Tuberculosis and mass gatherings-opportunities for defining burden, transmission risk, and the optimal surveillance, prevention, and control measures at the annual Hajj pilgrimage

Mass gathering in Qatar 2022 World Cup. What should be especially monitored?

OBJECTIVES

At the end of 2022, the football world championship will be held in Qatar. These types of meetings require a risk analysis. It proposes an approach to determine which health risks should be prioritized.

METHOD

We use a mixed methodology (Hierarchical Process Analysis, World Health Organization STAR and European Commission INFORM) to determine the risk level of a total of 12 health entities.

RESULTS

Our analysis identifies 6 health entities with a moderate risk. There are 4 whose valuation is as low risk and 2 as very low.

CONCLUSIONS

In our work we focus the analysis from a point of view of the route of transmission or presentation of health events, which facilitates a visualization of the preventive measures to be implemented, both organizationally and individually by the attendees.

Genetic diversity and molecular analysis of human influenza virus among pilgrims during Hajj

The risk of transmission of respiratory tract infections is considerably enhanced at mass gathering (MG) religious events. Hajj is an annual Islamic MG event with approximately 3 million Muslim pilgrims from over 180 countries concentrated in Makkah, Saudi Arabia. This study aimed to investigate the genetic diversity of influenza viruses circulating among pilgrims during the Hajj pilgrimage. We performed a cross-sectional analytical study where nasopharyngeal swabs (NPs) from pilgrims with respiratory tract illnesses presenting to healthcare facilities during the 2019 Hajj were screened for influenza viruses. Influenza A subtypes and influenza B lineages were determined by multiplex RT-PCR for positive influenza samples. The phylogenetic analysis was carried out for the hemagglutination (HA) gene. Out of 185 nasopharyngeal samples, 54 were positive for the human influenza virus. Of these, 27 were influenza A H1N1 and 19 H3N2, 4 were untypable influenza A, and 4 were influenza B. Phylogenetic analysis revealed that the H1N1 and H3N2 strains differentiated into different and independent genetic groups and formed close clusters with selected strains of influenza viruses from various locations. To conclude, this study demonstrates a high genetic diversity of circulating influenza A subtypes among pilgrims during the Hajj Season. There is a need for further larger studies to investigate in-depth the genetic characteristics of influenza viruses and other respiratory viruses during Hajj seasons.

Prevalence of emergency cases among pilgrims presenting at King Abdulaziz International Airport Health Care Center at Hajj Terminal, Jeddah, Saudi Arabia during Hajj Season, 1440 H - 2019

Introduction

About 2-3 million pilgrims come to Makkah, Saudi Arabia from all countries to perform Hajj. During the Hajj season of 2019 (1440 H), the total number of pilgrims was 2,489,406, of whom 1,855,027 came from foreign countries. This study aims to investigate the prevalence, pattern, and findings of emergency health problems among pilgrims travelling through King Abdul Aziz International Airport Health Care Center (KAIA-HC) at Hajj Terminal in Jeddah during hajj season of 1440-H.

Methodology

A cross-sectional study was conducted by reviewing the medical records of pilgrims coming for treatment at KAIA-HC, before and after Hajj between 1 Dhul Qi'dah to 29 Dhul Hijjah 1440 AH (Corresponding to 4 July to 31 August 2019 AD). The collected data included demographics, medical history, diagnoses of the emergency health problems, infections, and their findings. Data were analyzed using Epi Info 7 and SPSS 25.

