Measuring the impact of suspending Umrah, a global mass gathering in Saudi Arabia on the COVID-19 pandemic.

Since the early days of the coronavirus (COVID-19) outbreak in Wuhan, China, Saudi Arabia started to implement several preventative measures starting with the imposition of travel restrictions to and from China. Due to the rapid spread of COVID-19, and with the first confirmed case in Saudi Arabia in March 2019, more strict measures, such as international travel restriction, and suspension or cancellation of major events, social gatherings, prayers at mosques, and sports competitions, were employed. These non-pharmaceutical interventions aim to reduce the extent of the epidemic due to the implications of international travel and mass gatherings on the increase in the number of new cases locally and globally. Since this ongoing outbreak is the first of its kind in the modern world, the impact of suspending mass gatherings on the outbreak is unknown and difficult to measure. We use a stratified SEIR epidemic model to evaluate the impact of Umrah, a global Muslim pilgrimage to Mecca, on the spread of the COVID-19 pandemic during the month of Ramadan, the peak of the Umrah season. The analyses shown in the paper provide insights into the effects of global mass gatherings such as Hajj and Umrah on the progression of the COVID-19 pandemic locally and globally.

Knowledge, attitudes and practices concerning Middle East respiratory syndrome among Umrah and Hajj pilgrims in Samsun, Turkey, 2015.

We performed a questionnaire study to determine knowledge, attitudes and practices concerning Middle East respiratory syndrome (MERS) among people intending to participate in the Hajj or Umrah Muslim pilgrimages. Of the 381 respondents aged between 17 and 85 years, 55% had never heard of MERS, while only one in three knew that it is a respiratory disease. Approximately half were insufficiently informed about protective measures. Prospective pilgrims do not seem prepared to take such precautions.

The relationship between hand hygiene and rates of acute respiratory infections among Umrah pilgrims: A pilot randomised controlled trial.

BACKGROUND: There is a lack of randomised controlled trials (RCTs) investigating the role of hand hygiene in preventing and containing acute respiratory infections (ARIs) in mass gatherings. In this pilot RCT, we assessed the feasibility of establishing a large-scale trial to explore the relationship between practising hand hygiene and rates of ARI in Umrah pilgrimage amidst the COVID-19 pandemic. METHODS: A parallel RCT was conducted in hotels in Makkah, Saudi Arabia, between April and July 2021. Domestic adult pilgrims who consented to participate were randomised 1:1 to the intervention group who received alcohol-based hand rub (ABHR) and instructions, or to the control group who did not receive ABHR or instructions but were free to use their own supplies. Pilgrims in both groups were then followed up for seven days for ARI symptoms. The primary outcome was the difference in the proportions of syndromic ARIs among pilgrims between the randomised groups. RESULTS: A total of 507 (control: intervention = 267: 240) participants aged between 18 and 75 (median 34) years were randomised; 61 participants were lost to follow-up or withdrew leaving 446 participants (control: intervention = 237:209) for the primary outcome analysis; of whom 10 (2.2 %) had developed at least one respiratory symptom, three (0.7 %) had 'possible ILI' and two (0.4 %) had 'possible COVID-19'. The analysis of the primary outcome found no evidence of difference in the proportions of ARIs between the randomised groups (odds ratio 1.1 [0.3-4.0] for intervention relative to control). CONCLUSION: This pilot trial suggests that conducting a future definitive RCT to assess the role of hand hygiene in the prevention of ARIs is feasible in Umrah setting amidst such a pandemic; however, outcomes from this trial are inconclusive, and such a study would need to be very large given the low rates of outcomes observed here. TRIAL REGISTRATION: This trial was registered in the Australian New Zealand Clinical Trials Registry (ANZCTR) (ACTRN12622001287729), the full protocol can be accessed there.

Hand hygiene knowledge and practices, and rates of respiratory tract infections between Hajj and Umrah pilgrims: a comparative study.

