveled to complete their Pilgrimage during 2019 Hajj season. For the purpose of the study, questionnaires were distributed to Hajj pilgrims at three different time occasions-before travel, inquiring on demographics and medical comorbidities; and 1 and 4 weeks after returning recording any health problems encountered during or after travel. Initial recruitment included 111 Hajjis. The mean age of responders was 49.5 (±9.1) years, with an M:F ratio of 1.3:1. The mean travel duration was 18.7 (13-36) days. Altogether, 66.3% of the pilgrims reported at least one health problem during and after the trip, of which 38.6% sought medical attention. Five (4.8%) hajjis were hospitalized, including life-threatening conditions. Cough was the most common complaint (53.8%), and 11.5% also reported fever. Pretravel counseling was associated with reduced outpatient and emergency room visits. We therefore concluded that a high rate of morbidity was reported among this cohort of Hajj pilgrims with a morbidity spectrum similar to pilgrims from other countries. Pretravel consultation with the purpose of educating the pilgrims on the health risks of Hajj may help reduce the morbidity for future Hajj seasons.
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Background: Countries in the World Health Organization (WHO) Eastern Mediterranean Region (EMR) are predisposed to highly contagious, severe and fatal, emerging infectious diseases (EIDs), and re-emerging infectious diseases (RIDs). This paper reviews the epidemiological situation of EIDs and RIDs of global concern in the EMR between 2001 and 2018. Methods: To do a narrative review, a complete list of studies in the field was we prepared following a systematic search approach. Studies that were purposively reviewed were identified to summarize the epidemiological situation of each targeted disease. A comprehensive search of all published studies on EIDs and RIDs between 2001 and 2018 was carried out through search engines including Medline, Web of Science, Scopus, Google Scholar, and ScienceDirect. Results: Leishmaniasis, hepatitis A virus (HAV) and hepatitis E virus (HEV) are reported from all countries in the region. Chikungunya, Crimean Congo hemorrhagic fever (CCHF), dengue fever, and H5N1 have been increasing in number, frequency, and expanding in their geographic distribution. Middle East respiratory syndrome (MERS), which was reported in this region in 2012 is still a public health concern. There are challenges to control cholera, diphtheria, leishmaniasis, measles, and poliomyelitis in some of the countries. Moreover, Alkhurma hemorrhagic fever (AHF), and Rift Valley fever (RVF) are limited to some countries in the region. Also, there is little information about the real situation of the plague, Q fever, and tularemia. Conclusion: EIDs and RIDs are prevalent in most countries in the region and could further spread within the region. It is crucial to improve regional capacities and capabilities in preventing and responding to disease outbreaks with adequate resources and expertise.
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Background: Countries in the World Health Organization (WHO) Eastern Mediterranean Region (EMR) are predisposed to highly contagious, severe and fatal, emerging infectious diseases (EIDs), and re-emerging infectious diseases (RIDs). This paper reviews the epidemiological situation of EIDs and RIDs of global concern in the EMR between 2001 and 2018. Methods: To do a narrative review, a complete list of studies in the field was we prepared following a systematic search approach. Studies that were purposively reviewed were identified to summarize the epidemiological situation of each targeted disease. A comprehensive search of all published studies on EIDs and RIDs between 2001 and 2018 was carried out through search engines including Medline, Web of Science, Scopus, Google Scholar, and ScienceDirect. Results: Leishmaniasis, hepatitis A virus (HAV) and hepatitis E virus (HEV) are reported from all countries in the region. Chikungunya, Crimean Congo hemorrhagic fever (CCHF), dengue fever, and H5N1 have been increasing in number, frequency, and expanding in their geographic distribution. Middle East respiratory syndrome (MERS), which was reported in this region in 2012 is still a public health concern. There are challenges to control cholera, diphtheria, leishmaniasis, measles, and poliomyelitis in some of the countries. Moreover, Alkhurma hemorrhagic fever (AHF), and Rift Valley fever (RVF) are limited to some countries in the region. Also, there is little information about the real situation of the plague, Q fever, and tularemia. Conclusion: EIDs and RIDs are prevalent in most countries in the region and could further spread within the region. It is crucial to improve regional capacities and capabilities in preventing and responding to disease outbreaks with adequate resources and expertise.