Results

About 296 (3.87%) of 7,643 pilgrims treated at KAIA-HC were emergency cases. Their average age was 43 years (Standard Deviation (SD) ±7.5); 51.3% were females; the highest (45.3%) was between 30 - 59 years age group, both males and females; the highest two nationalities were Indonesian (14.2%) and Egyptian (12.5%). Diagnoses included hypertension 59(19.9%), bronchial asthma 53 (17.9%), and 23 cases (10.5%) were suffering from hypotension. 16 (5.4%) of patients had a myocardial infarction and 10 (3.4%) had cerebrovascular accidents. In 13 cases (4.4%), a chest infection was reported. Diabetes complications (hyperglycemia, hypoglycemia, and diabetic ketoacidosis) were reported in 28 (9.4%) of the cases. There were 28 (9.5%) surgical diagnoses, 13 (4.4%) were cut wounds, 11 (3.7%) were bone fracture and dislocation, and 4 (1.4%) were head trauma. With regard to the findings, 82 (27.7%) were referred to hospitals; 10 (3.3%) cases required Cardio-Pulmonary Resuscitation, seven of whom survived. The most common referral causes were myocardial Infarction amounting 12(4.05%), followed by cerebrovascular accident 10(3.3%) and chest infection in 8 (2.7%). 13 (4.4%) of the total cases died. The most common causes of death were myocardial infarction, asthma, hypertension and hyperglycemia.

Conclusion

Our study emphasizes that emergency cases presented at KAIA-HC were few. Cardiovascular diseases represented the main reason for emergency cases, followed by respiratory diseases. 51% of patients were discharged without the need for a higher level of medical care.

Undiagnosed and missed active pulmonary tuberculosis during mass gatherings: a prospective cross-sectional study from the Hajj pilgrimage

Mass gatherings increase the risk of infectious diseases transmission including tuberculosis (TB). The Hajj pilgrimage to Mecca, Saudi Arabia, is attended by over 2 million pilgrims many of whom are from high TB-burden countries, and has been linked to increased risk of TB acquisition among travellers. We investigated the burden of undiagnosed and missed active pulmonary TB (PTB) among Hajj pilgrims symptomatic for cough. The study was conducted among hospitalised and non-hospitalised travellers attending the Hajj pilgrimage in 2016 and 2017. Questionnaires were used to collect relevant data and sputum samples were collected from participants and processed using the Xpert MTB-RIF assay. Non-hospitalised pilgrims (n = 1510) originating from 16 high and medium TB-burden countries were enrolled. Undiagnosed, rifampicin-sensitive, active PTB was identified in 0.7%. Comorbidities (adjOR = 5.9 [95% CI = 1.2-27.8]), close contact with a TB case (adjOR = 5.9 [95% CI = 1.2-27.8]), cough in household (adjOR = 4.46 [95% CI = 1.1-19.5]), and previous TB treatment (adjOR = 10.1 [95% CI = 4.1-98.1]) were independent risk factors for TB. Of the hospitalised pilgrims (n = 304), 2.9% were positive for PTB, and 2.3% were missed, including a rifampicin-resistant case. History of TB treatment was associated with increased risk of TB (adjOR = 8.1 [95% CI = 1.3-48.7]). International mass gatherings may play an important role in the global epidemiology of TB. Preventive measures should be directed to reducing the risk of TB importation and transmission during Hajj and other similar events.

Risk factors of tuberculosis in Mizoram: First report of the possible role of water source

BACKGROUND

Various risk factors of tuberculosis have been studied across the globe, but these may be altered over time and can be specific to geographical regions and there is not much information available from Northeastern region of India. This study aims to investigate the various risk factors of tuberculosis and analyze the presence of any less-established risk factors.

METHODS

A total of 400 TB cases and 840 healthy controls were interviewed from December 2017 - June 2020. Logistic regression model was used to analyze associated risk factors. Patients were categorized into pulmonary and extrapulmonary TB.

RESULTS

Clinical presentation such as fever, cough, weight loss, chest pain and night sweats were more prominent among pulmonary TB patients. The most common mode of diagnosis among pulmonary and extrapulmonary TB were GeneXpert and X-ray, respectively. Tuberculosis was found to be strongly prevalent among patients from lower socio-economic status, less educated, unemployed and improper housing condition. Other risk factors associated were alcohol consumption, neighbours with TB, travel history, no BCG vaccine, mass gathering, and non-ideal weight. An interesting less-established risk factor that demands attention is the source of water supply (p-0.017, OR-2.313, CI: 1.160-4.613), which was significant in this study.

CONCLUSION

Our data suggests that apart from all the well-established risk factors for TB, water supply might play a crucial role towards the transmission of TB, since proper hospital waste water treatment is yet to be adopted in Mizoram, Northeast India. From a public health standpoint, this highlights the need for further research in this area.

