Public health planning for Hajj leads to success

Qanta Ahmed wrote about the Hajj in The Lancet during the last part of the 19th century, describing it as a haphazard affair for pilgrims who faced attack by thieves and communicable disease threats.

Last month, The Lancet Infectious Diseases Editor John McConnell noted these days, “much less is left to chance,” in planning for the Hajj, adding that changes in infrastructure, as well as technology, are boosting public health safety for all pilgrims.

Although the Hajj remains an epicenter for about 2 to 4 million Muslims throughout the world, the Hajj 2010, which started the first week of November, was regarded as a success in public health circles, in that nothing out of the ordinary happened, even in a year when the pandemic strain of influenza continues to circulate.

“Some pilgrims save for their entire lives to attend the Hajj,” said Scott McNabb, PhD. McNabb works with Emory University and has worked closely with the Saudi government for the past 2 years in public health planning for the annual pilgrimage. “Pilgrims travel by plane from all over the world to attend. Often, these people are older, come from poorer areas, and come from areas with limited health care. So there are multiple things to consider when discussing public health during this gathering.” McNabb said the Saudi response has been very strong in preparing and ensuring public health safety.

Ziad A Memish, MD, who is the Assistant Deputy Minister for Preventive Medicine for the Saudi Arabian Ministry of Healthy, said in an interview with Infectious Diseases in Children that he is “confident all the planning, active surveillance and early preventive recommendations for vaccination has had a major impact on reducing communicable diseases during Hajj.” “

The public health response in Saudi Arabia has evolved in recent years to include health screenings as people enter the country, free health care during the Hajj, stepped up infection control efforts in hospitals, more personnel to staff health care facilities surrounding the pilgrimage sites, and most recently, boosted surveillance strategies that are being regarded as groundbreaking within public health circles.

“On surveillance, we have intensified the role of mobile public health teams to review medical conditions at different Hajj camps and report any suspected infectious diseases even before they report to our health care facilities,” Memish said.

Rumi Chunara, PhD, of Harvard Medical School, who is part of a team that uses HealthMap internet-based surveillance technology to aid public health response at the Hajj, said that these types of technologies are critical to providing key information in real-time.

“Getting real time information on infectious threats is critical during mass gatherings like [the Hajj].” Chunara said. She said as of press time, their system was still tracking events related to this year’s Hajj, but she said, fortunately, nothing out of the ordinary had been reported as of mid December.

Infectious threats

McNabb noted several communicable disease areas that public health officials monitor closely during the Hajj.

Foodborne illness is common, McNabb said. Although improvements in water supply and sewage treatment have reduced illness, tight living quarters and the fact that food is often prepared on the road as pilgrims travel between destinations make for ideal conditions for these illnesses.

Another communicable disease threat that has been a traditional concern during the Hajj is meningococcal meningitis. The crowded conditions and air conditions lead to a perfect environment for meningococcal disease spread. Memish cited two large meningococcal outbreaks that occurred in the 1980s and early 21st Century that affected pilgrims both in Mecca and in other countries. He said that those outbreaks led to the implementation of meningococcal vaccine requirements.

“Although compliance with our vaccination recommendations are not 100%, every year is higher than the year before,” Memish said. “This year, for example, compliance with meningococcal vaccination recommendations at the Jeddah Hajj terminal, which receives the majority of international pilgrims, was above 97%.”

Respiratory tract infections are also common. McNabb said that the Saudi government stepped up surveillance efforts particularly in the wake of the H1N1 pandemic strain of influenza.

Other illnesses like respiratory syncytial virus and pertussis are also common. Memish said that although children are discouraged from attending, as Hajj is only required for physically able adults, “every year a few thousand children do accompany their parents and this population is vulnerable to many communicable diseases, especially viral URTIs.” In response, health officials encourage the use of facemasks, and vaccination against illnesses like influenza, according to Memish.

Tuberculosis is another respiratory illness that is particularly troublesome during the Hajj. Many Muslims travel from countries of high TB endemicity. “Although the exact risk of TB transmission among pilgrims is difficult to quantify, a study among 357 Singaporean pilgrims revealed that 10% showed a substantial rise in immune response to the QuantiFERON TB assay antigens post-Hajj when compared to a pre-Hajj test,” according to an article published by Wilder-Smith. Because of the heightened risk for TB, McNabb said it is possible that future surveillance efforts will utilize technologies like the mobile phone initiative that Chunara described.

Surveillance efforts

Writing in an editorial last month, McConnell praised initiatives like the mobile phone technology, noting that many attendees at the Lancet’s recent Mass Gathering meeting in Jeddah agreed that “systems that can provide rapid health surveillance information are essential.”

Chunara said many conference attendees were impressed with the HealthMap technology. She said the advantage of this type of technology is the potential to identify infectious threats before the pilgrims even depart for the Hajj, possibly precluding wider outbreaks once the pilgrimage begins. She said plans for next year’s Hajj are already in the works.

Memish also noted public health officials use of mobile technology to report potential communicable disease problems.

“For the past two years, we used mobile surveillance in collaboration with the CDC staff and we found the system to be convenient and prompt,” Memish said.

McConnell noted that it was clear from the conference that “the heterogeneous approach required for provision of a safe and healthy environment at mass gatherings goes well beyond the traditional concept of medicine. Indeed, the consensus among participants was that mass gatherings health was a better term.”

He then went on to cite “Maurizio Barbeschi from WHO, who endorsed the royal recommendation of the Custodian of the Two Holy Mosques King Abdullah Al-Saud, given in his opening speech and delivered by the Saudi Minister of Health, Abdullah Al-Rabeah, to regard mass gatherings health as a new academic and scientific discipline to address the multidimensional and multidisciplinary complexity of such events.”

Memish, who cowrote the editorial with McConnell, said he firmly backs this recommendation, and noted that a “a committee has been formed under the leadership of the Saudi Council for Health Specialties to discuss the training and requirements for such a discipline.” These recommendations will likely be at the upcoming GCC Minister of Health’s meeting in Qatar in February. - by Colleen Zacharyczuk

For more information:

• McConnell J, Memish ZA. Lancet Infect Dis.2010;818–819.
• Memish ZA. Euro Surveill.2010;15:pii=19671.

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