Saudi Arabia: Hajj and Umrah Pilgrimages

Destination overview

Hajj and Umrah are religious pilgrimages to Mecca, Saudi Arabia. Islamic religious doctrine dictates that every able-bodied adult Muslim who can afford to do so is obligated to perform Hajj at least once in their lifetime. Hajj takes place from the 8th to the 12th or 13th day of the last month of the Islamic year (Dhul Hijjah). The timing of Hajj is based on the Islamic lunar calendar; its dates shift relative to the Gregorian calendar, occurring approximately 11 days earlier each successive year. Muslims can perform Umrah, the "minor pilgrimage," any time of the year, and it is confined to the Grand Mosque in Makkah. Unlike Hajj, Umrah is not compulsory, but is highly recommended.

Normally, approximately 2–3 million Muslims from >183 countries perform Hajj each year, and the Kingdom of Saudi Arabia (KSA) continues its efforts to allow an even greater number of pilgrims (hajjis) to attend (see Mass Gatherings chapter). Due to the COVID-19 pandemic, however, only 1,000 pilgrims received permission to perform Hajj in 2020. In 2021, 60,000 were allowed, and in 2022, 1 million pilgrims made the pilgrimage. The numbers returned to near normal in 2023, when more than 1.8 million pilgrims attended, with about 1.6 million coming from outside KSA. In a typical year, >11,000 pilgrims travel from the United States; in 2022, just under 10,000 attended. As for Umrah, about 25 million pilgrims performed it in 2022, with 8 million being from outside KSA.

Performing the pilgrimage

Most international pilgrims fly into Jeddah or Medina and take a bus to Mecca. Although the actual pilgrimage lasts only 5–6 days, most foreign pilgrims visit KSA for 2–7 weeks.

Day 1

On the first day of Hajj (8th day of Dhul Hijjah), hajjis travel by foot or by bus approximately 9 km (5.5 miles) to Mina, the largest temporary city in the world, where most stay in air-conditioned tents.

Day 2

At dawn on the 9th day of Dhul Hijjah, hajjis begin an approximately 12.5 km (7.75 mile) trip by foot, shuttle bus, or train to the Plain of Arafat (Map 11.1.2.1; all distances shown are approximate). During the summer months, daytime temperatures can reach 50°C (122°F). The walking route features mist sprinklers, but the risk for heat-related illnesses is high, and ambulances and medical stations are positioned along the way to provide medical assistance. Hajj climaxes on the Plain of Arafat, a few miles east of Mecca. Pilgrims spend the day in supplication, praying and reading the Quran. Being on Arafat on the 9th of Dhul Hijjah, even for only a few moments, is an absolute rite of Hajj. Any hajji who fails to reach the Plain of Arafat on that day must repeat their pilgrimage. Some pilgrims supplicate at midday in the sun and may be susceptible to heat injuries. After sunset, pilgrims begin the approximate 10.5 km (6.5 mile) journey to Muzdalifah, where most sleep in the open air. Potential health threats in Muzdalifah include breathing the thick dust and inadequate or overcrowded washing and sanitation facilities.

Map 11.1.2.1

A map showing the route of the Hajj and Umrah pilgrimages in Mecca, Saudi Arabia, with key locations and distances marked. Umrah is shown with a red dashed line around the Grand Mosque of Mecca (Kaaba, Safa & Marwa, and Zamzam Well). The Hajj journey, shown with white lines, begins at the Grand Mosque of Mecca and continues to the Tent City of Mina and then to the Plain of Arafat and Jabal al Rahma (Mount of Mercy). The journey back leads from the Plain of Arafat and Jabal al Rahma (Mount of Mercy) to Muzdalifah then Jamarat then back to the Grand Mosque. A smaller inset map shows Mecca’s location within Saudi Arabia in relation to cities like Medina, Riyadh, and Jeddah.

Show Text Description

Day 3

At sunrise on the 10th day of Dhul Hijjah, pilgrims collect small pebbles to carry to Jamaraat. At Jamaraat, hajjis throw 7 tiny pebbles at the largest of 3 white pillars—the stoning of the effigy of the Devil. The Jamaraat has been the site of multiple deadly crowd crush disasters. Afterward, pilgrims traditionally sacrifice an animal. Some purchase vouchers to have licensed abattoirs perform this ritual on their behalf, thereby limiting potential exposure to zoonotic diseases. Other pilgrims visit farms where they sacrifice an animal themselves or have it done by an appointed representative.

