Seasonal Influenza and Avian Influenza A(H5N1) Virus Surveillance among Inpatients and Outpatients, East Jakarta, Indonesia, 2011-2014.

During October 2011-September 2014, we screened respiratory specimens for seasonal and avian influenza A(H5N1) virus infections among outpatients with influenza-like illness and inpatients with severe acute respiratory infection (SARI) in East Jakarta, an Indonesia district with high incidence of H5N1 virus infection among poultry. In total, 31% (1,875/6,008) of influenza-like illness case-patients and 15% (571/3,811) of SARI case-patients tested positive for influenza virus. Influenza A(H1N1)pdm09, influenza A(H3N2), and influenza B virus infections were detected in all 3 years, and the epidemic season extended from November through May. Although 28% (2,810/10,135) of case-patients reported exposure to poultry, only 1 SARI case-patient with an H5N1 virus infection was detected. Therefore, targeted screening among case-patients with high-risk poultry exposures (e.g., a recent visit to a live bird market or close proximity to sick or dead poultry) may be a more efficient routine surveillance strategy for H5N1 virus in these types of settings.

INA-RESPOND: a multi-centre clinical research network in Indonesia.

Nationally representative observational and translational research is needed to address the public health challenges in Indonesia due to the geographic disparity, recently decentralized health system, and diverse infectious disease priorities. To accomplish this, the Indonesian Ministry of Health in collaboration with the US National Institute of Health has established INA-RESPOND (Indonesia Research Partnership on Infectious Disease) - a clinical research network comprising 9 referral hospitals, 7 medical faculties, and 2 research centres across Indonesia. The network provides a forum to conduct research at a national scale and to address scientific questions that would be difficult to address in smaller research settings. Further, it is currently conducting multi-centre research on the etiologies of fever, sepsis, and tuberculosis. There are opportunities to leverage existing network resources for other public health research needs. INA-RESPOND is an Indonesian-led network in a country with diverse population groups and public health needs which is poised to collaborate with researchers, universities, donors, and industry worldwide. This paper describes the network and its goals and values, as well as the management structure, process for collaboration, and future vision.

Genetic characterization of clade 2.3.2.1 avian influenza A(H5N1) viruses, Indonesia, 2012.

After reports of unusually high mortality rates among ducks on farms in Java Island, Indonesia, in September 2012, influenza A(H5N1) viruses were detected and characterized. Sequence analyses revealed all genes clustered with contemporary clade 2.3.2.1 viruses, rather than enzootic clade 2.1.3 viruses, indicating the introduction of an exotic H5N1 clade into Indonesia.

Influenza seasonality and vaccination timing in tropical and subtropical areas of southern and south-eastern Asia.

OBJECTIVE: To characterize influenza seasonality and identify the best time of the year for vaccination against influenza in tropical and subtropical countries of southern and south-eastern Asia that lie north of the equator. METHODS: Weekly influenza surveillance data for 2006 to 2011 were obtained from Bangladesh, Cambodia, India, Indonesia, the Lao People's Democratic Republic, Malaysia, the Philippines, Singapore, Thailand and Viet Nam. Weekly rates of influenza activity were based on the percentage of all nasopharyngeal samples collected during the year that tested positive for influenza virus or viral nucleic acid on any given week. Monthly positivity rates were then calculated to define annual peaks of influenza activity in each country and across countries. FINDINGS: Influenza activity peaked between June/July and October in seven countries, three of which showed a second peak in December to February. Countries closer to the equator had year-round circulation without discrete peaks. Viral types and subtypes varied from year to year but not across countries in a given year. The cumulative proportion of specimens that tested positive from June to November was > 60% in Bangladesh, Cambodia, India, the Lao People's Democratic Republic, the Philippines, Thailand and Viet Nam. Thus, these tropical and subtropical countries exhibited earlier influenza activity peaks than temperate climate countries north of the equator. CONCLUSION: Most southern and south-eastern Asian countries lying north of the equator should consider vaccinating against influenza from April to June; countries near the equator without a distinct peak in influenza activity can base vaccination timing on local factors.

Application of WHO's guideline for the selection of sentinel sites for hospital-based influenza surveillance in Indonesia.

