Hajj, the annual pilgrimage to Makkah (Mecca), in the Kingdom of Saudi Arabia (KSA) is one of the largest gatherings of its kind in the world. Each year over two million Muslims from around the world gather in Makkah. The Hajj pilgrimage occurs between the 8th and 12th day of the twelfth month of the Islamic calendar. Umrah is a shorter, non-compulsory pilgrimage for Muslims that can be performed at any time. The Ministry of Health (MOH) KSA issues regulations and requirements for the Hajj and Umrah seasons.
The mixing of people from nations around the world creates a high risk of disease transmission between geographically otherwise diverse groups. In response to international outbreaks of disease, the Ministry of Health KSA recommends that, as a precautionary measure, elderly people, those suffering from chronic diseases (heart diseases, kidney disease, respiratory diseases, nervous system disorders and diabetes) and immunodeficient patients (congenital and acquired), pregnant women and children should postpone the performance of the Hajj and Umrah this year, for their own safety.
Meningococcal meningitis: All pilgrims who intend to undertake Hajj or Umrah and seasonal workers, are required to provide a certificate of proof of vaccination against meningococcal meningitis ACW135Y in order to obtain a visa for entry into KSA. The MOH KSA stipulate that one dose of meningitis ACW135Y vaccine should be received not more than three years and not less than ten days, before arrival in KSA.
The Department of Health, United Kingdom, recommends conjugated meningococcal ACWY vaccine as the preferred vaccine in all instances.
The Muslim Council of Britain provides vaccination advice at the following website: Muslim Council of Britain Hajj & Umrah Travel Vaccination, (www.mcb-vac.co.uk/)
Polio: All pilgrims to Hajj and Umrah are advised to ensure their polio vaccination is up-to-date. Travellers, who last received a dose of polio more than ten years ago, should receive a booster, using the trivalent tetanus, diphtheria and polio vaccine.
Yellow fever: All pilgrims to Hajj and Umrah arriving from countries or areas at risk for transmission of yellow fever must present a valid International Certificate of Vaccination or Prophylaxis documenting yellow fever vaccination and completed in accordance with International Health Regulations (2005).
All pilgrims should ensure that they are up-to-date with routine immunisations particularly:
Hepatitis B: Hepatitis B virus is found in body fluids and can be transmitted either percutaneously or by sexual contact. Percutaneous transmission can occur through the use of contaminated medical, dental, or other instruments; all pilgrims should consider hepatitis B vaccine.
One of the rites of Hajj is for men to have their head shaved. The KSA authorities provide licensed barbers with a new blade to use for each pilgrim, however, unlicensed barbers may not conform to this standard. Pilgrims should avoid shaving with a blade previously used by another, as this could result in transmission of hepatitis B, and other blood borne infections such as hepatitis C, for which there is no vaccine. Pilgrims can consider taking with them a disposable razor for personal use during this rite.
Rabies: There is a risk of rabies in KSA. Pilgrims should be advised of the importance of avoiding contact with wild or domestic animals and to seek urgent emergency medical treatment if any potential exposure (animal bite, lick or scratch) occurs. Pre-exposure vaccination can be considered, however, rabies vaccination prior to travel does not eliminate the need for post-exposure medical evaluation and additional doses of rabies vaccine.
Seasonal influenza: Viral respiratory infection (known as Hajj cough) experienced by many pilgrims at the Hajj, can range from a mild inconvenience to a severe illness, and can interfere with performing the rites. Influenza is transmitted via the respiratory route and through contact (direct or indirect) with surfaces on which the virus has been deposited by sneezing or coughing. It is easily transmitted in crowded conditions. Certain groups are considered at particular risk of complications from influenza.
The MOH KSA recommends that pilgrims are vaccinated against seasonal influenza before arrival into KSA, especially those suffering from chronic diseases (heart diseases, kidney disease, respiratory diseases, nervous system disorders and diabetes), and immunodeficiency patients (congenital and acquired), metabolic diseases, pregnant women, children (under 5 years) and obese persons.
Severe respiratory illness
Middle East respiratory syndrome coronavirus (MERS-CoV): Since 2012, when MERS-CoV was first identified, there have been 699 laboratory-confirmed cases and 209 deaths reported to the World Health Organization , the majority associated with KSA . Some cases associated with travel to the Middle East have been reported from European countries. This infection can cause severe illness and death. Since April 2014, there has been an increase in the number of reported cases of MERS-CoV, however, the risk to UK residents travelling to the Middle East of contracting MERS-CoV during travel remains very low.
Ebola Virus Disease (EVD): Due to the Ebola Outbreak in West Africa, KSA have announced that they will not be issuing visas to people traveling from Sierra Leone, Liberia, and Guinea. In addition all KSA embassies and consulates have been advised to make sure that all applicants for entry visas to KSA have not travelled to, or lived in EVD affected countries within the last 3 weeks before their applications. All visitors to KSA will be required to complete an Ebola screening card before entering the KSA.
Other health considerations
Accidents and injuries: Accidents and injuries are relatively common, particularly minor injuries to the feet. More serious injuries can occur as a result of stampedes as pilgrims undertake the stoning rite or other mass activities. Pilgrims are advised to avoid peak times; elderly and infirm people, who have decided to make their pilgrimage, may wish to consider appointing a proxy for the performance of this rite. All pilgrims to Hajj and Umrah should have adequate travel health insurance.
Environmental hazards (cold, heat and sun): During the winter months the weather can be very cold overnight. Pilgrims should ensure they take appropriate bedding with them such as blankets and sleeping bags.
Daytime temperatures in KSA, even during the winter months, can reach over 30°C. Associated risks include sunburn, dehydration, heat exhaustion, and heat stroke.
If possible, travel before the start of Hajj should be considered in order to allow a period of acclimatisation to the heat. Pilgrims should ensure that they drink plenty of clean water (preferably bottled or boiled and cooled) to avoid dehydration.
Sunscreen with a sun protection factor of at least 15 should be applied liberally to exposed skin - including to an exposed, shaved or balding head - every two to three hours. Male pilgrims are not allowed to cover their heads; however an umbrella will provide shade from the sun.
Desert sand can reach very high temperatures; good quality footwear should be worn to avoid burning the feet. Footwear must be removed during times of prayer, and to avoid losing them, pilgrims are advised to carry their footwear in a bag.
Food and water advice: Fresh food cannot be brought into KSA by travellers. Strict regulations about food materials apply. Diarrhoeal illnesses are transmitted by the consumption of contaminated food or water. Dehydration can occur with diarrhoea and is of particular risk in hot weather. Babies, infants, the elderly and those with chronic medical conditions are more vulnerable to dehydration. All pilgrims are advised to take personal, food and water hygiene precautions. Travellers should also take with them oral rehydration therapy and self-treatment for diarrhoea.
Vector-borne diseases: Malaria is not present in Medina or Makkah (or in the cities of Jeddah, Riyadh and Ta’if or areas of Asir province above 2,000m), but pilgrims are advised to practise insect bite avoidance measures that will reduce the risk of other vector-borne diseases, such as dengue fever.
Insurance: All pilgrims to Hajj and Umrah should have adequate travel health insurance. Pilgrims should carry with them their GP's details which may be required if emergency medical care is necessary.
Medical kits: All pilgrims should take a basic medical kit that includes simple analgesia (pain killers), plasters, and oral rehydration treatment. An anti-motility agent (such as loperamide) can be carried to treat the symptoms of diarrhoea. Pilgrims who take regular medication should ensure they have an adequate supply and carry a copy of their prescription.
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