Article
Background : Respiratory tract infections are common among pilgrims attending annual Hajj in Mecca, Saudi Arabia. Pilgrims typically spend most of the Hajj period inside ventilated tents, where microorganisms may be transmitted through bioaerosols and droplets. Objective : To perform microorganism surveillance inside Hajj tents and assess the similarities between microorganisms isolated from tent bioaerosol samples and nasopharyngeal swabs (NP) of tent occupants. Methods : Respiratory microorganisms in bioaerosols collected from Hajj tents over a 4-day period were compared with NP of tent occupants using real-time multiplex polymerase chain reaction analysis. Results : A total of 152 samples were collected: 120 tent bioaerosol samples collected on days 9, 10, 11, and 12 of Dhu al-Hijjah, and 32 NP collected on day 12 of Dhu al-Hijjah (corresponding to 23/08/2018). Eighty-three (69.2%) bioaerosol samples tested positive for at least one microorganism, with the number of pathogens increasing over the 4 days of sampling. Twenty-seven (84.38%) NP swabs from tent occupants also tested positive. Microorganisms identified in pilgrim nasal carriage and tent bioaerosol samples were similar, and included K. pneumonia, S. aureus, S. pneumonia, human adenovirus, Moraxella, influenza A, and H. influenza. Conclusion : The data suggest that the Hajj tent environment may contribute to the spread of airborne infections during Hajj. This can have important ramifications for novel pathogens with pandemic potential.
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KHALIL M1, ALMAZROU Y1, BORROW R2, BALMER P2, BRAMWELL J2, LAL G2, ALJEFFRI M1 1 Department of Preventive Medicine, MOH, Saudi Arabia. 2 Meningococcal Reference Unit, HPA North West Laboratory, Manchester, UK. Meningococcal disease remains a serious public health issue in Saudi Arabia where 4 million pilgrims visit each year for religious reasons. In response to a shift in prevalence of disease to those aged under 5 years, a national campaign was conducted in 2003, targeting children from 6 months up to 5 years. Serological responses to the four serogroups included in the polysaccharide vaccine were evaluated. Six age groups were included in the study; 6 months (n=43), 12 months (n=45), 18 months (n=49), 24 months (n=68), 36 months (n=69), and 48 months (n=92). After taking guardian consent, children were vaccinated with the tetravalent (ACYW135) polysaccharide meningococcal vaccine, (Mencevax ACWY, GSK). Children 24 months or older were given one dose while younger children were given two doses with an interval of 2-3 months. Blood samples were collected before the first dose and one month after the second for children younger than 24 months and before the single dose and one month after for older children. Serogroup specific antibody responses were determined by serum bactericidal antibody (SBA) assays using baby rabbit complement and a tetraplex IgG bead assay. Pre-vaccination SBA titres increased with age for serogroups A and Y but not for C or W135. Post-vaccination, for the age bands 6, 12, 18, 24, 36 and 48 months the percentage responders (SBA titre • 8) were: serogroup A 19, 29, 42, 80, 87, 94, respectively; serogroup C 10, 9, 11, 42, 42, 48, respectively; serogroup W135 12, 13, 18, 48, 55, 62, respectively; serogroup Y 15, 14, 19, 53, 64, 87, respectively. Serogroup-specific IgG levels increased significantly postvaccination in all age groups except for those aged 6 and 36 months for serogroup C and 6 month olds for serogroup W135. To our knowledge, this is the first reported study to evaluate functional antibody responses in young children following tetravalent polysaccharide vaccination. Two-doses of tetravalent polysaccharide vaccine in 6,12, and 18 months old children gives poor protection against serogroups C, Y, and W135. However, for serogroup A, two doses can give 42% responders (SBA titre • 8) at 18 months of age. A single dose of serogroup A polysaccharide from 2 years of age gives good protection and a similar level of protection was observed for serogroup Y at 4 years of age but not in younger age groups. However, for serogroups C and W135 poor response were still evident at 4 years of age.
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To date, tick-borne flaviviruses responsible for hemorrhagic fever in humans have been isolated in Siberia (Omsk hemorrhagic fever virus), India (Kyasanur Forest disease virus, KFDV), and in Saudi Arabia (Alkhurma virus, ALKV). Prior to this study, only partial coding sequences of these severe pathogens had been determined. We report here the complete coding sequence of ALK virus, which was determined to be 10,248 nucleotides (nt) long, and to encode a single 3,416 amino acid polyprotein. Independent analyses of the complete polyprotein and the envelope protein provided genetic and phylogenetic evidence that ALKV belongs to the tick-borne flavivirus group, within which it is most closely related to KFDV. Analysis of structural genes, genetic distances, and evolutionary relationship indicate that ALKV and KFDV derived from a common phylogenetic ancestor and constitute two genetic subtypes of the same virus species according to current genetic criteria of classification.