Knowledge and transmission risk awareness of tuberculosis among the pilgrims attending a religious mass gathering in India: a cross-sectional study

Background

Tuberculosis infection accounts for more annual deaths than any other single infectious disease, except the Corona Virus infection. It is a significant global issue and India is one of the most affected countries. Religious mass gatherings congregate millions of pilgrims at one place. Over-crowding is a high-risk factor for the transmission of tuberculosis. Knowledge and awareness of the disease are proven prerequisites for the spread-prevention and early diagnosis of tuberculosis. The present study was designed to explore the knowledge of tuberculosis and awareness of disease transmission risk among pilgrims attending a religious mass gathering, the Kumbh Mela (2016) in Ujjain, India.

Methods

Self-reported data on the pilgrims’ tuberculosis-knowledge were collected using a cross-sectional study design. A contextual, pre-tested questionnaire was used, using the convenience sampling method. In addition to the anonymous descriptive analyses, a composite knowledge-score was developed to enable comparisons between demographic groups.

Results

In total, 1665 pilgrims participated in the study with 38.8 years of mean age and 59% literacy rate. The most recognized symptoms of tuberculosis were “Cough for more than 15 days with sputum” (94%) and “Blood in sputum” (81%). Most participants knew that tuberculosis is an infectious disease (93%) and not hereditary (91%). Additionally, 84% considered it is a potentially lethal disease that requires extensive treatment. However, vaccine awareness was poor (4%). “Direct contact with tuberculosis patient” (78%) and “To be in a crowded area” (4%) were considered as the most important risk factors for tuberculosis transmission. For the composite knowledge-score, a significantly higher mean score was seen among those with at least ten years of schooling compared with illiterates (p <  0.001). Occupation and residency also affected the mean score.

Conclusion

Most pilgrims attending the Kumbh Mela had basic knowledge of the characteristics of tuberculosis, but some important knowledge gaps concerning the transmission risks associated with crowded situations existed. These gaps need to be addressed in future policies to enable safer mass gatherings and to end the TB epidemic, globally.

Emerging Status of Multidrug-Resistant Bacteria and Fungi in the Arabian Peninsula

Simple Summary

The incidence and developing status of multidrug-resistant bacteria and fungi, as well as their related mortality, is reviewed by a systematic published literature search from nine countries in the Arabian Peninsula. In order to analyse the emerging status and mortality, a total of 382 research articles were selected from a comprehensive screening of 1705 papers. More than 850 deaths reported since 2010 in the Arabian Peninsula due to the infection of multidrug-resistant bacteria and fungi. Multidrug-resistant bacteria Acinetobacter baumannii, Mycobacterium tuberculosis, Staphylococcus aureus, and fungi Candida auris are the most prevalent and causing high deaths. To control these infections and associated deaths in the Arabian Peninsula, continuous preventive measures, accurate methods for early diagnosis of infection, active surveillance, constant monitoring, developing vaccines, eradicating multidrug resistance modulators, and data sharing among countries are required.

Abstract

We aimed to identify the prevalence and emerging status of multidrug-resistant bacteria and fungi and their associated mortality in nine countries in the Arabian Peninsula. Original research articles and case studies regarding multidrug-resistant bacteria and fungi in the Arabian Peninsula, published during the last 10 years, were retrieved from PubMed and Scopus. A total of 382 studies were included as per the inclusion and exclusion criteria, as well as the PRISMA guidelines, from a thorough screening of 1705 articles, in order to analyse the emerging status and mortality. The emerging nature of >120 multidrug-resistant (MDR) bacteria and fungi in the Arabian Peninsula is a serious concern that requires continuous monitoring and immediate preventive measures. More than 50% (n = 453) of multidrug-resistant, microbe-associated mortality (n = 871) in the Arabian Peninsula was due to MDR Acinetobacter baumannii, Mycobacterium tuberculosis and Staphylococcus aureus infection. Overall, a 16.51% mortality was reported among MDR-infected patients in the Arabian Peninsula from the 382 articles of this registered systematic review. MDR A. baumannii (5600 isolates) prevailed in all the nine countries of the Arabian Peninsula and was one of the fastest emerging MDR bacteria with the highest mortality (n = 210). A total of 13,087 Mycobacterium tuberculosis isolates were reported in the region. Candida auris (580 strains) is the most prevalent among the MDR fungal pathogen in the Arabian Peninsula, having caused 54 mortalities. Active surveillance, constant monitoring, the development of a candidate vaccine, an early diagnosis of MDR infection, the elimination of multidrug resistance modulators and uninterrupted preventive measures with enhanced data sharing are mandatory to control MDR infection and associated diseases of the Arabian Peninsula. Accurate and rapid detection methods are needed to differentiate MDR strain from other strains of the species. This review summarises the logical relation, prevalence, emerging status and associated mortality of MDR microbes in the Arabian Peninsula.