BACKGROUND: Hajj and Umrah mass gatherings (MGs) in the Kingdom of Saudi Arabia amplify the risk of viral respiratory tract infections (RTIs), but there is a lack of comparative data from these two MGs. This study aims to compare pilgrims' hand hygiene knowledge, practices, and rates of RTIs during the peak periods of Umrah and Hajj in 2021. MATERIALS AND METHODS: The datasets of this comparative study were obtained from two previously conducted studies that used similar study tools and identical syndromic definitions. The binary logistic regression was applied to compare the categorical variables and, a t-test was used to compare the continuous variables. RESULTS: A total of 510 Hajj pilgrims and 507 Umrah pilgrims were recruited. The majority of Hajj pilgrims (68%) were ≥ 40 years old, while most Umrah pilgrims (63%) were < 40 years old. The mean total knowledge scores of hand hygiene between the Hajj and Umrah pilgrims differed significantly (4.1 vs. 3.7, respectively, p < 0.001) so did their compliance with frequent use of alcohol-based hand rubs (53.0% vs. 36.3%, respectively, p < 0.001) and the rates of RTIs (4.7% vs. 2.2%, respectively, p = 0.05). CONCLUSIONS: These differences could be attributable to the distinctive characteristics of Hajj and Umrah pilgrimages, and the unique differences in risks posed by those MGs.

Public Health Challenges in Saudi Arabia during the COVID-19 Pandemic: A Literature Review.

Similar to most countries, Saudi Arabia faced several challenges during the novel coronavirus disease 2019 (COVID-19) pandemic, some of which were related to the religious position of the country. The main challenges included deficits in knowledge, attitudes, and practices toward COVID-19, the negative psychological impacts of the pandemic on the general population and healthcare workers, vaccine hesitancy, the management of religious mass gatherings (e.g., Hajj and Umrah), and the imposition of travel regulations. In this article, we discuss these challenges based on evidence from studies involving Saudi Arabian populations. We outline the measures through which the Saudi authorities managed to minimize the negative impacts of these challenges in the context of international health regulations and recommendations.

Detection of causative agents of bacterial pneumonia in hospitalized hajj and umrah cases by multiplex real-time polymerase chain reaction.

Background and Objectives: Middle East Respiratory Syndrome Coronavirus (MERS-CoV) is commonly detected in pneumonia patients who travel from the Middle East regions. Besides MERS-CoV, many other pathogenic agents cause pneumonia. Detection of such organisms must be done swiftly, especially in case of the negative MERS-CoV samples. The aim of this study was to identify the pathogenic agents that might account for bacterial pneumonia, from Hajj and Umrah pneumonia cases. Materials and Methods: We conducted a cross-sectional study, 38 pneumonia clinical samples from suffering of Hajj and Umrah in 2017 with negative MERS-CoV were selected. The laboratory testing was done at National Reference Laboratory in Jakarta and performed by multiplex real-time PCR using a FTD respiratory pathogens. Results: Haemophilus influenzae (26.4%) was the most frequent bacteria detected. Other causative agents of bacterial pneumonia identified were Moraxella catarrhalis (20.8%), Klebsiella pneumoniae (13.2%), Streptococcus pneumoniae (9.4%), and Staphylococcus aureus (5.7%). From 38 samples showed that 25 (65.79%) samples were positive with bacteria, including five samples with coinfection. The coinfection were combinations among S. aureus and S. pneumoniae (1/20), S. pneumoniae and K. pneumoniae (1/20), S. pneumoniae and M. catarrhalis (2/20), S. pneumoniae and H. influenzae (2/20), K. pneumoniae and H. influenzae (5/20), and M. catarrhalis and H. influenzae (5/20). Conclusion: Haemophilus influenzae is the most recurrent bacteria to be identified in samples of pneumonia of hajj and umrah cases.

Incidence, risk factors, and whole-genome sequence of SARs-CoV-2 and influenza virus among the Egyptian pilgrims returning from Umrah mass gathering in Saudi Arabia, April-May 2022.