BACKGROUND: A sentinel hospital-based severe acute respiratory infection (SARI) surveillance system was established in Indonesia in 2013. Deciding on the number, geographic location and hospitals to be selected as sentinel sites was a challenge. Based on the recently published WHO guideline for influenza surveillance (2012), this study presents the process for hospital sentinel site selection. METHODS: From the 2,165 hospitals in Indonesia, the first step was to shortlist to hospitals that had previously participated in respiratory disease surveillance systems and had acceptable surveillance performance history. The second step involved categorizing the shortlist according to five regions in Indonesia to maximize geographic representativeness. A checklist was developed based on the WHO recommended attributes for sentinel site selection including stability, feasibility, representativeness and the availability of data to enable disease burden estimation. Eight hospitals, a maximum of two per geographic region, were visited for checklist administration. Checklist findings from the eight hospitals were analyzed and sentinel sites selected in the third step. RESULTS: Six hospitals could be selected based on resources available to ensure system stability over a three-year period. For feasibility, all eight hospitals visited had mechanisms for specimen shipment and the capacity to report surveillance data, but two had limited motivation for system participation. For representativeness, the eight hospitals were geographically dispersed around Indonesia, and all could capture cases in all age and socio-economic groups. All eight hospitals had prerequisite population data to enable disease burden estimation. The two hospitals with low motivation were excluded and the remaining six were selected as sentinel sites. CONCLUSIONS: The multi-step process enabled sentinel site selection based on the WHO recommended attributes that emphasize right-sizing the surveillance system to ensure its stability and maximizing its geographic representativeness. This experience may guide other countries interested in adopting WHO's influenza surveillance standards for sentinel site selection.

Managing seasonal influenza: oseltamivir treatment policy in indonesia?

To manage cases of avian influenza A/H5N1 virus infection and in anticipation of a pandemic triggered by this virus, Indonesia purchased and distributed oseltamivir to the government health facilities. Oseltamivir is an antiviral drug that was developed for the treatment of influenza infections. Disease surveillance and research suggests that seasonal influenza (A/H1N1, A/H3N2 or B) results in considerable morbidity and mortality in Indonesia, where over 15% of influenza-like illness and severe acute respiratory illness patients test positive for the influenza virus. Indonesia currently limits oseltamivir for the management of avian influenza A/H5N1cases and in anticipation of a pandemic triggered by the A/H5N1 virus. We present the evidence for the use of oseltamivir in the treatment of seasonal influenza infections so that doctors have the option to prescribe the drug. We propose that the benefits of this approach will largely outweigh the risk of antiviral resistance. We recommend that oseltamivir be available for administration to patients with seasonal influenza infections, especially for those hospitalized and for groups with high risk of complications and adverse outcomes. Overall, this will reduce morbidity and mortality of seasonal influenza.

Investing in health preparedness, response and resilience: a genomics costing tool focused on next generation sequencing.

The world has seen unprecedented gains in the global genomic surveillance capacities for pathogens with pandemic and epidemic potential within the last 4 years. To strengthen and sustain the gains made, WHO is working with countries and partners to implement the Global Genomic Surveillance Strategy for Pathogens with Pandemic and Epidemic Potential 2022-2032. A key technical product developed through these multi-agency collaborative efforts is a genomics costing tool (GCT), as sought by many countries. This tool was developed by five institutions - Association of Public Health Laboratories, FIND, The Global Fund to Fight AIDS, Tuberculosis and Malaria, UK Health Security Agency, and the World Health Organization. These institutions developed the GCT to support financial planning and budgeting for SARS-CoV-2 next-generation sequencing activities, including bioinformatic analysis. The tool costs infrastructure, consumables and reagents, human resources, facility and quality management. It is being used by countries to (1) obtain costs of routine sequencing and bioinformatics activities, (2) optimize available resources, and (3) build an investment case for the scale-up or establishment of sequencing and bioinformatics activities. The tool has been validated and is available in English and Russian at https://www.who.int/publications/i/item/9789240090866. This paper aims to highlight the rationale for developing the tool, describe the process of the collaborative effort in developing the tool, and describe the utility of the tool to countries.

Strengthening pathogen genomic surveillance for health emergencies: insights from the World Health Organization's regional initiatives.