A Saudi Arabian Public Health Perspective of Tuberculosis

Tuberculosis is a global health challenge due to its spreading potential. The Kingdom of Saudi Arabia (KSA) faces a challenge in the spread of tuberculosis from migrant workers, but the foremost threat is the huge number of pilgrims who travel to visit sacred sites of the Islamic world located in the holy cities of Makkah and Al Madina. Pilgrims visit throughout the year but especially in the months of Ramadan and Zul-Hijah. The rise of resistance in Mycobacterium tuberculosis is an established global phenomenon that makes such large congregations likely hotspots in the dissemination and spread of disease at a global level. Although very stringent and effective measures exist, the threat remains due to the ever-changing dynamics of this highly pathogenic disease. This overview primarily highlights the current public health challenges posed by this disease to the Saudi health system, which needs to be highlighted not only to the concerned authorities of KSA, but also to the concerned global quarters since the pilgrims and migrants come from all parts of the world with a majority coming from high tuberculosis-burdened countries.

Disease surveillance during a large religious mass gathering in India: The Prayagraj Kumbh 2019 experience

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At Kumbh Mela 2019, disease surveillance was established for 22 acute diseases and syndromes.

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Among the reported illnesses, 95% were communicable diseases such as acute respiratory illness (35%), acute fever (28%), and skin infections (18%).

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The incident command centre generated 12 early warning signals from indicator-based and event-based surveillance: acute diarrheal diseases (n = 8, 66%), vector-borne diseases (n = 2, 16%), vaccine-preventable disease (n = 1, 8%), and thermal event (n = 1, 8%).

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There were two outbreaks (acute gastroenteritis and chickenpox) that were investigated and controlled.

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Implementation of disease surveillance facilitated early outbreak detection and response.

Background

Mass gathering (MG) events are associated with public health risks. During the period January 14 to March 4, 2019, Kumbh Mela in Prayagraj, India was attended by an estimated 120 million visitors. An onsite disease surveillance was established to identify and respond to disease outbreaks.

Methods

A health coordination committee was established for planning. Disease surveillance was prioritized and risk assessment was done to identify diseases/conditions based on epidemic potential, severity of illness, and reporting requirement under the International Health Regulations (IHR) of 2005. A daily indicator and event-based disease surveillance was planned. The indicator-based surveillance (IBS) manually and electronically recorded data from patient hospital visits and collected MG area water testing data to assess trends. The event-based surveillance (EBS) helped identify outbreak signals based on pre-identified event triggers from the media, private health facilities, and the food safety department. Epidemic intelligence was used to analyse the data and events to detect signals, verify alerts, and initiate the response.

Results

At Kumbh Mela, disease surveillance was established for 22 acute diseases/syndromes. Sixty-five health facilities reported 156 154 illnesses (21% of a total 738 526 hospital encounters). Among the reported illnesses, 95% (n = 148 834) were communicable diseases such as acute respiratory illness (n = 52 504, 5%), acute fever (n = 41 957, 28%), and skin infections (n = 27 094, 18%). The remaining 5% (n = 7300) were non-communicable diseases (injuries n = 6601, 90%; hypothermia n = 224, 3%; burns n = 210, 3%). Water samples tested inadequate for residual chlorine in 20% of samples (102/521). The incident command centre generated 12 early warning signals from IBS and EBS: acute diarrheal disease (n = 8, 66%), vector-borne disease (n = 2, 16%), vaccine-preventable disease (n = 1, 8%), and thermal event (n = 1, 8%). There were two outbreaks (acute gastroenteritis and chickenpox) that were investigated and controlled.

