Hajj 2021: Role of mitigation measures for health security

Vaccinations for Hajj: Enhancing health and global health security

The Hajj pilgrimage, one of the world's largest and most diverse mass gatherings, poses unique challenges for preventing infectious disease outbreaks. Vaccinations are vital in reducing the risk and spread of diseases during this event. This narrative review examines the impact of vaccination programs on infectious disease mitigation during the Hajj and their broader implications for global health security (GHS). Mandatory vaccination protocols against Meningococcal Meningitis, Yellow Fever, Influenza, pneumococcal diseases, and COVID-19 have demonstrated significant success in controlling infection spread during Hajj. Furthermore, the integration of digital health passports or similar technologies offers the potential to enhance surveillance, streamline vaccination verification, and further minimize risks associated with mass gatherings. This study demonstrates the critical role of vaccination programs in protecting pilgrims. It also explores how technologies can be used to monitor pilgrim health status, enabling rapid identification and mitigation of potential outbreaks, thus contributing to GHS.

Detection of COVID-19 incidence among attendees of the 2022 Hajj season

Objectives

This study investigated the presence of COVID-19 cases among pilgrims, health care workers (HCWs), and non-HCWs of Hajj 2022.

Methods

Nasopharyngeal samples were collected from 491 attendees of Hajj 2022. All participants received three doses of COVID-19 vaccines. Paired (n = 138; 69 participants) and unpaired (n = 422; 422 participants) nasopharyngeal swabs were subjected to reverse transcription-polymerase chain reaction targeting E gene of β-coronaviruses and RNA-dependent RNA polymerase of SARS-CoV-2. The results were linked to the participants' profiles, including role during Hajj, presence of respiratory symptoms or comorbidities, contact with symptomatic individuals, smoking status, and COVID-19 recovery.

Results

A total of 20 (20 of 560; 3.6%) samples tested positive for COVID-19. Most cases (18 of 20; 90%) were pilgrims and non-HCWs. Six (30%) samples belonged to participants with previous positive reverse transcription-polymerase chain reaction. A total of 12 (60%) samples belonged to participants with respiratory symptoms. Three (15%) cases were linked to participants who had contact with individuals with respiratory symptoms. All cases belonged to individuals with no comorbidities, apart from a single case who has a chronic sinusitis. Five (25%) cases were smokers. No significant association was found between positive COVID-19 test and participants' profiles.

Conclusions

Few COVID-19 cases were detected in this study. Sustainable surveillance of COVID-19 and other respiratory viruses during Hajj seasons remains necessary.

Evidence for transmission of SARS-CoV-2 at religious mass gatherings: A systematic review

Background

Transmission of SARS-CoV-2 at major mass gatherings (MGs) has been observed during the COVID-19 pandemic.

Methods

In this systematic review done according to the PRISMA guidelines, PubMed and Scopus databases were searched for relevant studies to describe the epidemiology of SARS-CoV-2 in relation to major religious MGs including the Grand Magal of Touba (GMT), Hajj, Umrah, Kumbh Mela, Arbaeen and Lourdes pilgrimage during the COVID-19 pandemic.

Results

Ten articles met the inclusion criteria and were included.No cases of SARS-CoV-2 were detected at 2020 and 2021 GMT or at the 2020 Hajj. In a small study, 7 % of tested individuals were positive after the 2022 GMT. SARS-CoV-2 prevalence during the 2021-2022 Hajj and Umrah seasons varied from 0 to 15 % in different studies. At the 2021 Kumbh Mela, 0.4 million COVID-19 cases were diagnosed among returning pilgrims across India and 1 % tested positive during a one-day survey conducted on participants. During the 2021 Arbaeen pilgrimage, 3 % pilgrims were tested positive. No relevant data were found in relation to SARS-CoV-2 transmission at the 2021 Arbaeen and Lourdes pilgrimages.

Conclusion

The transmission of the SARS-CoV-2 virus during religious MG events depends on many factors such as: the number and density of pilgrims, the intensity of circulation of the virus in the hosting country and in countries sending international participants at the time of the event, the transmissibility of virus variants at the time of the event, the various preventive measures adopted, and the immune status of the pilgrims.