BACKGROUND: Ramadan Umrah is the second largest Islamic pilgrimage with 2.75 million pilgrims allowed in 2022. This report presents the results of a survey among Egyptian pilgrims returning from Ramadan Umrah to monitor SARS-CoV-2 and influenza activity and identify prevalent SARS-CoV-2 variants after this mass gathering. METHODS: Cross-sectional survey conducted at Cairo airport from 30th April 2022-5 th May 2022. Pilgrims were invited to participate voluntarily. After consenting, participants interviewed using questionnaire including demographics, health status, and vaccination information and asked to provide NP/OP swabs for SARS-CoV-2 and influenza testing by RT-PCR. Whole-genome sequencing performed for 29 SARS-CoV-2 isolates. Incidence calculated, descriptive data analysis performed, and SARS-CoV-2 patients were compared to negatively tested participants using chi2 and p value< 0.05. RESULTS: Overall, 1003 subjects participated, their mean age 50.9 ± 13 years, 594 (59.2%) were males. Of them, 76(7.6%) tested positive including 67(6.7%) SARS-CoV-2, 7(0.7%) influenza and 2(0.2%) SARS-CoV-2/influenza coinfection. Omicron sublineage BA.2 was the prevalent variant with no difference in severity identified between BA.1 and BA.2. No difference was identified between COVID-19 incidence among receivers of different vaccine types or between fully vaccinated and booster dose receivers. CONCLUSIONS: Survey indicated a low incidence of SARs-CoV-2 and influenza among Egyptian pilgrims returning from Ramadan Umrah. Patients had mild or no symptoms with no hospitalization or deaths reported. Full vaccination and booster doses of COVID-19 vaccines proved equally effective. Enhancing COVID-19 and influenza vaccination before mass gatherings and close monitoring of respiratory viruses among pilgrims returning from Hajj and Umrah are crucial for outbreak early detection and mitigation.

Hajj and Umrah management during COVID-19.

COVID-19 has changed the way crowded events are organised. Every year thousands of crowded events are organised around the globe. Majority of the crowded events are religious in nature, with sensitivities and emotions attached. Organisation of crowded events, especially during a pandemic like COVID-19, poses a considerable challenge. To contain the spread of a human to human contagious disease, several restrictions, including wearing face masks, maintain social distancing, and adhering to regular cleaning and sanitisation, are critical. These restrictions stress the need for the event organisers, including the local or central government, to overhaul policies and practices about crowd management during a pandemic. Some crowded events are regular, whereas the others are occasional, which could be spontaneous such as a protest march, a political rally or a funeral procession. Controlling spontaneous crowded events can be quite difficult, especially during a crisis like COVID-19 pandemic. In this article, we shall review several crowded events which have taken place during the ongoing pandemic and investigate their impact and contribution in the spreading or containing COVID-19. We shall also provide a framework for effectively organising crowded events during the ongoing and future pandemics.

A Saudi Arabian Public Health Perspective of Tuberculosis.

Tuberculosis is a global health challenge due to its spreading potential. The Kingdom of Saudi Arabia (KSA) faces a challenge in the spread of tuberculosis from migrant workers, but the foremost threat is the huge number of pilgrims who travel to visit sacred sites of the Islamic world located in the holy cities of Makkah and Al Madina. Pilgrims visit throughout the year but especially in the months of Ramadan and Zul-Hijah. The rise of resistance in Mycobacterium tuberculosis is an established global phenomenon that makes such large congregations likely hotspots in the dissemination and spread of disease at a global level. Although very stringent and effective measures exist, the threat remains due to the ever-changing dynamics of this highly pathogenic disease. This overview primarily highlights the current public health challenges posed by this disease to the Saudi health system, which needs to be highlighted not only to the concerned authorities of KSA, but also to the concerned global quarters since the pilgrims and migrants come from all parts of the world with a majority coming from high tuberculosis-burdened countries.

Project execution obstacles: a case of King Abdulaziz Airport in Saudi Arabia.

The purpose of this research is to examine the causes of delay in airport projects in general and the King Abdulaziz International Airport (KAIA) of Saudi Arabia in particular. The KAIA is the most strategic and busiest airport of Saudi Arabia, which transports millions of pilgrims from two hundred countries to perform Hajj and Umrah in Makkah. In general, more than 50% of construction projects fail on one more area. Our method of research is empirical based on the analysis of responses received from seventy-one respondents to our survey questions. We shall also synthesize literature that utilizes previous research and case studies on aviation and public project failures. We believe that this research will be valuable in ascertaining and mitigating direct causes for the numerous project delays in Kingdom of Saudi Arabia.

