Chapter 4 Select Destinations The 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 days 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 October 1–6 in 2014 and September 20–25 in 2015).
More than 2 million Muslims from >183 countries make Hajj each year (approximately 2.8 million in 2010), >11,000 of whom travel from the United States.
Most international pilgrims fly into Jeddah and take a bus to Mecca. By foot or by bus, the pilgrim then travels 8 km to the massive tent city of Mina, where most pilgrims are housed in air-conditioned tents.
At dawn on the 9th day of Dhu al-Hijja, pilgrims begin a 14.4-km walk to the plain of Arafat, passing Muzdalifah along the way (Map 4-16). The route is littered with cool mist sprinklers to counteract the oppressive daytime temperatures, but the risk of heat-related illnesses during this part of the journey is high. Hajj ambulances and medical stations along the route are available for medical assistance. 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. After sunset, pilgrims begin the 9-km walk back to Muzdalifah, where they sleep in the open air.
At sunrise on the 10th day of Dhu al-Hijja, 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 each of 3 white pillars. The crowded conditions at this site pose potential hazards; multiple deadly stampedes occurred from 1994 to 2004. 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. However, after another stampede in 2006 that killed 380 pilgrims and injured 289, the single-tiered Jamaraat pedestrian bridge was demolished and replaced with a wider, multilevel bridge. Subsequently, no further incidents have occurred at Jamaraat.
Traditionally after Jamaraat, pilgrims sacrifice an animal to symbolize the ram that Abraham sacrificed instead of his son. More recently, pilgrims are required 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.
After returning to 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 may perform sa’i, walking or running 7 times between the hills of Safa and Marwah and then drinking water from the Well of Zamzam. Previously performed 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.
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. In Medina, pilgrims visit the Mosque of the Prophet, which contains the tomb of Mohammed and is the second holiest site in Islam.
Map 4-16. Hajj destination map
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 adult pilgrims from the United States, it is best to ensure full vaccination against polio before travel. Children up to 15 years of age must show proof of vaccination with quadrivalent meningococcal vaccine and polio vaccine. Children older than 15 years of age have the same vaccination requirements as adults.
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 meningococcal vaccination. All adults and children >2 years of age 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. Children between 3 months and 2 years of age must show proof of vaccination with 2 doses of meningococcal A monovalent vaccine with a 3-month interval between the doses. Hajj pilgrims must have had the meningococcal vaccine ≤3 years and ≥10 days before arriving in Saudi Arabia.
Current Hajj vaccination requirements are available from the following sources:
- Saudi Arabian Ministry of Health (http://www.moh.gov.sa/en/Hajj/Pages/HealthRegulations.aspx)
- Saudi Arabian Embassy (www.saudiembassy.net/services/hajj_requirements.aspx)
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, including H1N1, is strongly 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. Pre-Hajj travel advice about common respiratory conditions should include a general assessment for respiratory fitness, necessary vaccinations, and prescription of adequate supplies of portable respiratory medications (prefer inhalers over nebulizers).
The crowded conditions during Hajj increase the probability of tuberculosis transmission. Pilgrims are advised to see their doctors if they develop signs of active tuberculosis: cough with sputum and blood at times, chest pains, weakness, weight loss, fever, and night sweats.
Middle East respiratory syndrome (MERS) was first identified in Saudi Arabia in 2012. The illness is caused by a novel coronavirus that is similar to the virus responsible for the 2003 global outbreak of severe acute respiratory syndrome (SARS). Cases have been identified in and around the Arabian Peninsula, but cases have also been exported to other countries, including the United States. The most common symptoms include fever, cough, and shortness of breath. However, myalgias, diarrhea, vomiting, abdominal pain, thrombocytopenia, and leukopenia have also been reported. The severity of illness has ranged from mild to severe, and approximately 35% 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, 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 pre-travel visit should include discussions about prevention, oral rehydration strategies, antimotility agents, and emergency antibiotic use for treatment of traveler’s diarrhea.
Chafing caused by long rituals 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.
Nasal ablution, called istinshaaq, is the practice of rinsing your nose with water before performing some rituals during the Hajj. Medical literature has identified rare cases of primary amebic meningoencephalitis (PAM) caused by Naegleria fowleri. Even though no cases of Hajj-related PAM have been reported, nasal ablution is common during Hajj, and pilgrims are advised to use safe water to protect themselves from this potential risk. When in doubt, they should use bottled water. Boiling or filtering the water are other ways to decrease the risk of PAM.
At the end of Hajj, Muslim men must shave their heads. The use of 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
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. Travelers 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 on 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 leading causes 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 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 >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.
Special Health Considerations
Women are not permitted to perform tawaf around the Ka’aba stone if they are menstruating. The remainder of the rituals may be performed during menstruation if the tawaf was performed before the menstrual period began. Thus, a female Hajj pilgrim who suspects that she may be menstruating during the Hajj may request hormonal suppression of menstrual bleeding.
Muslims with diabetes planning to make Hajj should make a pre-Hajj travel clinic visit with enough advanced notice to carefully construct a diabetes management plan tailored to the health challenges of the Hajj. Diabetic patients 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 are necessary to avoid minor foot trauma that can lead to infections.
Before making Hajj, a pilgrim’s seizure disorder must be controlled on stable doses of medications. Before departure, Hajj travelers should ensure they have adequate supplies of routine medications, as well as a buccal or rectal formulation of antiseizure medications.
SAUDI GOVERNMENT SAFETY MEASURES
The Saudi government has created a Ministry of Hajj that collaborates with the Ministry of Health to improve pilgrims’ experience, including mitigating health risks during Hajj. The hospitals and health centers in and around the holy sites are adequately staffed and equipped for the large gathering. The medical facilities offer high quality of care, and services are offered free to Hajj pilgrims.
To ensure efficient transport through the King Abdulaziz International Airport in Jeddah, the Saudi government has built a modern airport terminal solely dedicated to Hajj pilgrims. Furthermore, modern modes of transportation (light rail, 15,000 Hajj dedicated buses, and even high-speed rail lines) have been developed to safely transport pilgrims to the city of Mecca and other holy sites.
To mitigate the risk of heat exposure during this journey, the government provides complimentary water distributed from refrigerated trucks, more air conditioned sites (tents at Mina), large sun-blocking canopies, and thousands of fine mist sprinklers. To further protect themselves, travelers are urged to avoid the most densely crowded areas during Hajj. When the option exists, performance of rituals at nonpeak hours is encouraged. 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 or even by proxy, if the pilgrim cannot access the Jamaraat bridge.
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- Page created: July 10, 2015
- Page last updated: July 10, 2015
- Page last reviewed: July 10, 2015
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