Conclusions

This onsite disease surveillance imparted a public health legacy by successfully implementing an epidemic intelligence enabled system for early disease detection and response to monitor public health risks. Acute respiratory illnesses emerged as a leading cause of morbidity among visitors. Future MG events should include disease surveillance as part of planning and augment capacity for acute respiratory illness diagnosis and management.

Public health implications of Sabarimala mass gathering in India: A multi-dimensional analysis

INTRODUCTION

Mass gathering for religious and spiritual purposes are common in India. However, mass gathering health and travel medicine is still in its infancy in India.

OBJECTIVES

The study explored bio-medical, environmental and psycho-social dimensions of mass gathering in Sabarimala pilgrimage, which is annually attended by 25 million pilgrims.

METHODS

In a cross sectional design, the investigators travelled the pilgrim trail and stayed in the shrine area to conduct the interviews (sample = 1259), to observe the practices as well as to assess the environmental conditions including sanitation. We did in-depth interviews of a subset of samples of the pilgrims, laboratory tests for water quality and secondary analysis of health services data.

RESULT

43.4% pilgrims reported at least one health problem. Leg pain, joint/muscle pain, breathlessness, were the common symptoms. Pilgrims expressed concern about drinking water and food safety and majority of them felt the crowd management as unsatisfactory. Untreated sewage and solid waste were found to pollute the water downstream. Average patient presentation rate for 2014-2017 was 4999.6 per 100,000 pilgrims and referral to Hospital Rate was 19 per 100,000 pilgrims. Mortality rate ranged from 18.5 to 21 per 100,000 pilgrims among those who attended the health centers for ailments. Death due to Coronary Artery Heart Disease (CAHD) has slightly decreased over the period of 3 years from 97.6% to 85.1%.

CONCLUSION

Data with respect to safety, health and environment at the pilgrim sites need to be continuously assessed to understand changes and trends and to develop an effective mass gathering and safe pilgrimage policy (MGSPP).

Mass gatherings medicine: public health issues arising from mass gathering religious and sporting events

Mass gathering events are associated with major public health challenges. The 2014 Lancet Series on the new discipline of mass gatherings medicine was launched at the World Health Assembly of Ministers of Health in Geneva in May, 2014. The Series covered the planning and surveillance systems used to monitor public health risks, public health threats, and experiences of health-care providers from mass gathering events in 2012 and 2013. This follow-up Review focuses on the main public health issues arising from planned mass gathering events held between 2013 and 2018. We highlight public health and research data on transmission of infectious diseases and antibiotic-resistant bacteria, mass casualty incidents, and non-communicable diseases, including thermal disorders. In the events discussed in this Review, the combination of a large influx of people, many from countries with outbreak-prone infectious diseases, with a high degree of crowd interactions imposed substantial burdens on host countries' health systems. The detection and transmission of antibiotic-resistant bacteria in pilgrims attending the Kumbh Mela and the Hajj raise concern of possible globalisation from mass-gathering religious events. Priorities for further investments and opportunities for research into prevention, surveillance, and management of these public health issues are discussed.

Impact of Mycobacterium tuberculosis complex lineages as a determinant of disease phenotypes from an immigrant rich moderate tuberculosis burden country

Background

Growing evidences suggested that the Mycobacterium tuberculosis complex (MTBC) lineages can determine the clinical outcome of pulmonary and extra-pulmonary tuberculosis. However, limited data only available revealing such association of bacterial genotypes and clinical phenotypes from immigrant rich countries.

Methods

A multicenter study has been carried out on a collection of 2092 (1003 extrapulmonary and 1089 pulmonary) MTBC isolates. Genotyping of all the isolates were carried out by spoligotyping and 24 loci based MIRU-VNTR typing.