The onset of the COVID-19 pandemic triggered a rapid scale-up in the use of genomic surveillance as a pandemic preparedness and response tool. As a result, the number of countries with in-country SARS-CoV-2 genomic sequencing capability increased by 40% from February 2021 to July 2022. The Global Genomic Surveillance Strategy for Pathogens with Pandemic and Epidemic Potential 2022-2032 was launched by the World Health Organization (WHO) in March 2022 to bring greater coherence to ongoing work to strengthen genomic surveillance. This paper describes how WHO's tailored regional approaches contribute to expanding and further institutionalizing the use of genomic surveillance to guide pandemic preparedness and response measures as part of a harmonized global undertaking. Challenges to achieving this vision include difficulties obtaining sequencing equipment and supplies, shortages of skilled staff, and obstacles to maximizing the utility of genomic data to inform risk assessment and public health action. WHO is helping to overcome these challenges in collaboration with partners. Through its global headquarters, six regional offices, and 153 country offices, WHO is providing support for country-driven efforts to strengthen genomic surveillance in its 194 Member States, with activities reflecting regional specificities. WHO's regional offices serve as platforms for those countries in their respective regions to share resources and knowledge, engage stakeholders in ways that reflect national and regional priorities, and develop regionally aligned approaches to implementing and sustaining genomic surveillance within public health systems.

Application of a healthy food markets guide to two Indonesian markets to reduce transmission of "avian flu".

PROBLEM: The World Health Organization (WHO) developed a guideline with 10 control measures to reduce transmission of A(H5N1) avian influenza virus in markets in low-resource settings. The practical aspects of guide implementation have never been described. APPROACH: WHO's guideline was implemented in two Indonesian markets in the city of Makassar to try to reduce transmission of the A(H5N1) virus. The guideline was operationalized using a participatory approach to introduce a combination of infrastructural and behavioural changes. LOCAL SETTING: Avian influenza is endemic in birds in Makassar. Two of the city's 22 dilapidated, poorly-run bird markets were chosen for the study. Before the intervention, neither market was following any of WHO's 10 recommended control measures except for batch processing. RELEVANT CHANGES: Market stakeholders' knowledge about the avian influenza A(H5N1) virus improved after the interventions. WHO guideline recommendations for visual inspection, cleaning and poultry-holding practices, as well as infrastructural requirements for zoning and for water supply and utilities, began to conform to the WHO guideline. Low-maintenance solutions such as installation of wastewater treatment systems and economic incentives such as composting were well received and appropriate for the low-resource setting. LESSONS LEARNT: Combining infrastructural changes with behaviour change interventions was critical to guideline implementation. Despite initial resistance to behaviour change, the participatory approach involving monthly consultations and educational sessions facilitated the adoption of safe food-handling practices and sanitation. Market authorities assumed important leadership roles during the interventions and this helped shift attitudes towards regulation and market maintenance needs. This shift may enhance the sustainability of the interventions.

Serving the Vulnerable: The World Health Organization's Scaled Support to Countries During the First Year of the COVID-19 Pandemic.

The Inter-Agency Standing Committee (IASC), created by the United Nations (UN) General Assembly in 1991, serves as the global humanitarian coordination forum of the UN s system. The IASC brings 18 agencies together, including the World Health Organization (WHO), for humanitarian preparedness and response policies and action. Early in the COVID-19 pandemic, the IASC recognized the importance of providing intensified support to countries with conflict, humanitarian, or complex emergencies due to their weak health systems and fragile contexts. A Global Humanitarian Response Plan (GHRP) was rapidly developed in March 2020, which reflected the international support needed for 63 target countries deemed to have humanitarian vulnerability. This paper assessed whether WHO provided intensified technical, financial, and commodity inputs to GHRP countries (n = 63) compared to non-GHRP countries (n = 131) in the first year of the COVID-19 pandemic. The analysis showed that WHO supported all 194 countries regardless of humanitarian vulnerability. Health commodities were supplied to most countries globally (86%), and WHO implemented most (67%) of the $1.268 billion spent in 2020 at country level. However, proportionally more GHRP countries received health commodities and nearly four times as much was spent in GHRP countries per capita compared to non-GHRP countries ($232 vs. $60 per 1,000 capita). In countries with WHO country offices (n = 149), proportionally more GHRP countries received WHO support for developing national response plans and monitoring frameworks, training of technical staff, facilitating logistics, publication of situation updates, and participation in research activities prior to the characterization of the pandemic or first in-country COVID-19 case. This affirms WHO's capacity to scale country support according to its humanitarian mandate. Further work is needed to assess the impact of WHO's inputs on health outcomes during the COVID-19 pandemic, which will strengthen WHO's scaled support to countries during future health emergencies.