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During March and April of 1992, the health surveillance system began detecting increasing numbers of cases of meningococcal disease (MCD) in the Islamic holy city of Makkah (Mecca). We identified 102 bacteriologically confirmed cases (CC) and 80 suspected cases (SC) of MCD. Neisseria meningitidis was identified as Group A, III-1 clone. The ratio of male:female cases was 2.9:1. All age groups of males were affected. There was only one case among women aged 10-30; 50% of the adult female cases were 55 or older. The case-fatality ratio (CFR) was 14.7% among CC. Pakistanis, who comprised about one-third of the CC, had a CFR of 26.7%. Fifty-nine percent of CC were religious visitors. CC in residents were most common in persons living near the Holy Mosque (Haram), where the carriage rate reached 86%. A mass vaccination program against MCD was instituted, using AC bivalent meningococcal vaccine (MCV). An abrupt drop, from a mean of 15 CC per week to 2 CC per week (only in visitors), coincided with vaccinating 600,000 persons over 2 weeks. Makkah residents who had been vaccinated against MCD were less likely to have contracted MCD (OR = 0.17, 95% CI: 0.06-0.50). MCV was of no significant protective value if it had been administered 5 years before the outbreak. The main reason for not being vaccinated as stated by both cases (71%) and controls (45%) was not knowing about the disease. The age and sex differences probably relate to differences in exposures to crowded conditions. Health education should illuminate the seriousness of the disease and the importance of vaccination.
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In May 1997, a 3-year-old boy in Hong Kong died of a respiratory illness related to influenza A (H5N1) virus infection, the first known human case of disease from this virus. An additional 17 cases followed in November and December. A case-control study of 15 of these patients hospitalized for influenza A (H5N1) disease was conducted using controls matched by age, sex, and neighborhood to determine risk factors for disease. Exposure to live poultry (by visiting either a retail poultry stall or a market selling live poultry) in the week before illness began was significantly associated with H5N1 disease (64% of cases vs. 29% of controls, odds ratio, 4.5, P = .045). By contrast, travel, eating or preparing poultry products, recent exposure to persons with respiratory illness, including persons with known influenza A (H5N1) infection, were not associated with H5N1 disease.
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One of the most disastrous forms of collective human behaviour is the kind of crowd stampede induced by panic, often leading to fatalities as people are crushed or trampled. Sometimes this behaviour is triggered in life-threatening situations such as fires in crowded buildings; at other times, stampedes can arise during the rush for seats or seemingly without cause. Although engineers are finding ways to alleviate the scale of such disasters, their frequency seems to be increasing with the number and size of mass events. But systematic studies of panic behaviour and quantitative theories capable of predicting such crowd dynamics are rare. Here we use a model of pedestrian behaviour to investigate the mechanisms of (and preconditions for) panic and jamming by uncoordinated motion in crowds. Our simulations suggest practical ways to prevent dangerous crowd pressures. Moreover, we find an optimal strategy for escape from a smoke-filled room, involving a mixture of individualistic behaviour and collective 'herding' instinct.
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A seroprevalence study of hepatitis A virus (HAV), hepatitis B virus (HBV), and varicella-zoster virus (VZV) was carried out among Saudi Arabian National Guard soldiers with the objective of determining the cost-saving potential of prevaccination antibody tests when implementing an immunization program for the soldiers. A systematic sampling of 450 blood samples from 1,350 soldiers who donated blood at our hospital was carried out. Antibody tests were performed using the enzyme-linked immunosorbent assay method. The seropositivity rates for antibodies to HAV, HBV, and VZV were 97.5, 17.8, and 88.5%, respectively. Comparing the cost of prevaccine screening with that of universal vaccination, it was estimated that savings of 76 and 32% could be effected for HAV and VZV. Conversely, screening for HBV before immunization could increase the cost of vaccinating against the disease by 49%. A seroprevalence study could be a useful cost-saving approach to a mass immunization program against endemic, natural immunity-conferring diseases.