The cancellation of mass gatherings (MGs)? Decision making in the time of COVID-19.

Our recommendation, as experts who have monitored health hazards at the Hajj for over 15 years, especially if the situation with COVID-19 continues to escalate globally is that Hajj 2020 will be at risk of being suspended and a means for Muslims to fulfill their rights in the future either personally or even by proxy need to be announced. The same holds true for the Summer 2020 Olympics in Japan and for many other MGs and large gatherings. Decisions in the time of COVID-19 will be closely followed and will be a blueprint for other mass gatherings.

Hajj and Umrah Mass Gatherings and COVID-19 Infection.

Purpose of Review: We discuss the risk of COVID-19 in religious mass gathering events including Hajj and Umrah pilgrimages. Recent Findings: The risk of transmission of respiratory viruses including COVID-19 is particularly high due to the overcrowding conditions at the Hajj and Umrah. The profile of the Hajj pilgrims who tend to be older and with multiple comorbidities corresponds to that of individuals at risk for severe COVID-19. In order to avoid a COVID-19 outbreak with potential spreading to many countries through returning pilgrims, Saudi Arabia suspended the Umrah, and access to the 2020 Hajj was very limited. Summary: A clear relation between early suspension of religious mass gatherings and lower occurrence of COVID-19 transmission in countries that took such measures promptly was noticed. There are lessons to national and international health organizations for other mass gatherings in the context of the pandemic.

Assessment of Preventative Measures Practice among Umrah Pilgrims in Saudi Arabia, 1440H-2019.

:Background: Annually, approximately 10 million pilgrims travel to the Kingdom of Saudi Arabia (KSA) for Umrah from more than 180 countries. This event presents major challenges for the Kingdom's public health sector, which strives to decrease the burden of infectious diseases and to adequately control their spread both in KSA and pilgrims home nations. The aims of the study were to assess preventative measures practice, including vaccination history and health education, among Umrah pilgrims in Saudi Arabia. Methods: A cross sectional survey was administered to pilgrims from February to April 2019 at the departure lounge at King Abdul Aziz International airport, Jeddah city. The questionnaire comprised questions on sociodemographic information (age, gender, marital status, level of education, history of vaccinations and chronic illnesses), whether the pilgrim had received any health education and orientation prior to coming to Saudi Arabia or on their arrival, and their experiences with preventative practices. Results: Pilgrims (n = 1012) of 41 nationalities completed the survey. Chronic diseases were reported among pilgrims (n = 387, 38.2%) with cardiovascular diseases being the most reported morbidity (n = 164, 42.3%). The majority of pilgrims had been immunized prior to travel to Saudi Arabia (n = 770, 76%). The most commonly reported immunizations were influenza (n = 514, 51%), meningitis (n = 418, 41%), and Hepatitis B virus vaccinations (n = 310, 31%). However, 242 (24%) had not received any vaccinations prior to travel, including meningitis vaccine and poliomyelitis vaccine, which are mandatory by Saudi Arabian health authorities for pilgrims coming from polio active countries. Nearly a third of pilgrims (n = 305; 30.1%) never wore a face mask in crowded areas during Umrah in 2019. In contrast, similar numbers said they always wore a face mask (n = 351, 34.6%) in crowded areas, while 63.2% reported lack of availability of face masks during Umrah. The majority of participants had received some form of health education on preventative measures, including hygiene aspects (n = 799, 78.9%), mostly in their home countries (n = 450, 44.4%). A positive association was found between receiving health education and practicing of preventative measures, such as wearing face masks in crowded areas (p = 0.04), and other health practice scores (p = 0.02). Conclusion: Although the experiences of the preventative measures among pilgrims in terms of health education, vaccinations, and hygienic practices were at times positive, this study identified several issues. These included the following preventative measures: immunizations, particularly meningitis and poliomyelitis vaccine, and using face masks in crowded areas. The recent COVID-19 pandemic highlights the need for further studies that focus on development of accessible health education in a form that engages pilgrims to promote comprehensive preventative measures during Umrah and Hajj and other religious pilgrimages.

