Saudi Arabia: Hajj/Umrah Pilgrimage
The Hajj and Umrah are religious pilgrimages to Mecca, Saudi Arabia. Islamic religious doctrine dictates that every able-bodied adult Muslim who can afford to do so is required to make Hajj at least once in his or her lifetime. Hajj takes place from the 8th through the 12th day of Dhul Hijah, the last month of the Islamic year. Because the Islamic calendar is lunar, the timing of Hajj varies with respect to the Gregorian calendar, occurring about 11 days earlier the following year (for example, it was held September 22–27 in 2015 and September 10–14 in 2016). Umrah is called the “minor pilgrimage,” can be completed at any time of the year, and is not compulsory.
More than 2 million Muslims from over183 countries make Hajj each year (approximately 2.8 million in 2010); more than 11,000 pilgrims travel from the United States. The Kingdom of Saudi Arabia (KSA) continues to undertake engineering efforts to allow for an even greater number of pilgrims. Most international pilgrims fly into Jeddah or Medina and take a bus to Mecca. Pilgrims travel by foot or by bus approximately 5 miles (8 km) to the tent city of Mina, the largest temporary city in the world, where most pilgrims are housed in air-conditioned tents.
At dawn on the 9th day of Dhul Hijah, pilgrims begin a nearly 9 mile (14.4 km) walk, bus ride, or train ride to the plain of Arafat, passing Muzdalifah along the way (Map 4-2). Though the route features mist sprinklers to mitigate the oppressive daytime temperatures (which can reach 122°F [50°C]), the risk of heat-related illnesses during this part of the journey is still high. Ambulances and medical stations along the route are available for medical assistance. Hajj climaxes on the Plain of Arafat, a few miles east of Mecca. Pilgrims spend the day in supplication, praying and reading the Quran. The presence on Arafat, even if only for a few moments, on the ninth day of Dhul Hijah is an absolute rite of Hajj. If the pilgrim fails to reach the Plain of Arafat on that day, the Hajj is invalid and will have to be repeated. After sunset, pilgrims begin the 5.5 mile (9 km) journey back to Muzdalifah, where most sleep in the open air. Dust, inadequate and overcrowded washing and sanitation facilities, and the possibility of getting separated or lost are some potential problems pilgrims face.
At sunrise on the 10th day of Dhul Hijah, pilgrims collect small pebbles at Muzdalifah and carry them to Mina. This day’s ritual is called the Stoning of the Devil at Jamaraat. During this ritual, pilgrims throw 7 tiny pebbles (specifically, no larger than a chickpea) at the largest of 3 white pillars. The crowded conditions at this site pose potential hazards; multiple deadly crowd crush disasters have occurred at and around Mina.
Traditionally after Jamaraat, pilgrims sacrifice an animal. Pilgrims have the option to purchase a “sacrifice voucher” in Mecca and have this sacrifice performed by proxy. Centralized, licensed abattoirs perform the sacrifice on behalf of the pilgrim, limiting the exposure of pilgrims to potential zoonotic diseases. However, some pilgrims may visit farms where they either sacrifice an animal themselves or have it done by an appointed representative. The World Health Organization recommends travelers visiting farms or other areas where animals are present practice general hygiene measures, including regular handwashing before and after touching animals and avoiding contact with sick animals. Travelers should avoid the consumption of raw or undercooked animal products (including milk and meat).
After returning to Mecca, pilgrims go immediately to the Grand Mosque, which contains the Ka’aba, and perform a tawaf , which involves circling the Ka’aba 7 times counterclockwise. Because of the vast number of people (each floor of the 3-level mosque has a capacity of 750,000 people), performing a tawaf can take hours. In addition to tawaf , pilgrims may perform sa’i , walking (and running during certain parts) 7 times between the hills of Safa and Marwah, and then drinking water from the Well of Zamzam. This route is enclosed by the Grand Mosque and can be traversed via air-conditioned tunnels, with separate sections for walkers, runners, and disabled pilgrims. Pilgrims then return to Mina and pelt all three columns at the Jamaraat on the 11th and 12th of the month, with the option of repeating it on the 13th.
After performing a final tawaf , pilgrims leave Mecca, ending Hajj. Although it is not required as part of Hajj, many pilgrims extend their trips to travel to Medina. In Medina, pilgrims visit the Mosque of the Prophet, which contains the tomb of Mohammed. Physicians should query patients about their itineraries to ensure they have adequate medication and supplies for the length of their trip.
The Kingdom of Saudi Arabia (KSA) sets medical requirements such as proof of vaccination as part of the visa application process for Hajj pilgrims. These vaccinations may include seasonal influenza, H1N1, and meningitis. Health experts in KSA currently advise that the elderly, the terminally ill, pregnant women, and children postpone their plans for Hajj and Umrah for safety reasons. KSA may also choose to limit issuance of visas to travelers from countries experiencing infectious disease outbreaks. In 2012, Uganda was not permitted to send pilgrims due to an Ebola outbreak in that country, and the same restriction applied to Liberia, Guinea, and Sierra Leone in 2015. Multiple medical facilities are located in and around the holy sites; medical services are offered free of charge to pilgrims. An estimated 20,000 health care workers were in attendance during the 2012 Hajj.
