August 13, 2018

The Hajj – the annual pilgrimage to Mecca, Saudi Arabia, and the largest mass gathering in the world – is an annual event typically occurring during late August to early September. Officials often identify sporadic outbreaks of diarrhea, respiratory, or bloodborne diseases during and immediately following the Hajj. Those with pre-existing heart or respiratory conditions are more likely to experience negative health consequences when participating in Hajj events.

To protect the health and safety of the travelers and residents alike, Saudi authorities have mandated several immunizations. These include proof of vaccination against both meningococcal meningitis and yellow fever. Individuals arriving from countries within the African “Meningitis Belt” must be vaccinated against the disease prior to arrival in Saudi Arabia. Yellow fever vaccination is required of all travelers arriving from countries considered at risk for yellow fever transmission, which includes select countries in Africa and the Americas. Furthermore, the US CDC maintains an “Alert-Level 2” advisory due to the ongoing threat of Middle East Respiratory Syndrome (MERS) in Saudi Arabia and nearby countries within and near the Arabian Peninsula, highlighting the importance of being up-to-date on all routine and recommended vaccinations prior to departure.

Crowd Control

Large crowds present varied disease risks to individuals, particularly when groups of people congregate from many different parts of the world. Large crowds also present a significantly increased risk of physical trauma, cardiac (heart) events, dehydration and heat-related illnesses, and acute mental distress. Travelers participating in Hajj events should take special precautions to protect themselves from these risks.

According to international health officials, cardiovascular disease is the primary cause of death among Hajj pilgrims. The Hajj is arduous even for young, healthy individuals, and many Muslims wait until they are older before making the pilgrimage. The complexity and occasional chaos of traveling to and attending the Hajj can interfere with pilgrims’ ability to take their usual medication. Pilgrims with pre-existing cardiac (heart) conditions should consult a medical professional prior to travel; ensure they take an adequate supply of medication; adhere to their usual medication regimen, and immediately seek medical attention if they notice cardiac symptoms.

Finally, physical trauma is a major concern. Motor vehicle accidents are common. However, the most common trauma hazard is the possibility of a stampede. In the dense crowds that form during the Hajj, little can be done to avoid or escape a stampede once it has begun, and such events usually begin because of a minor incident. Deaths from stampede usually result from suffocation or head trauma and providing prompt medical care is almost impossible in large crowds. Travelers should avoid the most densely crowded areas and, when possible, perform rituals at nonpeak hours.

Prevention of Food- and Waterborne Illnesses

The pressure to serve such huge numbers of people also increases the potential for transmission of food- or waterborne diseases through food and beverage vendors. Diarrheal diseases are common during the Hajj, and travelers should practice general hand, food, and water hygiene. Travelers should drink only recognized brands of sealed bottled water or water that has been boiled or chemically treated. Pilgrims should regularly wash their hands with soap and water, or with alcohol-based hand sanitizer, especially before preparing or eating food.

Additional Concerns

Long rituals of standing and walking - combined with heat and sweating - can contribute to the risk for skin infections. Travelers should keep their skin dry, use talcum powder, and be aware of any pain or soreness caused by garments. Similarly, heat exhaustion and heatstroke are major causes of death, as temperatures in Mecca can exceed 37.8 C (100 F) in August and September. Pilgrims should stay hydrated, wear sunscreen, and seek shade when possible. Some rituals may also be performed at night to avoid daytime heat.

After the Hajj, many Muslim men shave their heads. Unclean razors can transmit bloodborne pathogens such as hepatitis B, hepatitis C, and HIV. Licensed barbers are tested for such pathogens and are required to use disposable, single-use blades. However, unlicensed barbers who may use nonsterile blades on multiple customers operate along roadsides. Pilgrims should only visit officially designated barbers, whose establishments are clearly marked.

Nonpilgrim travelers may encounter Hajj pilgrims en route, a fact which requires that all travelers be aware of the increased risk of infectious disease associated with international travel. Pilgrims may have been exposed to a variety of diseases, such as measles or polio, which can be avoided by ensuring a traveler is fully vaccinated against both routine and exotic diseases prior to departure.

WorldAware’s Health Intelligence team tracks and analyzes emerging and sustained outbreaks around the world. With Intel Central Health Intelligence, our analysts offer disease fact sheets and advice, articles on global health concerns, and health security assessment ratings so you can plan for mitigating health risks. 

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This blog is an updated version of an article previously published in 2017. 

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