Hajj & Umrah Health and safety Advice

Advice for Pilgrims: Hajj and Umrah 1434 (2013)

This information sheet details the health regulations for 1434 Hajj and Umrah, as published by the Ministry of Health, Kingdom of Saudi Arabia, 12 July, 2013

Further updates may be added

Hajj, the annual pilgrimage to Makkah (Mecca), in the Kingdom of Saudi Arabia (KSA), is the largest gathering 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. The 1434 H season is estimated to fall between 13 and 15 October 2013 [1]. Umrah is a shorter, non-compulsory pilgrimage for Muslims that can be performed at any time.

Each year, the KSA Ministry of Health (MOH) issues specific requirements for entry to the Hajj and Umrah, usually during the summer months before the Hajj and Umrah season commences.

Hajj and Umrah: required vaccinations

Meningococcal meningitis: All pilgrims aged two years and older, who intend to undertake Hajj or Umrah and seasonal workers, are required to provide proof of vaccination against meningococcal meningitis ACW135Y in order to obtain a visa for entry into KSA [2, 3].

Meningococcal ACW135Y vaccine should have been received not more than three years and not less than ten days, before arrival in KSA, and should be recorded in a vaccination book showing the traveller’s full name. If a traveller is in possession of an International Certificate of Vaccination or Prophylaxis (ICVP) booklet, meningococcal meningitis ACW135Y vaccine can be recorded in the ‘Other Vaccinations’ pages.

A conjugated meningococcal ACWY vaccine is the preferred vaccine for all travellers. Full details of vaccines and schedules can be found in the meningococcal chapter of Immunisation against infectious diseases (the ‘Green Book’) and the manufacturer’s Summary of Product Characteristics [4].

In order to lower the rate of carriers, visitors arriving from countries in the African meningitis belt (Benin, Burkina Faso, Cameroon, Chad, Central African Republic, Côte d’Ivoire, Eritrea, Ethiopia, Gambia, Guinea, Guinea-Bissau, Mali, Niger, Nigeria, Senegal and the Sudan) will be administered ciprofloxacin tablets (500 mg) at the port of entry, in addition to the requirement for proof of vaccination against meningococcal meningitis ACW135Y [2].

Polio: All travellers arriving from polio-endemic countries and re-established transmission countries (Afghanistan, Chad, Nigeria and Pakistan), regardless of age and vaccination status, should receive one dose of oral polio vaccine (OPV). As part of visa application, visitors from these countries must provide proof of polio vaccination, at least six weeks prior to departure. These travellers will also receive a dose of OPV at border points on arrival in KSA [2].

All travellers from recently endemic countries at high risk of re-importation of polio, such as India have the same entry requirements.

All visitors age under 15 years travelling to KSA from countries reporting polio following importation or due to circulating vaccine-derived polio in the past 12 months (Chad, Kenya, Niger, Somalia and Yemen) should be vaccinated against polio with the OPV.

Proof of polio vaccination is required 6 weeks prior to the application for entry visa. Irrespective of previous immunisation history, all visitors under 15 years of age arriving in KSA will receive an additional dose of OPV at border points [2].

All pilgrims to Hajj and Umrah are advised to ensure their polio vaccination is up-to-date. Travellers whose last dose of polio was 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 ICVP documenting yellow fever vaccination completed in accordance with International Health Regulations (2005) [5]. This requirement will be enforced. Risk countries are listed by the WHO in International Travel and Health 2012, Annex 1 [6].

Hajj and Umrah: recommended vaccinations:

General vaccination advice for travellers to KSA can be found on the NaTHNaC Country Information Page. All pilgrims should ensure that they are up-to-date with routine immunisations including measles, mumps and rubella (MMR).

The following vaccine-preventable diseases have particular relevance to Hajj and Umrah pilgrims.

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 [7]. 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.

Meningococcal ACWY: Meningococcal meningitis has occurred during previous Hajj pilgrimages and has spread to other countries in association with returning pilgrims [8]. A conjugated meningococcal ACWY vaccine is the preferred vaccine for all travellers. Vaccination is advised for personal protection of all pilgrims, including those under the age of two years and is a visa requirement.