Day 4

The next morning, on the 11th day of Dhul Hijjah, hajjis go to the Grand Mosque, which houses the Ka'aba ("The Cube"), and which Muslims consider the house of God. Pilgrims perform tawaf, 7 complete counterclockwise circuits around the Ka'aba. Because each floor of the 3-level mosque can hold about 750,000 people, performing tawaf can take hours. In addition to tawaf, pilgrims perform sa'i, walking (some parts running, among males) 7 times between the hills of Safa and Marwah, then drinking water that originates from the Well of Zamzam. Hajjis can travel between Safa and Marwah via air-conditioned pathways on 4 levels, which have separate sections for walkers and disabled pilgrims. At the end of the day, pilgrims return to Mina, pelting all 3 pillars with pebbles.

Day 5

The next day, the 12th day of Dhul Hijjah, pilgrims pelt all 3 pillars in Mina with pebbles again and then, after performing a final tawaf, some leave Mecca, ending their Hajj. Other pilgrims stay an additional night, pelt the 3 pillars with pebbles once more the next day, perform their final tawaf, and end the pilgrimage. Except for being on Arafat on the second day, some deviations to the sequence of rituals are permitted if necessary due to illness or logistical reasons. Although not required, some hajjis include a trip to Medina, where they visit the Mosque of the Prophet, home to the grave of Mohammed.

Infectious disease risks

KSA can elect to restrict the entry of travelers coming from countries experiencing infectious disease outbreaks. In 2012, for example, KSA did not permit anyone from Uganda to attend Hajj due to an Ebola outbreak in that country; the same restriction applied to Guinea, Liberia, and Sierra Leone in 2014 and 2015, and the Democratic Republic of the Congo in 2019.

Required vaccines

Current Hajj vaccination requirements are available from the Embassy of the KSA in the United States. As part of the Hajj and Umrah visa application process, KSA required proof of vaccination against COVID-19 and meningococcal disease (for all pilgrims), polio (for pilgrims coming from countries where the disease is reported), and yellow fever (for all pilgrims arriving from yellow fever–endemic countries) in 2024.

Coronavirus disease 2019

In 2020 and 2021, KSA only permitted Saudi residents <65 years old to apply for pilgrimage permits. In 2022, the Saudi government reopened Hajj to pilgrims (<65 years old) from countries outside KSA, and to all adults in 2023. Priority was granted to those who had not previously performed the pilgrimage. For the 2020 Hajj, because COVID-19 vaccines were not yet available, KSA required Hajj pilgrims to have a negative PCR test. In 2021, 2022, and 2023, hajjis also had to provide proof of immunization with an approved COVID-19 vaccine. The Kingdom recognizes vaccines produced by Johnson & Johnson, Moderna, Oxford/Astra Zeneca, and Pfizer/BioNTech.

For current information on COVID-19 and associated requirements in KSA, consult the U.S. Embassy & Consulates in KSA website. All travelers going to KSA should be up to date with their COVID-19 vaccines.

Meningococcal

The Hajj has been associated with meningococcal outbreaks. In 1987, serogroup A was responsible for an outbreak and carriage by returning pilgrims to certain countries that resulted in disease among local contacts. Serogroup W was responsible for similar occurrences in 2000 and 2001.

KSA requires all pilgrims ≥1 year of age to submit a certificate of vaccination with the quadrivalent (ACYW) vaccine against meningitis, issued no more than 3 years (in the case of the polysaccharide vaccine) or 5 years (conjugate vaccine) and no less than 10 days before arrival in KSA. The conjugate vaccine is preferred because it is associated with reduced carriage, unlike the polysaccharide vaccine.

If pregnant women and children travel to the Hajj, they should receive meningococcal vaccination according to licensed indications for pregnancy and age, respectively. For more details on meningococcal disease and its prevention, see the Meningococcal Disease chapter.

Polio

Although KSA's requirement for polio vaccine does not apply to adult pilgrims from the United States, ensuring full vaccination before travel is recommended because persons attending the Hajj are at risk of poliovirus exposure (see Poliomyelitis chapter). Adults who are known or suspected to be unvaccinated or incompletely vaccinated against polio should complete a primary vaccination series with the inactivated polio vaccine (IPV). Previously vaccinated adults who are attending the Hajj may receive a single lifetime booster dose of IPV prior to travel. All pilgrims traveling from countries where polio is reported are required to show proof of vaccination ≤6 weeks prior to departure. KSA also administers a single dose of the oral polio vaccine to pilgrims coming from countries where polio has been reported; this is in addition to any polio vaccine the hajji might have received in their country of origin. About 500,000 doses of polio vaccine are given at ports of entry, representing >90% of eligible pilgrims.