Risk factors for cluster outbreaks of avian influenza A H5N1 infection, Indonesia.

BACKGROUND: By 30 July 2009, Indonesia had reported 139 outbreaks of avian influenza (AI) H5N1 infection in humans. Risk factors for case clustering remain largely unknown. This study assesses risk factors for cluster outbreaks and for secondary case infection. METHODS: The 113 sporadic and 26 cluster outbreaks were compared on household and individual level variables. Variables assessed include those never reported previously, including household size and genealogical relationships between cases and their contacts. RESULTS: Cluster outbreaks had larger households and more blood-related contacts, especially first-degree relatives, compared with sporadic case outbreaks. Risk factors for cluster outbreaks were the number of first-degree blood-relatives to the index case (adjusted odds ratio [aOR], 1.50; 95% confidence interval [CI]: 1.20-1.86) and index cases having direct exposure to sources of AI H5N1 virus (aOR, 3.20; 95% CI: 1.15-8.90). Risk factors for secondary case infection were being aged between 5 and 17 years (aOR, 8.32; 95% CI: 1.72-40.25), or 18 and 30 years (aOR, 6.04; 95% CI: 1.21-30.08), having direct exposure to sources of AI H5N1 virus (aOR, 3.48; 95% CI: 1.28-9.46), and being a first-degree relative to an index case (aOR, 11.0; 95% CI: 1.43-84.66). Siblings to index cases were 5 times more likely to become secondary cases (OR, 4.72; 95% CI: 1.67-13.35). CONCLUSIONS: The type of exposure and the genealogical relationship between index cases and their contacts impacts the risk of clustering. The study adds evidence that AI H5N1 infection is influenced by, and may even depend on, host genetic susceptibility.

Taeniasis/cysticercosis in Bali, Indonesia.

Taenia solium and Taenia saginata are found in humans in Bali, Indonesia. During a field survey of 660 people in Bali from 2002-2009 of taeniasis/cysticercosis cases using mitochondrial DNA confirmation of the species, we detected 80 cases of T. saginata taeniasis, 2 dual T. saginata/T. solium infections with T. solium metacestodes in the brain and 12 neurocysticercosis (NCC) cases at Sanglah Hospital, Denpasar. Although the prevalence of NCC in Bali is low, sporadic cases are still present. There is no Taenia asiatica in Bali. We summarize here the field survey findings of taeniasis, including 1 dual infection with taeniasis and cysticercosis in 2007, and the reason why there are no T. asiatica cases and we describe 3 NCC cases admitted to Sanglah Hospital, Denpasar, Bali in 2004. Diagnosis was based on anamnesis, clinical examination, including CT Scan, histopathological, serological and mitochondrial DNA examinations. In order to prevent unexpected symptomatic NCC after treatment with praziquantel, we recommend introducing a rapid test to confirm taeniasis carriers and cysticercosis cases as a tool for real time diagnosis.

The World Health Organization's Actions Within the United Nations System to Facilitate a Whole-of-Society Response to COVID-19 at Country Level.

The coronavirus disease (COVID-19) pandemic highlighted that managing health emergencies requires more than an effective health response, but that operationalizing a whole-of-society approach is challenging. The World Health Organization (WHO), as the lead agency for health within the United Nations (UN), led the UN response at the global level through the Crisis Management Team, and at the country level through the UN Country Teams (UNCTs) in accordance with its mandate. Three case studies-Mali, Cox's Bazar in Bangladesh, and Uzbekistan-provide examples of how WHO contributed to the whole-of-society response for COVID-19 at the country level. Interviews with WHO staff, supplemented by internal and external published reports, highlighted that the action of WHO comprised technical expertise to ensure an effective whole-of-society response and to minimize social disruption, including those affecting peacekeeping in Mali, livelihood sectors in Cox's Bazar, and the education sector in Uzbekistan. Leveraging local level volunteers from various sectors led to both a stronger public health response and the continuation of other sectoral work. Risk communication and community engagement (RCCE) emerged as a key theme for UN engagement at country level. These collective efforts of operationalizing whole-of-society response at the country level need to continue for the COVID-19 response, but also in preparedness for other health and non-health emergencies. Building resilience for future emergencies requires developing and exercising multi-sectoral preparedness plans and benefits from collective UN support to countries. Coronavirus disease had many impacts outside of health, and therefore emergency preparedness needs to occur outside of health too.