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. A three dose course of rabies vaccine given pre-exposure simplifies post exposure rabies treatment and removes the need for post exposure rabies immunoglobulin, which is in short supply worldwide.

Seasonal influenza: The MOH, KSA recommends that international pilgrims be vaccinated against seasonal influenza before arrival into KSA, particularly those at increased risk of severe influenza diseases, including pregnant women, children under five years, the elderly, individuals with underlying health conditions such as HIV/AIDS, asthma and chronic heart or lung diseases [2].

Influenza is transmitted via the respiratory route and is easily transmitted in crowded conditions. Certain groups are at particular risk of complications from influenza including those aged 65 years and older, pregnant women and those with pre-existing medical conditions such as chest, heart, liver or kidney conditions, a history of splenectomy, or diabetes [9] (see MOH KSA recommendations on travel for these risk groups). Travellers who fall into any relevant risk categories should receive influenza vaccine annually from their usual healthcare provider. For those who do not fall into any of these risk categories, vaccine can be purchased and administered at some high street pharmacies, other retailers, or private travel clinics.

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. Advice about the prevention of influenza can be found on the NaTHNaC Health Information Sheet on seasonal influenza.

Severe respiratory illness

Middle East respiratory syndrome coronavirus (MERS-CoV):

From September 2012 to date, a small number of cases of a respiratory illness, caused by a novel coronavirus infection (MERS-CoV), have been identified in a number of countries in the Middle East including (Jordan, KSA, Qatar, United Arab Emirates) and in persons returning from travel to the Middle East (or persons linked to them) in other countries (including France, Germany, Italy, Tunisia and UK). This infection, now named Middle East respiratory syndrome (MERS-CoV), has in some cases, caused severe illness and death [10]. The risk of contracting MERS-CoV during travel is very low [11].

MERS-COV Precautions: The Ministry of Health, KSA recommends that the following groups postpone the performance of the Hajj and Umrah this year for their own safety:

The elderly (above 65 years of age).

Those with chronic diseases (e.g. heart, kidney or respiratory disease, diabetes), immune deficiency (congenital and acquired), malignancy and terminal illnesses.

Pregnant women and children (under 12 years) [2].

The Ministry of Health, KSA also advises all pilgrims comply with the following measures:

Wash hands with soap and water or disinfectant, especially after coughing and sneezing.

Use disposable tissues when coughing or sneezing and dispose it in the waste basket.

Try as much as possible to avoid hand contact with the eyes, nose and mouth.

Avoid direct contact with infected persons (people with symptoms such as cough, sneeze, expectoration, vomiting, and diarrhoea).

Wear masks, especially when in crowded places.

Maintain good personal hygiene [2].

The World Health Organization does not currently advise special screening relating to MERS-CoV at points of entry or any travel or trade restrictions [12]. The situation continues to be monitored and travel advice will be reviewed as information becomes available [13]. Health Professionals are advised to consult NaTHNaC clinical updates on MERS-CoV for up to date information.

Travellers returning from the Middle East with mild respiratory symptoms are most likely to have a common respiratory illness such as a cold. However, if symptoms worsen considerably with breathlessness, medical advice should be sought from the GP or NHS Direct. Returning travellers should mention which countries of the Middle East they have visited.

Further information for health professionals is available on thePublic Health England website.

Other health considerations and advice

Accidents and injuries

Minor injuries are relatively common, particularly 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 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

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. An anti-motility agent such as loperamide can be carried and an antibiotic considered, especially for those travellers who have an underlying medical condition. Ciprofloxacin (500mg twice daily for up to three days) in the absence of contraindications is generally the antibiotic of choice for adults.

Hajj and Umrah pilgrims are not allowed to bring fresh food into KSA. Only properly canned or sealed food or food stored in containers with easy access for inspection is allowed in small quantities, sufficient for one person for the duration of their trip [2].

Menstruation: Women who anticipate their periods occurring during the Hajj may wish to delay menstruation, which is possible to achieve using hormonal treatment. Women should discuss this with their GP or family planning clinic well before departure.