Uptake of Recommended Vaccines and Its Associated Factors Among Malaysian Pilgrims During Hajj and Umrah 2018.

This study aimed to assess the uptake of recommended vaccines and to identify the factors associated with the vaccines' uptake among Malaysian Hajj and Umrah pilgrims. A cross-sectional survey among Malaysian Hajj and Umrah pilgrims in 2018. The uptake of the recommended vaccines was surveyed through an anonymous self-administered questionnaire to pilgrims attending a pre-departure Hajj/Umrah orientation course. Descriptive statistics were used for elaborating the demographic characteristics and vaccines uptake of the respondents. Multiple logistic regression was used for predicting the factors associated with the vaccines' uptake. A total of 1,274 pilgrims participated in the study with a mean age (standard deviation) of 42.42 (15.6). A total of 833 (65.4%) participants were females and 232 of the participants (18.2%) had at least more than one chronic disease. The uptake of influenza and pneumococcal vaccines were 28.6% (364/1,274) and 25.4% (324/1,274), respectively. Among the 527 pilgrims who were "at increased risk" of infections, 168 (31.9%) and 184 (34.9%) received influenza and pneumococcal vaccines, respectively. Gender, marital status and occupation were the common predictors associated with vaccines uptake. The vaccination uptake among Malaysian Hajj and Umrah pilgrims is low and declining from previous years. Educating the pilgrims toward vaccine uptake is essential and exploring the barriers for vaccination.

Pneumococcal disease during Hajj and Umrah: Research agenda for evidence-based vaccination policy for these events.

Pneumococcal disease is an important cause of morbidity and mortality worldwide with a significant financial burden. Pneumococcal vaccines are available and recommended in many countries for at-risk populations including young children, the elderly and those with underlying medical conditions. The Hajj and Umrah mass gatherings attract millions of Muslim pilgrims to the Kingdom of Saudi Arabia each year. These events increase the risk of pneumococcal disease especially among the large number of elderly pilgrims with co-morbidities. However, there is no unified official policy for vaccination against pneumococcal disease for pilgrims attending Hajj and Umrah, largely due to the lack of a strong evidence-base in the context of these events. Here we review knowledge gaps regarding pneumococcal disease during Hajj and Umrah and highlight important research agendas to strengthen the evidence-base to inform pneumococcal vaccination policy for pilgrims. Available data indicates that the true clinical and financial burdens of pneumococcal disease at Hajj and Umrah are still not determined. There is limited information on antimicrobial resistance among S. pneumoniae isolated from diseased pilgrims and no information on the serotypes involved. Finally, the efficacy and effectiveness of the current vaccines in the context of Hajj and Umrah have not been studied. Research agendas proposed in this article would help fill knowledge gaps regarding pneumococcal disease at Hajj and Umrah and would constitute a strong basis for an informed and potentially unified policy regarding pneumococcal vaccination for these events.

An Overview of the Most Significant Zoonotic Viral Pathogens Transmitted from Animal to Human in Saudi Arabia.

Currently, there has been an increasing socioeconomic impact of zoonotic pathogens transmitted from animals to humans worldwide. Recently, in the Arabian Peninsula, including in Saudi Arabia, epidemiological data indicated an actual increase in the number of emerging and/or reemerging cases of several viral zoonotic diseases. Data presented in this review are very relevant because Saudi Arabia is considered the largest country in the Peninsula. We believe that zoonotic pathogens in Saudi Arabia remain an important public health problem; however, more than 10 million Muslim pilgrims from around 184 Islamic countries arrive yearly at Makkah for the Hajj season and/or for the Umrah. Therefore, for health reasons, several countries recommend vaccinations for various zoonotic diseases among preventive protocols that should be complied with before traveling to Saudi Arabia. However, there is a shortage of epidemiological data focusing on the emerging and reemerging of zoonotic pathogens transmitted from animal to humans in different densely populated cities and/or localities in Saudi Arabia. Therefore, further efforts might be needed to control the increasing impacts of zoonotic viral disease. Also, there is a need for a high collaboration to enhance the detection and determination of the prevalence, diagnosis, control, and prevention as well as intervention and reduction in outbreaks of these diseases in Saudi Arabia, particularly those from other countries. Persons in the health field including physicians and veterinarians, pet owners, pet store owners, exporters, border guards, and people involved in businesses related to animal products have adopted various preventive strategies. Some of these measures might pave the way to highly successful prevention and control results on the different transmission routes of these viral zoonotic diseases from or to Saudi Arabia. Moreover, the prevention of these viral pathogens depends on socioeconomic impacts, available data, improved diagnosis, and highly effective therapeutics or prophylaxis.