Blood-borne pathogens

After completing Hajj, men shave their heads. KSA limits barber licenses and requires barbers to use only disposable, single-use blades to limit transmission of blood-borne pathogens between customers. Remind male travelers to patronize only officially licensed barbers whose establishments are clearly marked. The Centers for Disease Control and Prevention (CDC) recommends that all travelers to KSA, particularly healthcare professionals (see International Travel to Deliver Health Care in Resource-Limited Settings chapter) or other caretakers participating in Hajj, be up to date with routine immunizations (see Vaccination and Immunoprophylaxis—General Principles chapter), including hepatitis B vaccine.

Enteric infections and diseases

Diarrheal disease is common during Hajj. During the pre-travel consultation, inform travelers about prevention, oral rehydration strategies, proper use of antimotility agents, and self-treatment of travelers' diarrhea with antibiotics. Most travelers' diarrhea in hajjis is bacterial (≤83%), with smaller proportions caused by viruses or parasites. More information on travelers' diarrhea can be found in the Travelers' Diarrhea chapter.

Transmission of hepatitis A, typhoid, or cholera is also possible during Hajj for reasons including overcrowding, poor personal hygiene, and ingestion of contaminated water or food. The use of communal toilets—about 1 toilet is available for every 100 pilgrims on Arafat and Mina—increases the risk of fecal-oral spread of pathogens. Adequate sanitization is not always possible. Pilgrims are advised to wash their hands thoroughly and avoid unsafe food, water, and ice from unknown sources. Hygienic measures should be taken when visiting farms to slaughter animals.

Respiratory infections and diseases

Respiratory tract infections are common during Hajj, and pneumonia is among the most common causes of hospital admission. The risk for respiratory infections underscores the need to follow recommendations from the Advisory Committee on Immunization Practices for pneumococcal conjugate and polysaccharide vaccines for pilgrims aged ≥65 years and for younger travelers with comorbidities.

Although not a requirement, the CDC strongly recommends that hajjis be vaccinated against seasonal influenza with the current vaccine (see Influenza chapter). Behavioral interventions, including regular handwashing with soap and water (or personal supply of hand sanitizer), properly wearing a facemask, cough etiquette, and, if possible, physical distancing can help mitigate the risk for respiratory illnesses among pilgrims. Assess travelers for respiratory fitness, administer necessary vaccines, and prescribe adequate supplies of portable respiratory medications (inhalers are easier to transport than nebulizers) as needed.

Crowded conditions, even outdoors (densities can reach 9 pilgrims per square meter), can increase the probability of respiratory disease transmission during Hajj, including COVID-19 (see COVID-19 chapter) and Middle East respiratory syndrome (MERS). Measures put in place by the KSA authorities during the pandemic led to minimal spread of COVID-19, with 41 cases detected in 2021 among the 60,000 pilgrims. Many pilgrims come from areas with high tuberculosis burden; some arrive for Hajj with active pulmonary disease (see Tuberculosis chapter). Educate pilgrims about the risk for tuberculosis and instruct them to follow up with their doctor if they develop symptoms of active tuberculosis or are concerned about exposure.

Middle East respiratory syndrome

MERS, caused by the Middle East respiratory syndrome coronavirus (MERS-CoV), was identified in KSA in 2012. Domestic cases in and around the Arabian Peninsula and exported cases, including in the United States, have ranged from mild to severe; approximately 35% of reported cases have been fatal. Close contact with someone who has confirmed MERS-CoV infection, exposure to camels, and consuming raw or undercooked camel products (e.g., milk, urine, meat) are all considered risk factors for human infection with MERS-CoV.

Skin infections

Chafing caused by long periods of standing and walking in the heat can lead to bacterial or fungal skin infections. Dermatitis is not uncommon, especially in the folds of the thighs, armpits, and under the breasts, during the Hajj season. Obtaining good ventilation of these folds in the body, combined with daily washing, helps avoid skin infection. Advise travelers to keep their skin dry, to use talcum powder, and to be aware of any pain or irritation caused by garments. Travelers should disinfect open sores and blisters and keep them covered. As a sign of respect, pilgrims enter the Grand Mosque with bare feet. While most hajjis perform tawaf and sa'i barefoot, travelers with diabetes (or other diseases associated with peripheral neuropathy) are encouraged to wear appropriate protective footwear.

Vector-borne diseases

Aedes mosquitoes, vectors for dengue and other arboviruses, and Anopheles mosquitoes, vectors for malaria, are present in KSA. Travelers should follow mosquito-bite prevention measures outlined in the Mosquitoes, Ticks, and Other Arthropods chapter. Dengue has been documented in Mecca and Jeddah, but not in association with Hajj. KSA conducts extensive spraying campaigns before Hajj and especially targets the housing units of pilgrims from malaria- and dengue-endemic areas. The cities of Jeddah, Mecca, Medina, Riyadh (the capital of KSA), and Ta'if have had no malaria transmission, and prophylaxis against malaria is neither recommended nor required for pilgrims.