Environmental sampling for avian influenza virus A (H5N1) in live-bird markets, Indonesia.

To identify environmental sites commonly contaminated by avian influenza virus A (H5N1) in live-bird markets in Indonesia, we investigated 83 markets in 3 provinces in Indonesia. At each market, samples were collected from up to 27 poultry-related sites to assess the extent of contamination. Samples were tested by using real-time reverse transcription-PCR and virus isolation. A questionnaire was used to ascertain types of birds in the market, general infrastructure, and work practices. Thirty-nine (47%) markets showed contamination with avian influenza virus in ≥ 1 of the sites sampled. Risk factors were slaughtering birds in the market and being located in West Java province. Protective factors included daily removal of waste and zoning that segregated poultry-related work flow areas. These results can aid in the design of evidence-based programs concerning environmental sanitation, food safety, and surveillance to reduce the risk for avian influenza virus A (H5N1) transmission in live-bird markets.

Strengthening Indonesia's Field Epidemiology Training Programme to address International Health Regulations requirements.

PROBLEM: According to the International Health Regulations (IHR), countries need to strengthen core capacity for disease surveillance and response systems. Many countries are establishing or enhancing their field epidemiology training programmes (FETPs) to meet human resource needs but face challenges in sustainability and training quality. Indonesia is facing these challenges, which include limited resources for field training and limited coordination in a newly decentralized health system. APPROACH: A national FETP workplan was developed based on an evaluation of the existing programme and projected human resource needs. A Ministry of Health Secretariat linking universities, national and international partners was established to oversee revision and implementation of the FETP. LOCAL SETTING: The FETP is integrated into the curriculum of Indonesian universities and field training is conducted in district and provincial health offices under the coordination of the universities and the FETP Secretariat. RELEVANT CHANGES: The FETP was included in the Ministry of Health workforce development strategy through governmental decree. Curricula have been enhanced and field placements strengthened to provide trainees with better learning experiences. To improve sustainability of the FETP, links were established with the Indonesian Epidemiologists' Association, local governments and donors to cultivate future FETP champions and maintain funding. Courses, competitions and discussion forums were established for field supervisors and alumni. These changes have increased the geographic distribution of students, intersectoral and international participation and the quality of student performance. LESSONS LEARNT: The main lesson learnt is that linkages with universities, ministries and international agencies such as the World Health Organization are critical for building a sustainable high-quality programme. The most critical factors were development of trusting relationships and clear definitions of the responsibilities of each stakeholder.

Pandemic influenza preparedness (PIP) framework: Progress challenges in improving influenza preparedness response capacities in the Eastern Mediterranean Region, 2014-2017.

Influenza viruses with pandemic potential have been detected in humans in the Eastern Mediterranean Region. The Pandemic Influenza Preparedness (PIP) Framework aims to improve the sharing of influenza viruses with pandemic potential and increase access of developing countries to vaccines and other life-saving products during a pandemic. Under the Framework, countries have been supported to enhance their capacities to detect, prepare for and respond to pandemic influenza. In the Eastern Mediterranean Region, seven countries are priority countries for Laboratory and Surveillance (L&S) support: Afghanistan, Djibouti, Egypt, Jordan, Lebanon, Morocco and Yemen. During 2014-2017, US$ 2.7 million was invested in regional capacity-building and US$ 4.6 million directly in the priority countries. Countries were supported to strengthen influenza diagnostic capacities to improve detection, enhance influenza surveillance systems including sentinel surveillance for severe acute respiratory infection and influenza-like illness, and increase global sharing of surveillance data and influenza viruses. This paper highlights the progress made in improving influenza preparedness and response capacities in the Region from 2014 to 2017, and the challenges faced. By 2017, 18 of the 22 countries of the Region had laboratory-testing capacity, 19 had functioning sentinel influenza surveillance systems and 22 had trained national rapid response teams. The number of countries correctly identifying all influenza viruses in the WHO external quality assurance panel increased from 9 countries scoring 100% in 2014 to 15 countries in 2017, and the number sharing influenza viruses with WHO collaborating centres increased by 75% (from eight to 14 countries); more than half now share influenza data with regional or global surveillance platforms. Seven countries have estimated influenza disease burden and seven have introduced influenza vaccination for high-risk groups. Challenges included: protracted complex emergencies faced by nine countries which hindered implementation of influenza surveillance in areas with the most needs, high staff turnover, achieving timely virus sharing and limited utilization of influenza data where they are available to inform vaccine policies or establish threshold values to measure the start and severity of influenza seasons.