A Master of Public Health with a Concentration in Mass Gatherings Health.

Introduction The Kingdom of Saudi Arabia (KSA) is in a unique position and different from other nations that periodically host an event, such as the World Cup or the Olympics. The KSA is faced annually with millions of pilgrims coming from around the world to participate in the Hajj, Umrah, and Ziarah rituals. Continuously hosting such huge mass gatherings poses overwhelming challenges to the Saudi healthcare system. Consequently, an additional specialized cadre of qualified public health personnel is needed. The purpose of this article is to describe the establishment of an academic public health program that addresses this need. Materials & Methods In response to the dire need for public health specialists, a landmark project was launched in 2013 at Alfaisal University (AU). The project aimed to establish a Master of Public Health (MPH) program with a concentration in the health aspects of mass gatherings. The MPH program was created in collaboration with the United States-based Partners HealthCare International (PHI), the Saudi Global Center for Mass Gatherings Medicine (GCMGM) at the Ministry of Health (MOH), the Ministry of Education (MOE), and the Ministry of Hajj and Umrah (MOHU). A needs assessment was conducted to help in the program development. The needs assessment drew on the unpublished findings of an institutional review board (IRB)-approved anonymous market survey that was administered to prospective students of the MPH program. Results The needs assessment study revealed the need for an MPH program with concentrations in mass gatherings health, health policy and management, and biostatistics and epidemiology. Consequently, we designed an MPH program to include these three concentrations. In particular, the mass gatherings health concentration aimed at preparing qualified public health specialists to help manage risks to the Saudi public health system, to analyze health data, and to recommend policies associated with the continuous mass gatherings events. Challenges to program development included working with multiple governmental agencies, absence of a frame of reference to develop a program curriculum, a lack of qualified faculty, lengthy and tedious government approval procedures, and inadequate funding. After obtaining the required approvals, the MPH program with a concentration in mass gatherings health was inaugurated in the fall of 2016. This program is accredited by the Saudi government to prepare public health specialists trained and locally certified in mass gatherings health issues. Conclusions The public health experts of the AU have established what may be the first MPH program with a concentration in mass gatherings health. The main challenges to program development were identified, and appropriate actions to meet these challenges were taken. This innovative MPH produces certified specialists equipped with the analytical and policy-making tools necessary to continuously monitor and improve the public health aspects of mass gatherings. Besides, the program provides a frame of reference for the development of unique public health programs, not only in the KSA but worldwide.

Hajj-associated viral respiratory infections: A systematic review.

Respiratory tract infections (RTI) are the most common infections transmitted between Hajj pilgrims. The aim of this systematic review was to determine the prevalence of virus carriage potentially responsible for RTI among pilgrims before and after participating in the Hajj. A systematic search for relevant literature was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. 31 studies were identified. Severe Acute Respiratory Syndrome coronavirus and Middle East Respiratory Syndrome coronavirus (MERS) were never isolated in Hajj pilgrims. The viruses most commonly isolated from symptomatic patients during the Hajj by PCR were rhinovirus (5.9-48.8% prevalence), followed by influenza virus (4.5-13.9%) and non-MERS coronaviruses (2.7-13.2%) with most infections due to coronavirus 229E; other viruses were less frequently isolated. Several viruses including influenza A, rhinovirus, and non-MERS coronaviruses had low carriage rates among arriving pilgrims and a statistically significant increase in their carriage rate was observed, following participation in the Hajj. Further research is needed to assess the role of viruses in the pathogenesis of respiratory symptoms and their potential role in the severity of the symptoms.