CDC recommends all travelers to Saudi Arabia be up-to-date with routine immunizations. In addition, hepatitis A vaccine is recommended for most travelers, and hepatitis B vaccine is recommended for travelers who might be exposed to blood or other body fluids. Travelers from yellow fever–endemic countries, or those who travel via these areas, must provide proof of yellow fever vaccination. Although a requirement for polio vaccine does not include adult pilgrims from the United States, it is best to ensure full vaccination against polio before travel. All pilgrims who travel from countries where polio is reported are required to show proof of polio vaccination at least 6 weeks prior to arrival in Saudi Arabia. In addition, a single dose of the polio vaccine is administered to all pilgrims in Saudi Arabia from countries where polio has been reported irrespective of previous immunization against the disease. The number of polio doses administered at ports of entry is about 500,000, representing more than 90% of eligible pilgrims.
The Kingdom of Saudi Arabia will not issue Hajj or Umrah visas without proof of meningococcal vaccination at least 10 days and no more than 3 years before arrival for polysaccharide vaccine and no more than 8 years before arrival for conjugate vaccine. (CDC recommends revaccination with conjugate vaccine after 5 years for people at continued risk.) All pilgrims must have received a single dose of quadrivalent ACWY vaccine and must show proof of vaccination on a valid International Certificate of Vaccination or Prophylaxis. Although the KSA Ministry of Health currently advises against travel to the Hajj for pregnant women or children, if they choose to travel these groups should receive meningococcal vaccination according to licensed indications for their age. These requirements are regularly updated on the Saudi Ministry of Hajj website and should be consulted before travel.
Current Hajj vaccination requirements are available from the following sources:
- Saudi Arabian Embassy (http://embassies.mofa.gov.sa/sites/usa/AR/Pages/default.aspx)
- Saudi Arabian Ministry of Hajj (http://haj.gov.sa/english/pages/default.aspx)
- Saudi Arabian Ministry of Health (www.moh.gov.sa/en/Hajj/HealthGuidelines/HealthGuidelinesBeforeHajj/Pages/default.aspx)
Respiratory tract infections are common during Hajj, with pneumonia being the most common cause of hospital admission. These risks underscore the need to follow recommendations from the Advisory Committee on Immunization Practices for pneumococcal conjugate and polysaccharide vaccines for pilgrims aged ≥65 years and for younger travelers with comorbidities.
Seasonal influenza vaccine is strongly recommended for all pilgrims. Behavioral interventions such as hand hygiene, wearing a face mask, cough etiquette, social distancing, and contact avoidance may mitigate respiratory illness among pilgrims. Pretravel advice about common respiratory conditions should include a general assessment for respiratory fitness, necessary vaccinations, and prescription of adequate supplies of portable respiratory medications (inhalers are easier to transport than nebulizers).
The crowded conditions during Hajj increase the probability of tuberculosis transmission. Risk is estimated to be about 10% in those with high level of exposure. Many pilgrims come from highly endemic areas and some arrive for Hajj with active pulmonary disease. Pilgrims are advised to see their doctors if they develop signs of active tuberculosis.
Middle East respiratory syndrome (MERS) is caused by the MERS coronavirus, which was first identified in Saudi Arabia in 2012. Cases have been identified in and around the Arabian Peninsula, and cases have also been exported to other countries, including the United States. The most common symptoms include fever, cough, and shortness of breath. However, myalgia, diarrhea, vomiting, abdominal pain, thrombocytopenia, and leukopenia have also been reported. The severity of illness has ranged from mild to severe, and approximately 40% of reported cases have been fatal. The role of animal-to-human transmission is unclear, but the virus has been found in camels in this region. The diagnosis can be suspected on clinical grounds and confirmed by PCR testing. More information is available in Chapter 3, Middle East Respiratory Syndrome (MERS).
Other Health and Safety Risks
Diarrheal disease is common during Hajj, and travelers should be educated on usual prevention measures and self-treatment. A pretravel visit should include discussions about prevention, oral rehydration strategies, antimotility agents, and emergency antibiotic use for treatment of travelers’ diarrhea. More information can be found in Chapter 2, Travelers’ Diarrhea.
Chafing caused by long periods of standing and walking in the heat can lead to fungal or bacterial skin infections. Clothing should be light, not restrictive, and changed often to maintain hygiene. Travelers should be advised to keep skin dry, use talcum powder, and be aware of any pain or soreness caused by garments. Any sores or blisters that develop should be disinfected and kept covered. Special attention should be paid to protect the feet, which are bare when inside the Grand Mosque. People with diabetes are at increased risk of skin infections.