Strengthening global health security through health early warning systems: A literature review and case study

Disease transmission is dependent on a variety of factors, including the characteristics of an event, such as crowding and shared accommodations, the potential of participants having prolonged exposure and close contact with infectious individuals, the type of activities, and the characteristics of the participants, such as their age and immunity to infectious agents [1-3]. Effective control of outbreaks of infectious diseases requires rapid diagnosis and intervention in high-risk settings. As a result, syndromic and event-based surveillance may be used to enhance the responsiveness of the surveillance system [1]. In public health, surveillance is collecting, analyzing, and interpreting data across time to inform decision-making and aid policy implementation [1]. In this review article we aimed to provide an overview of the principles, types, uses, advantages, and limitations of surveillance systems and to highlight the importance of early warning systems in response to the information received by disease surveillance. The study conducted a comprehensive literature search using several databases, selecting, and reviewing 78 articles that covered different types of surveillance systems, their applications, and their impact on controlling infectious diseases. The article also presents a case study from the Hajj gathering, which highlighted the development, evaluation, and impact of early warning systems on response to the information received by disease surveillance. The study concludes that ongoing disease surveillance should be accompanied by well-designed early warning and response systems, and continuous efforts should be invested in evaluating and validating these systems to minimize the risk of reporting delays and reducing the risk of outbreaks.

Respiratory viral infections during Hajj seasons

Respiratory viral infections pose a public health concern during mass gathering (MG) events. Sustainable and continuous surveillance of respiratory viruses remains a priority to early identify and prevent potential outbreaks. This article reviews recent literature addressed the prevalence and diversity of circulating respiratory viruses during Hajj pilgrimage, one of the largest planned religious MG events held annually in Saudi Arabia. The variation between studies with respect to study design, sample size, time of sample collection (pre-, during, and pos-Hajj), type of participants (e.g., symptomatic vs. a symptomatic pilgrims), and laboratory procedure was highlighted. The majority of these studies were conducted on the 2019 Hajj season or earlier, prior to the emergence of COVID-19 which had significant impact on the past three Hajj seasons (2020, 2021, and 2022). A summary about key aspects related to organization of Hajj during COVID-19 pandemic and the implementation of exceptional infection control strategies is provided.

Healthcare policies, precautionary measures and outcomes of mass gathering events in the era of COVID-19 pandemic: Expedited review

With the onset of the COVID-19 pandemic in early 2020, several countries suspended or restricted mass gathering (MG) events to mitigate the risk of superspreading events. Prohibiting MGs aimed to lessen the likelihood of highly infectious persons coming into close contact with many others. Now that the world has opened its doors wide and removed most of precautionary measures, many questions arise. In this review, we aimed to summarize the current evidence regarding the policies and regulations that were implemented for the safe return of MG events. Besides, we highlighted the impact of the return of MG events during 2021 on the trajectory of COVID-19 spread. Canceling MG events can carry religious, societal, economic, and public negative consequences necessitating the safe return of these events. The experience with the COVID-19 pandemic was the foundation for the recommendations for the safe conduction of MG events during the pandemic by international public health bodies. When policymakers adequately applied precautionary measures and strategic approaches, we witnessed the safe holding of huge MG events without aggravating the COVID-19 situation or increasing the number of new cases beyond the capacity and readiness of the national healthcare system.

Hand Hygiene Knowledge and Practices Among Visitors to the Holy Masjid (Masjid Al-Haram) During the Month of Ramadan in 2023

Introduction Visits to the Holy Masjid are considered mass gatherings (MGs), defined as concentrations of people at a specific location for a certain objective over a predetermined amount of time. Such gatherings might strain the host nation's preparation and reaction capabilities, increasing the chances of spreading infectious diseases. Aim To evaluate the comprehension of hand hygiene (HH) and proper HH habits among visitors to the Holy Masjid during the month of Ramadan in 2023. Methods A total of 690 visitors to the Holy Masjid were interviewed for this cross-sectional study. The questionnaire was developed using model questions from another published survey. Results Of the participants, 541 (78.4%), predominantly female, had generally good knowledge about HH. A total of 282 (40.9%) participants used nothing to clean their hands after shaking hands with someone. Four hundred and eighty (69.6%) participants were aware that poor HH does not spread HIV/AIDS, and 504 (73%) stated that consistent HH does not reduce the body's natural immunity. A total of 530 (76.8%) participants with good knowledge about HH cleaned their hands before meals, compared to 131 (19%) participants with poor knowledge of HH. Conclusion Based on the results of our study, the participants' awareness of HH was generally high, with most recognizing the role of good HH in preventing common infectious diseases, such as gastrointestinal and respiratory infections. However, certain aspects of HH, such as the necessity and proper use of alcohol-based hand sanitizers, were not well understood. Regular, focused awareness-raising initiatives are recommended to enhance HH knowledge and practices among visitors to the Holy Masjid.