Results

Demographically domination of young Saudi nationals (61.4%) and men (61.2%) were found in this cohort. Lymph nodes (62.4%) and gastrointestinal sites (16.7%) were the most common anatomical sites of infection. The predominant lineages were Delhi/CAS (26.9%), EAI (14.2%) and Ghana (9.9%). Mycobacterium africanum type I and II were reported for the first time in the country among extrapulmonary cases. ‘Ancestral’ lineages M.bovis (OR-5.22; 95% CI-2.23-8.22, p- < 0.001) and Delhi/CAS (OR-0.57; 95% CI-0.411-0.734, p- < 0.001) were directly associated with lymph node tuberculosis and gastrointestinal tuberculosis (M. bovis-OR-0.33; 95% CI-0.085-0.567, p-0.001 and Delhi/CAS-OR-1.87; 95% CI-1.22-2.53, p- < 0.001) respectively. Among the ‘Modern’ lineages, EAI showed significant association to central nervous system tuberculosis (OR-1.98; 95% CI-0.76-3.19, p-0.04) and Uganda-I to gastrointestinal tuberculosis (OR-2.41; 95% CI-0.77-4.06, p-0.02).

Conclusions

The findings substantially contribute to the emerging evidences that MTBC lineages influence disease phenotypes and epidemiological consequences.

Electronic supplementary material

The online version of this article (10.1186/s12931-018-0966-x) contains supplementary material, which is available to authorized users.

Exploring challenges of health system preparedness for communicable diseases in Arbaeen mass gathering: a qualitative study

Background: Infectious diseases are common problems in mass gatherings, especially when there is a lack of health system preparedness. Since Iran is one of the most important countries on the walking path of Arbaeen and has a vital role in providing health services to pilgrims, the experiences of health challenges by participants is of key importance. The aim of this study is to explore stakeholders' experiences on the health system's preparedness and challenges, and to provide suggestions for preventing infectious diseases during the Arbaeen mass gathering. Methods: A qualitative research method was used with a conventional content analysis approach. The number of participants was 17, including 13 executive managers and 4 health policymakers who entered the study among participants. Semi-structured interviews were used to generate the data. Interviews were analyzed by means of content analysis after face-to-face interviews. Results: Data analysis resulted in the extraction of four main themes and 11 sub-themes. Health infrastructure defects in Iraq has three sub-themes (health abandonment in Iraq, the weaknesses in health culture and problems related to the health system); poor control of the causative factors of infectious diseases has three sub-themes (the underlying factors of the prevalence of contagious diseases, health system response to communicable diseases and ignoring the risks of the Arbaeen ceremony); the low perception of risk in pilgrims has three sub-themes (lack of awareness in pilgrims, fatalism in pilgrims and unhygienic belief in pilgrims); and the ineffectiveness of health education has two sub-themes (training shortage in the targeted group and educational content problems) that shows participant's experiences of the health system's challenges for coping with infectious diseases during the Arbaeen ceremony. Conclusion: Pilgrim-based training, planning and controlling other challenges may change these threats to opportunities and improve the health of participants of the mass gathering of Arbaeen in the region.

Infectious Diseases and Mass Gatherings

Purpose of Review

Mass gatherings (MGs) are characterized by a high concentration of people at a specific time and location. Infectious diseases are of particular concern at MGs. The aim of this review was to summarize findings in the field of infectious diseases with a variety of pathogens associated with international MGs in the last 5 years.

Recent Findings

In the context of Hajj, one of the largest religious MGs at Mecca, Saudi Arabia, respiratory tract infections are the leading cause of infectious diseases in pilgrims with a prevalence of 50–93%. The most commonly acquired respiratory viruses were human rhinovirus, followed by human coronaviruses and influenza A virus, in decreasing order. Haemophilus influenzae, Staphylococcus aureus, and Streptococcus pneumoniae were the predominant bacteria. The prevalence of Hajj-related diarrhea ranged from 1.1 to 23.3% and etiologies included Salmonella spp., and Escherichia coli, with evidence of acquisition of antimicrobial-resistant bacteria. In other MGs such as Muslim, Christian, and Hindu religious events, sports events, and large-scale open-air festivals, outbreaks have been reported less frequently. The most common outbreaks at these events involved diseases preventable by vaccination, notably measles and influenza. Gastrointestinal infections caused by a variety of pathogens were also recorded.