Nasal ablution, called istinshaaq , is the practice of rinsing your nose with water before performing some rituals during the Hajj. Medical literature has identified cases of primary amebic meningoencephalitis (PAM) caused by Naegleria fowleri transmitted as a result of nasal ablution. Nasal ablution is common during Hajj, and pilgrims are advised to use safe water to protect themselves from this potential risk (see Chapter 2, Water Disinfection for Travelers).
At the end of Hajj, Muslim men must shave their heads. The use of unclean blades can transmit bloodborne pathogens, such as hepatitis B virus, hepatitis C virus, and HIV. Licensed barbers are tested for these bloodborne pathogens and are required to use disposable, single-use blades. Unfortunately, unlicensed barbers continue to operate by the roadside, where they use nonsterile blades on multiple men. Male travelers should be advised to be shaved only at officially designated centers, which are clearly marked.
Aedes and Anopheles mosquitoes, which transmit dengue and malaria, respectively, are present in Saudi Arabia, and mosquito bite prevention measures are advisable. Dengue has been documented in Mecca but not during Hajj. Intensive insecticide spraying campaigns are undertaken before Hajj, and the housing units of pilgrims arriving from endemic areas are especially targeted before their arrival. Prophylaxis against malaria is not required.
Noncommunicable Diseases and Other Hazards
Hajj is arduous even for young, healthy pilgrims, and many Muslims may wait until they are older before making Hajj. Travelers who are caught up in the experience of Hajj or Umrah may forget to take their usual medications. People with chronic medical conditions should undergo a functional assessment before leaving for Hajj. The medical provider should identify each traveler’s unique risks and tailor a plan for how to reduce them. The provider should make any adjustments to the usual medical regimen, ensure that the traveler has an adequate supply of medications, and educate the traveler about symptoms that should prompt urgent medical attention.
Heat exhaustion and heatstroke are a threat to the health and well-being of travelers, can exacerbate chronic conditions, and are a leading cause of death, particularly when Hajj occurs during the summer months. Pilgrims should stay hydrated, wear sunscreen, and seek shade when possible. Umbrellas are frequently used to provide portable sun protection. Travelers should be counseled on minimizing the risk of heat-related injuries, as well as sun avoidance. Some rituals may also be performed at night to avoid daytime heat. Pilgrims can be reassured that religious leaders have deemed night rituals as legitimate. Except for the absolute presence on Arafat on the ninth of Dhul Hijah, most compulsory rituals can be postponed or done by proxy, or a penalty can be paid.
Fire is a potential risk at Hajj. In 1997, open stoves set tents on fire, and the resulting blaze killed 343 pilgrims and injured more than 1,500. As a result, makeshift tents were replaced with permanent fiberglass structures; pilgrims are not allowed to set up their own tents or prepare their own food. Cooking in the tents is also prohibited. In 2015, a hotel caught fire, leading to the evacuation of more than 1,000 pilgrims.
Trauma is a major cause of injury and death during Hajj. Motor vehicle crashes are the primary risk for US travelers overseas, and pilgrims may walk long distances through or near dense traffic. In such dense crowds, crush disasters (or “stampedes”) are also a risk. In 2004, after 251 pilgrims were killed and another 244 injured, the Saudi government replaced the round pillars with wide, elliptical columns to reduce crowd densities. After another crowd crush in 2006 that killed 280 pilgrims and injured 289, the single-tiered Jamaraat pedestrian bridge was demolished and replaced with a wider, multilevel bridge. In 2015, thousands of pilgrims were killed during a crush at Mina, making it the deadliest Hajj disaster on record. Death usually results from asphyxiation or head trauma, and large crowds limit the movement of emergency medical services, making prompt treatment difficult.
Special Health Considerations
Menstruating women are not permitted to perform tawaf around the Ka’aba, one of the obligatory rituals. All other rituals are independent of menses. Pilgrims generally know well in advance that they will be making Hajj/Umrah and female pilgrims are advised to consult their doctors 2–3 months before the journey if they intend to manipulate their periods before the pilgrimage.
Chronic Health Conditions
Close to 64% of admissions to intensive care units and 46%–66% of deaths among pilgrims during Hajj are caused by cardiovascular conditions. Physicians should ensure any preexisting conditions are stabilized and advise travelers on prudent activities during the pilgrimage. Pilgrims with heart disease should carry a supply of all their medications, including copies of all prescriptions.
Diabetic pilgrims should carefully construct a diabetes management plan tailored to the physical challenges of the Hajj and the traveler’s specific needs. Diabetic travelers should ensure adequate prescriptions for all medications, including syringes and needles. A diabetes emergency kit should include easily accessible carbohydrate sources to counter hypoglycemia, glucometer and test strips, urine ketone sticks to evaluate for ketoacidosis, a list of medications and care plans, and glucagon as indicated. Lastly, durable and protective footwear is necessary to avoid minor foot trauma that can lead to infections.
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Salim Parker, Joanna Gaines