Physical fitness: Performing the rituals of Hajj is demanding and involves walking great distances usually in hot weather. Pilgrims should ensure that they are physically fit before travelling.

Vector-borne diseases

Malaria is not present in Medina or Makkah, but malaria is a risk in the south-western, rural region of KSA. Pilgrims planning further travel before or after Hajj or Umrah to malaria risk areas in KSA or Asia, Africa and Latin America, should seek advice about malaria prevention. Pilgrims are advised to practiseinsect bite avoidance measures that will reduce the risk of other vector-borne diseases, such as dengue fever.

Other advice

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.

Further information on health risks for travellers to KSA can be found on the NaTHNaC Saudi Arabia Country Information Page. Pilgrims should also seek advice about the health risks for any travel that may be undertaken either before or following Hajj or Umrah. Information on health risks for other destinations throughout the world can be found on the NaTHNaC Country Information Pages.

References

1. The Council of British Hajjis. Hajj dates 2013. [Accessed 8 October, 2013]. Available at:

http://dobuy.co.uk/cbhuk/?s=Hajj+dates

2. Kingdom of Saudi Arabia. Ministry of Health. Health Regulations for travellers to Saudi Arabia for Umrah & Pilgrimage (Hajj)-1434 (2013). July 2013. [Accessed 8 Oct, 2013]. Available at:

http://www.moh.gov.sa/en/Hajj/Pages/HealthRegulations.aspx

3. Kingdom of Saudi Arabia. Ministry of Hajj. Hajj Visas. [Accessed 8 October, 2013]. Available at:

http://www.hajinformation.com/main/t1510.htm

4. Meningococcal Ch 22. In: Salisbury D, Ramsay M, Noakes K (eds). Immunisation against infectious disease. 2006. Updated 7 May 2013. Department of Health, London. [Accessed 8 October, 2013]. Available at:

https://www.gov.uk/government/publications/meningococcal-the-green-book-chapter-22

5. World Health Organization. International Health Regulations (2005). [Accessed 8 October, 2013]. Available at:

http://www.who.int/topics/international_health_regulations/en/

6. World Health Organization. International and travel health. 2012; World Health Organization, Geneva. [Accessed 8 October, 2013]. Available at:

http://www.who.int/ith/en/

7. Memish ZA. The Hajj: Communicable and non-communicable health hazards and current guidance for pilgrims. Eurosurveillance. 15(39); 30 September 2010. [Accessed 8 October, 2013]. Available at:http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19671

8. World Health Organization. 2001 – Meningococcal disease, serogroup W135 – update. 16 May 2001 [Accessed 8 October, 2013]. Available at:

http://www.who.int/csr/don/2001_05_16/en/.

9. Influenza. Chapter 19. In: Salisbury D, Ramsay M, Noakes K (eds). Immunisation against infectious disease. 2006. Updated 11 September, 2013. Department of Health, London. [Accessed 8 October, 2013]. Available at:

https://www.gov.uk/government/publications/influenza-the-green-book-chapter-19

10. World Health Organization. Middle East respiratory syndrome coronavirus (MERS-Cov) summary and literature update – as of 20 September 2013. [Accessed 8 October, 2013]. Available at:

http://www.who.int/csr/disease/coronavirus_infections/update_20130920/en/index.html

11. Public Health England. Risk Assessment Novel Coronavirus 2012. Last updated January 2013. [Accessed 8 October, 2013]. Available at:http://www.hpa.org.uk/webc/HPAwebFile/HPAweb

_C/1317137939035

12. World Health Organization. World – travel advice on MERS_CoV for pilgrimages. 25 July 2013. [Accessed 8 October, 2013]. Available at:http://www.who.int/ith/updates/20130725/en/index.html

13. World Health Organization. International travel and health. Middle East respiratory syndrome - coronavirus (MERS-CoV) - update. 4 October, 2013. [Accessed 8 October, 2013]. Available at:

http://www.who.int/csr/don/2013_10_04/en/index.html

Last updated: October 2013

Source - http://www.nathnac.org/pro/factsheets/hajj_umrah.htm