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To investigate potential transmission of Mycobacterium tuberculosis in aircraft from a crew member with tuberculosis. Retrospective cohort study and survey. A large US airline carrier. A total of 212 crew members and 59 passengers who were exposed to a crew member with tuberculosis during a potentially infectious period (May through October 1992). Comparison volunteer sample of 247 unexposed crew members. Positive tuberculin skin test (TST) result or tuberculosis. Rates of positive TST results were higher among foreign-born persons in all study groups. Among US-born comparisons and contacts, rates of positive TST results did not differ between comparisons and contacts exposed from May through July (5.3% vs 5.9%, respectively). However, contacts exposed from August through October had significantly higher rates of positive TST results than did contacts exposed from May through July (30% vs 5.8%, respectively; P < .001); two had documented TST conversions between September 1992 and February 1993. The risk of infection increased with increasing hours of exposure to the index case. Four (6.7%) of 59 frequent flyers were TST-positive; all flew in October. Data support the conclusion that M tuberculosis was transmitted from an infectious crew member to other crew members on an aircraft. Because of the clustering of TST-positive frequent flyers in October when the index patient was most infectious, transmission of M tuberculosis to passengers cannot be excluded.
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In April 1994, a passenger with infectious multi-drug resistant tuberculosis traveled on commercial-airline flights from Honolulu to Chicago and from Chicago to Baltimore and returned one month later. We sought to determine whether she had infected any of her contacts on this extensive trip. Passengers and crew were identified from airline records and were notified of their exposure, asked to complete a questionnaire, and screened by tuberculin skin tests. Of the 925 people on the airplanes, 802 (86.7 percent) responded. All 11 contacts with positive tuberculin skin tests who were on the April flights and 2 of 3 contacts with positive tests who were on the Baltimore-to-Chicago flight in May had other risk factors for tuberculosis. More contacts on the final, 8.75-hour flight from Chicago to Honolulu had positive skin tests than those on the other three flights (6 percent, as compared with 2.3, 3.8, and 2.8 percent). Of 15 contacts with positive tests on the May flight from Chicago to Honolulu, 6 (4 with skin-test conversion) had no other risk factors; all 6 had sat in the same section of the plane as the index patient (P=0.001). Passengers seated within two rows of the index patient were more likely to have positive tuberculin skin tests than those in the rest of the section (4 of 13, or 30.8 percent, vs. 2 of 55, or 3.6 percent; rate ratio, 8.5; 95 percent confidence interval, 1.7 to 41.3; P=0.01). The transmission of Mycobacterium tuberculosis that we describe aboard a commercial aircraft involved a highly infectious passenger, a long flight, and close proximity of contacts to the index patient.
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This report relates to burns of the feet suffered by a pilgrim to Mecca who walked barefoot in the hot desert sun. He subsequently presented with full-thickness burn injuries to the soles of his feet. When the patient developed acute coronary insufficiency, immediate surgery could not be performed. He was therefore treated conservatively with salicylic acid and Silverol cream. Spontaneous closure of the wounds was achieved in the course of 2 months.
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A flavivirus related to the tick-borne encephalitis complex was isolated from the blood of 6 male butchers, aged 24-39 years, in Jeddah, Saudi Arabia in November and December 1995. Two of the patients died and the other 4 recovered completely. Four more patients, 3 males and 1 female, were diagnosed serologically by immunoglobulin M capture enzyme-linked immunosorbent assay and seroconversion in acute and convalescent blood samples examined by indirect immunofluorescent test using Vero cells infected with the isolated virus. The virus identity was confirmed at the Centers for Disease Control and Prevention, Fort Collins, Colorado, USA, by the polymerase chain reaction; it was closely related to Kayasanur Forest disease virus. All infected patients had similar clinical and laboratory symptoms and signs, including fever, headache, generalized body aches, arthralgia, anorexia, vomiting, leucopenia, thrombocytopenia, elevated liver enzymes (serum glutamic oxalacetic and serum glutamic pyruvic transaminases), elevated creatinine phosphokinase, and elevated blood urea. One patient developed symptoms of encephalitis, but survived without any sequel. Skin rash developed in 2 patients, morbilliform on the hands, feet, and lower abdomen of one patient and purpuric associated with melaena in the second patient. Eight of the 10 confirmed patients were working with sheep, and the disease may be a zoonotic viral infection.