Chapter 4Select DestinationsThe Middle East & North Africa
Saudi Arabia: Hajj Pilgrimage
They will come to thee on foot and (mounted) on every kind of camel, lean on account of journeys through deep and distant mountain highways . . . (Quran 22:27)
The Hajj is the annual pilgrimage to Mecca, Saudi Arabia, and the largest mass gathering in the world. 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 of Dhu al-Hijja, the last month of the Islamic year. Because the Islamic calendar is lunar, the timing of Hajj varies with respect to the Gregorian calendar (for example, it was November 4–7 in 2011 and October 24–27 in 2012 and will be October 13–16 in 2013, and October 3–6 in 2014).
More than 2 million Muslims from >183 countries make Hajj each year (2.5 million in 2009), >11,000 of whom travel from the United States. Most international pilgrims fly into Jeddah and take a bus to Mecca. After arriving in Mecca, pilgrims go immediately to the Grand Mosque, which contains the Ka’aba, the most sacred site in Islam, and perform a tawaf, 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), a single tawaf can take hours. In addition to tawaf, pilgrims perform sa’i, walking or running 7 times between the hills of Safa and Marwah. Once in open air, this route is now enclosed by the Grand Mosque and can be traversed via air-conditioned tunnels, with separate sections for walkers, runners, and disabled pilgrims.
Hajj culminates on the Plain of Arafat, a few miles east of Mecca, where the Prophet Muhammad delivered his final sermon. Pilgrims spend the day in supplication, praying and reading the Quran; it is the pinnacle of most pilgrims’ spiritual lives. The following day’s ritual, the Stoning of the Devil at Jamaraat, is the site of some of the densest crowds during Hajj. During this ritual, pilgrims throw 7 tiny pebbles (specifically, no larger than a chickpea) at each of 3 white pillars. Because of the sheer number of people crowding around the pillars, panic can easily trigger crowd turbulence and stampede. 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 a stampede in 2006 that killed 380 pilgrims and injured 289, the Jamaraat pedestrian bridge was demolished and replaced with a wider, multilevel bridge.
After Jamaraat, pilgrims traditionally sacrificed an animal to symbolize the ram that Abraham sacrificed instead of his son. In modern times, pilgrims must purchase a “sacrifice voucher” in Mecca and perform this sacrifice by proxy. Centralized, licensed abattoirs then perform the sacrifice on behalf of the pilgrim, and meat is immediately donated to charity, often reaching international locations. Each year, >600,000 animals are sacrificed. After 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 to visit the Mosque of the Prophet, which contains the tomb of Mohammed and is the second holiest site in Islam.
All pilgrims should be up-to-date with routine immunizations. In addition, hepatitis A and B and typhoid vaccines are recommended. Although a requirement for polio vaccine does not include pilgrims from the United States, it is best to ensure full vaccination against polio before travel. Current vaccination requirements are available from the website of the Saudi Arabian Ministry of Health (www.moh.gov.sa/en/Pages/Default.aspx).
Because of the intensely crowded conditions of the Hajj and high carrier rates of Neisseria meningitidis among pilgrims, outbreaks of meningococcal disease have historically been a problem during Hajj. In the aftermath of outbreaks in 2000 and 2001 that affected 1,300 and 1,109 people, respectively, the Saudi Ministry of Health began requiring all pilgrims and local at-risk populations to receive the meningococcal vaccine—Hajj visas cannot be issued without proof of vaccination. All adults and children aged >2 years must have received a single dose of quadrivalent A/C/Y/W-135 vaccine and must show proof of vaccination on a valid International Certificate of Vaccination or Prophylaxis. Hajj pilgrims must have had the meningococcal vaccine ≤3 years and ≥10 days before arriving in Saudi Arabia.
Respiratory tract infections are common during Hajj; the most common cause of hospital admission is pneumonia. These risks underscore the need to follow the Advisory Committee on Immunization Practices recommendations for pneumococcal polysaccharide vaccine for pilgrims aged ≥65 years and for younger pilgrims with comorbidities. Seasonal influenza vaccine is recommended for all pilgrims. Behavioral interventions such as hand hygiene, wearing a face mask, cough etiquette, social distancing, and contact avoidance can be effective at mitigating respiratory illness among Hajj pilgrims.
Other Health and Safety Risks
Diarrheal disease is common during Hajj, and travelers should be educated on usual prevention measures and self-treatment. Environmental conditions during the summer months can be extremely hot, with air temperatures exceeding 122°F (50°C), further increasing risks for dehydration. Adequate fluid intake must be a priority for every pilgrim. Fortunately, millions of containers of water are distributed to pilgrims from refrigerated trucks located along the pilgrim route. In addition, Saudi authorities have erected thousands of sprinklers on top of 30-foot poles that spray a fine mist of water to cool pilgrims.
Long rituals of standing and walking, heat, sweating, and obesity contribute to the risk for chafing, leading to skin infections. 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 the feet, which are bare when inside the Grand Mosque.
At the end of Hajj, Muslim men must shave their heads, and unclean blades can transmit bloodborne pathogens, such as hepatitis B, hepatitis C, 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.
Noncommunicable Diseases and Other Hazards
Cardiovascular disease is the primary cause of death during Hajj. Hajj is arduous even for young, healthy pilgrims, and many Muslims wait until they are older before making Hajj. Pilgrims who are caught up in the spiritual experience of Hajj may forget to take their usual medications. Consequently, travelers with preexisting cardiovascular disease should be advised of this risk and specifically consult with their doctors before leaving, ensure that they have an adequate supply of medication, adhere to their usual regimen, and immediately report to the nearest health center if they notice symptoms of cardiac decompensation.
Heat exhaustion and heatstroke are also leading causes of death, particularly when Hajj occurs during the summer. Pilgrims should stay hydrated, wear sunscreen, and seek shade when possible. Some rituals may also be performed at night to avoid daytime heat. Pilgrims can be reassured that night rituals have been advocated as legitimate by religious clerics.
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; no pilgrim is allowed to set up his own tent or prepare his own food. Cooking in the tents is also prohibited.
Trauma is a major cause of injury and death during Hajj. Pilgrims may walk long distances through or near dense traffic, and motor vehicle accidents are inevitable. The most feared trauma hazard, however, is stampede. In such dense crowds, little can be done to avoid or escape a stampede once it has begun, but the physical environment of the Hajj has been engineered specifically to minimize this risk. Past stampedes have often begun as minor incidents; the 2006 Hajj stampede, for example, began when some pilgrims tripped over fallen luggage, but it resulted in hundreds of injuries and deaths. Death usually results from asphyxiation or head trauma, and providing prompt treatment is next to impossible in large crowds.
The Saudi government is committed to mitigating health risks during Hajj, and it has spent >$25 billion to date, in efforts to prevent stampedes. The round columns at Jamaraat have been replaced with wider elliptical ones to dissipate crowd pressure and ease crowd density, and a new Jamaraat bridge has been built. The new bridge has a capacity to hold 5 million pilgrims over a 6-hour period. Bottlenecks have been engineered out, and large canopies have been added to protect pilgrims from the sun. To further protect themselves, travelers should try to avoid the most densely crowded areas during Hajj and, when options exist, perform rituals at nonpeak hours, which is advocated by Saudi religious authorities and underlines their concern about the safety of all pilgrims. For example, most pilgrims prefer to perform the Stoning of the Devil at midday, but Saudi authorities have decreed that it may be performed anytime between sunrise and sunset.
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