Epidemiological Differences in Hajj-Acquired Airborne Infections in Pilgrims Arriving from Low and Middle-Income versus High-Income Countries: A Systematised Review

This systematised review aims to compare the epidemiological patterns of Hajj-acquired airborne infections among pilgrims from low and middle-income countries (LMIC) versus those from high-income countries (HIC). A PubMed search was carried out for all published articles before February 2023, using a combination of MeSH terms and text words. The Newcastle-Ottawa Scale (NOS) was used to assess data quality. From a total of 453 titles identified, 58 studies were included in the review (LMIC = 32, and HIC = 26). In the pooled sample, there were 27,799 pilgrims aged 2 days to 105 years (male: female = 1.3:1) from LMIC and 70,865 pilgrims aged 2 months to 95 years (male: female = 1:1) from HIC. Pilgrims from both HIC and LMIC had viral and bacterial infections, but pilgrims from HIC tended to have higher attack rates of viral infections than their LMIC counterparts. However, the attack rates of bacterial infections were variable: for instance, pilgrims from LMIC seemed to have higher rates of meningococcal infections (0.015-82% in LMIC vs. 0.002-40% in HIC) based on the study population, but not Mycobacterium tuberculosis (0.7-20.3% in LMIC vs. 38% in HIC). Targeted measures are needed to prevent the spread of airborne infections at Hajj.

Threat of Antimicrobial Resistance among Pilgrims with Infectious Diseases during Hajj: Lessons Learnt from COVID-19 Pandemic

Hajj pilgrimage is a large mass gathering global event that may facilitate the spread and emergence of various infectious diseases as well as antimicrobial resistance (AMR) in a local and global scenario. Planning and preparing for these public health issues is a challenging and complex process for the Kingdom of Saudi Arabia (KSA) health authorities. Despite multiple efforts for the prevention and treatment of infectious diseases through longtime funding in education and medical care, the prevalence of infectious disease is still high among Hajj pilgrims. The commonly observed infectious diseases during Hajj include respiratory tract infections (influenza and pneumonia), urinary tract infections and skin infections that may necessitate the use of antimicrobials. Beta-lactams are used as a first-line treatment for hospital acquired infections as well as community acquired infections due to their broad-spectrum activity. However, most of the bacterial isolates such as Staphylococcus spp., Pseudomonas spp. and E. coli are resistant to beta-lactams. Irrational use of antimicrobials, lack of infection prevention practices and suboptimal healthcare access further exacerbate the risk of spreading AMR among Hajj pilgrims. Enhanced collaboration between countries, sharing of best practices and international cooperation are crucial in addressing AMR threats among pilgrims. Consequently, robust surveillance systems for early detection and monitoring of AMR, collaboration with national as well as international healthcare agencies, effective infection prevention and control measures, public awareness and rational use of antimicrobials via antimicrobial stewardship programs are required to mitigate the risk of AMR and ensure the health and well-being of pilgrims during Hajj.

Public Health Challenges in Saudi Arabia during the COVID-19 Pandemic: A Literature Review

Similar to most countries, Saudi Arabia faced several challenges during the novel coronavirus disease 2019 (COVID-19) pandemic, some of which were related to the religious position of the country. The main challenges included deficits in knowledge, attitudes, and practices toward COVID-19, the negative psychological impacts of the pandemic on the general population and healthcare workers, vaccine hesitancy, the management of religious mass gatherings (e.g., Hajj and Umrah), and the imposition of travel regulations. In this article, we discuss these challenges based on evidence from studies involving Saudi Arabian populations. We outline the measures through which the Saudi authorities managed to minimize the negative impacts of these challenges in the context of international health regulations and recommendations.