Summary

Because social distancing and contact avoidance are difficult measures to implement in the context of many MGs, individual preventive measures including vaccination, use of face mask, disposable handkerchief and hand hygiene may be recommended. Nevertheless, the effectiveness of these measures has been poorly investigated in the context of MGs.

Screening of latent tuberculosis infection among health care workers working in Hajj pilgrimage area in Saudi Arabia, using interferon gamma release assay and tuberculin skin test

BACKGROUND

Interferon gamma release assays (IGRA) is highly specific for Mycobacterium tuberculosis and is the preferred test in BCG-vaccinated individuals. The few studies that have screened health care workers (HCWs) in Saudi Arabia for latent tuberculosis infection (LTBI) using IGRA have varied in agreement with the traditional tuberculin skin test (TST).

OBJECTIVE

Assess the prevalence of LTBI among HCWs working in the Hajj pilgrimage using IGRA and TST and measuring their agreement.

DESIGN

Cross-sectional prospective.

SETTING

Multiple non-tertiary care hospitals.

PATIENTS AND METHODS

HCWs who worked during the Hajj pilgrimage in Saudi Arabia in December 2015. Data was collected by standarized questionnaire. Samples were drawn and analyzed by standard methods.

MAIN OUTCOME MEASURES

The prevalence of LTBI among HCW and the agreement by kappa statistic between QFT-GIT and TST.

SAMPLE SIZE

520 subjects.

RESULTS

Nurses accounted for 30.7% of the sample and physicians, 19.2%. The majority were BCG vaccinated (98.5%). There were a total of 56 positive by QFT-GIT and the LTBI rate was 10.8%. In 50 QFT positive/476 TST negative the LTBI rate was 10.5% in discordant tests, and in 6 QFT positive/44 TST positive it was 13.6% in concordant tests. The overall agreement between both tests was poor-83% and kappa was 0.02. LTBI prevalence was associated with longer employment (13.1 [9.2] years). The QFT-GIT positive test was significantly higher in physicians (P=.02) and in HCWs working in chest hospitals 16/76 (21.05%) (P=.001).

CONCLUSION

Agreement between the tests was poor. QFT-GIT detected LTBI when TST was negative in HCWs who had a history of close contact with TB patients.

LIMITATIONS

A second step TST was not feasible within 2-3 weeks.

CONFLICT OF INTEREST

None.

Undiagnosed Active Pulmonary Tuberculosis among Pilgrims during the 2015 Hajj Mass Gathering: A Prospective Cross-sectional Study

Mass gatherings pose a risk for tuberculosis (TB) transmission and reactivation of latent TB infection. The annual Hajj pilgrimage attracts 2 million pilgrims many from high TB-endemic countries. We evaluated the burden of undiagnosed active pulmonary TB in pilgrims attending the 2015 Hajj mass gathering. We conducted a prospective cross-sectional study in Mecca, Kingdom of Saudi Arabia, for nonhospitalized adult pilgrims from five high TB-endemic countries. Enrollment criteria were the presence of a cough and the ability to produce a sputum sample. Sputum samples were processed using the Xpert MTB-RIF assay. Data were analyzed for drug-resistant TB, risk factors, and comorbidities by the country of origin. Of 1,164 consenting pilgrims enrolled from five countries: Afghanistan (316), Bangladesh (222), Nigeria (176), Pakistan (302), and South Africa (148), laboratory results were available for 1,063 (91.3%). The mean age of pilgrims was 54.5 (range = 18-94 years) with a male to female ratio of 2.6:1; 27.7% had an underlying comorbidity, with hypertension and diabetes being the most common, 20% were smokers, and 2.8% gave a history of previous TB treatment. Fifteen pilgrims (1.4%) had active previously undiagnosed drug-sensitive pulmonary TB (Afghanistan [12; 80%], Pakistan [2; 13.3%], and Nigeria [1; 6.7%]). No multidrug-resistant TB cases were detected. Pilgrims from high TB-endemic Asian and African countries with undiagnosed active pulmonary TB pose a risk to other pilgrims from over 180 countries. Further studies are required to define the scale of the TB problem during the Hajj mass gathering and the development of proactive screening, treatment and prevention guidelines.