Factors associated with case fatality of human H5N1 virus infections in Indonesia: a case series.

BACKGROUND: Indonesia has had the most human cases of highly pathogenic avian influenza A (H5N1) and one of the highest case-fatality rates worldwide. We described the factors associated with H5N1 case-fatality in Indonesia. METHODS: Between June, 2005, and February, 2008, there were 127 confirmed H5N1 infections. Investigation teams were deployed to investigate and manage each confirmed case; they obtained epidemiological and clinical data from case-investigation reports when possible and through interviews with patients, family members, and key individuals. FINDINGS: Of the 127 patients with confirmed H5N1 infections, 103 (81%) died. Median time to hospitalisation was 6 days (range 1-16). Of the 122 hospitalised patients for whom data were available, 121 (99%) had fever, 107 (88%) cough, and 103 (84%) dyspnoea on reaching hospital. However, for the first 2 days after onset, most had non-specific symptoms; only 31 had both fever and cough, and nine had fever and dyspnoea. Median time from onset to oseltamivir treatment was 7 days (range 0-21 days); treatment started within 2 days for one patient who survived, four (36.4%) of 11 receiving treatment within 2-4 days survived, six (37.5%) of 16 receiving treatment within 5-6 days survived, and ten (18.5%) of 44 receiving treatment at 7 days or later survived (p=0.03). Initiation of treatment within 2 days was associated with significantly lower mortality than was initiation at 5-6 days or later than 7 days (p<0.0001). Mortality was lower in clustered than unclustered cases (odds ratio 33.3, 95% CI 3.13-273). Treatment started at a median of 5 days (range 0-13 days) from onset in secondary cases in clusters compared with 8 days (range 4-16) for primary cases (p=0.04). INTERPRETATION: Development of better diagnostic methods and improved case management might improve identification of patients with H5N1 influenza, which could decrease mortality by allowing for earlier treatment with oseltamivir.

Three Indonesian clusters of H5N1 virus infection in 2005.

BACKGROUND: Since 2003, the widespread ongoing epizootic of avian influenza A (H5N1) among poultry and birds has resulted in human H5N1 cases in 10 countries. The first case of H5N1 virus infection in Indonesia was identified in July 2005. METHODS: We investigated three clusters of Indonesian cases with at least two ill persons hospitalized with laboratory evidence of H5N1 virus infection from June through October 2005. Epidemiologic, clinical, and virologic data on these patients were collected and analyzed. RESULTS: Severe disease occurred among all three clusters, including deaths in two clusters. Mild illness in children was documented in two clusters. The median age of the eight patients was 8.5 years (range, 1 to 38). Four patients required mechanical ventilation, and four of the eight patients (50%) died. In each cluster, patients with H5N1 virus infection were members of the same family, and most lived in the same home. In two clusters, the source of H5N1 virus infection in the index patient was not determined. Virus isolates were available for one patient in each of two clusters, and molecular sequence analyses determined that the isolates were clade 2 H5N1 viruses of avian origin. CONCLUSIONS: In 2005 in Indonesia, clusters of human infection with clade 2 H5N1 viruses included mild, severe, and fatal cases among family members.

Indonesian Hajj Cohorts and Mortality in Saudi Arabia from 2004 to 2011.

The Hajj is an annual pilgrimage that 1-2 million Muslims undertake in the Kingdom of Saudi Arabia (KSA), which is the largest mass gathering event in the world, as the world's most populous Muslim nation, Indonesia holds the largest visa quota for the Hajj. All Hajj pilgrims under the quota system are registered in the Indonesian government's Hajj surveillance database to ensure adherence to the KSA authorities' health requirements. Performance of the Hajj and its rites are physically demanding, which may present health risks. This report provides a descriptive overview of mortality in Indonesian pilgrims from 2004 to 2011. The mortality rate from 2004 to 2011 ranged from 149 to 337 per 100,000 Hajj pilgrims, equivalent to the actual number of deaths ranging between 501 and 531 cases. The top two mortality causes were attributable to diseases of the circulatory and respiratory systems. Older pilgrims or pilgrims with comorbidities should be encouraged to take a less physically demanding route in the Hajj. All pilgrims should be educated on health risks and seek early health advice from the mobile medical teams provided.