Emergence of drug resistant bacteria at the Hajj: A systematic review

BACKGROUND

Hajj is the annual mass gathering of Muslims, and is a reservoir and potential source of bacterial transmission. The emergence of bacterial transmission, including multi-drug resistance (MDR) bacteria, during Hajj has not been systematically assessed.

METHODS

Articles in Pubmed, Scopus, and Google scholar were identified using controlled words relating to antibiotic resistance (AR) at the Hajj from January 2002 to January 2017. Eligible studies were identified by two researchers. AR patterns of bacteria were obtained for each study.

RESULTS

We included 31 publications involving pilgrims, Hajj workers or local patients attending hospitals in Mecca, Mina, and the Medina area. Most of these publications provided antibiotic susceptibility results. Ten of them used the PCR approach to identify AR genes. MRSA carriage was reported in pilgrims and food handlers at a rate of 20%. Low rates of vancomycin-resistant gram-positive bacteria were reported in pilgrims and patients. The prevalence of third-generation cephalosporin-resistant bacteria was common in the Hajj region. Across all studies, carbapenem-resistant bacteria were detected in fewer than 10% of E.coli isolates tested but up to 100% in K. pneumoniae and A. baumannii. Colistin-resistant Salmonella enterica, including mcr-1 colistin-resistant E.coli and K.pneumoniae were only detected in the pilgrim cohorts.

CONCLUSION

This study provides an overview of the prevalence of MDR bacteria at the Hajj. Pilgrims are at high risk of AR bacterial transmission and may carry and transfer these bacteria when returning to their home countries. Thus, pilgrims should be instructed by health care practitioners about hygiene practices aiming at reducing traveler's diarrhea and limited use of antibiotics during travel in order to reduce the risk of MDR bacterial transmission.

Strengthening health security at the Hajj mass gatherings: characteristics of the infectious diseases surveillance systems operational during the 2015 Hajj

BACKGROUND

Hajj is one of the largest and the most ethnically and culturally diverse mass gatherings worldwide. The use of appropriate surveillance systems ensures timely information management for effective planning and response to infectious diseases threats during the pilgrimage. The literature describes infectious diseases prevention and control strategies for Hajj but with limited information on the operations and characteristics of the existing Hajj infectious diseases surveillance systems.

METHOD

We reviewed documents, including guidelines and reports from the Saudi Ministry of Health's database, to describe the characteristics of the infectious diseases surveillance systems that were operational during the 2015 Hajj, highlighting best practices and gaps and proposing strategies for strengthening and improvement. Using Pubmed and Embase online search engines and a combination of search terms including, 'mass gatherings' 'Olympics' 'surveillance' 'Hajj' 'health security', we explored the existing literature and highlighted some lessons learnt from other international mass gatherings.

RESULTS

A regular indicator-based infectious disease surveillance system generates routine reports from health facilities within the Kingdom to the regional and central public health directorates all year round. During Hajj, enhanced indicator-based notifiable diseases surveillance systems complement the existing surveillance tool to ensure timely reporting of event information for appropriate action by public health officials.

CONCLUSION

There is need to integrate the existing Hajj surveillance data management systems and to implement syndromic surveillance as an early warning system for infectious disease control during Hajj. International engagement is important to strengthen Hajj infectious diseases surveillance and to prevent disease transmission and globalization of infectious agents which could undermine global health security.

What is the experience from previous mass gathering events? Lessons for Zika virus and the Olympics 2016

All previous experiences from different mass gathering show that vaccine preventable diseases is the most important infections like influemza, hepatitis A, polio and meningitis. Three mass gathering held in Africa during the Ebola outbreak accepted participants from West Africa and was able to handle the theoretical risk without any incident. Therefore we believe that the Olympc games in Rio de Janeiro should not be canceled. The number of visitors to the games is a tine fraction (1%) of other visitors to Zika endemic con tries and it will have no measurable effect on the risk of spreading Zika virus, if the games was cancelled.