Environmental hazards and risks

Animal bites

Pilgrims bitten by animals should seek immediate medical attention to address any potential rabies exposure (see Zoonotic Exposures: Bites, Scratches, and Other Hazards and Rabies chapters).

Climate and sun exposure

The risk of sunburn is high, and sunscreens and appropriate clothing are recommended during the day (see Sun Exposure in Travelers chapter). Heat is a threat to the health and well-being of all travelers; both heat exhaustion and heatstroke can cause incapacitation and death among pilgrims (see Heat and Cold Illness in Travelers chapter). Travelers are particularly at risk when Hajj occurs during summer months; the average high temperatures during June–September are ≥43°C (110°F). More than 1300 heat-related deaths were recorded during the 2024 Hajj. High temperatures, combined with high humidity, can lead to a high heat index which may result in the issuing of an extreme heat warning. High heat alone can exacerbate chronic conditions.

Depending on the exact location of their lodgings within Mina and whether they use trains or shuttle buses to get from one location to another, hajjis might walk up to approximately 35–40 miles (approximately 55–65 km) over the 5 days; about 45% of pilgrims walk during the Hajj rituals. Counsel pilgrims to stay well-hydrated, wear sunscreen, and seek shade or use umbrellas when possible. Religious leaders have ruled that it is permissible for hajjis to perform some rituals after sunset. In addition, except for a pilgrim's required presence on Arafat on the 9th day of Dhul Hijjah, most other compulsory rituals can be postponed, done by proxy, or redeemed by paying a penalty.

Other health considerations

Chronic health conditions

Hajj is arduous, even for young, healthy pilgrims. Because many Muslims wait until they are older before performing Hajj, they are more likely to have chronic health conditions (see Travelers with Chronic Illnesses chapter). Travelers caught up in the experience of Hajj or Umrah might forget to take their usual medications. People with chronic medical conditions should have a health assessment before traveling to Hajj. Tailor a plan for each traveler's unique risks, including adjusting the usual medical regimen if necessary, ensuring an adequate supply of medications, and providing education about symptoms that indicate a condition requiring urgent attention. In a recently published systematic review, the weighted pooled prevalence rates for diabetes and hypertension among pilgrims were 5% and 12%, respectively.

Pilgrims with diabetes should have a customized management plan that enables them to meet the arduous physical challenges of the Hajj. They should bring adequate amounts of all medications, plus syringes and needles if they are insulin-dependent. They also should carry an emergency kit with them on their pilgrimage; the kit should include easily accessible carbohydrate sources, glucagon, a glucometer and test strips, urine ketone sticks to evaluate for ketoacidosis, and a list of medications and care plans (see Travel Health Kits chapter). Emphasize the importance of wearing durable and protective footwear to reduce the incidence of minor foot trauma, which can lead to infections. Basic and light meals during travel and pilgrimage performance are also important to adequately control blood glucose levels.

Menstruation

Muslim law prohibits a woman who is menstruating from performing tawaf. All other rituals are independent of menses. Because pilgrims generally know well in advance that they will be making a pilgrimage, those who intend to manipulate their menstrual cycle should consult with a physician 2–3 months before the journey.

Safety and security

Fire

Fire is a potential risk during Hajj. In 1997, open stoves set tents on fire, and the resulting blaze killed 343 pilgrims and injured >1,500. In 2015, a hotel caught fire and >1,000 pilgrims were evacuated. KSA no longer allows pilgrims to erect their own lodgings or prepare their own food; permanent fiberglass structures have replaced former makeshift accommodations.

Traffic-related injuries

As in other countries, motor vehicle crashes are the primary safety risk for U.S. travelers to KSA. Remind Hajj pilgrims of the importance of seat belt use in any vehicle, including buses (see Injury and Death During Travel chapter). Encourage pilgrims to be mindful of their own safety when they walk long distances through or near dense traffic.

Trauma

Trauma is a major cause of injury and death during Hajj (see Mass Gatherings chapter). Hajj is associated with dense crowding, leading to crush disasters or stampedes. Thousands of pilgrims were killed during a crush at Mina in 2015, making it the deadliest Hajj disaster on record. Death usually results from asphyxiation or head trauma, and large crowds limit the movement of emergency medical services, making prompt rescue and treatment difficult.

Availability and quality of medical care

Travelers who become ill during Hajj have access to medical facilities located in and around the holy sites. An estimated 25,000 healthcare workers are typically in attendance, and medical services are offered free of charge to all pilgrims and are easily accessible. A number of countries have medical missions which are the first port of call for pilgrims. These missions liaise with KSA health authorities when needed. For safety reasons, KSA advises that children, frail older adults, seriously ill people, and pregnant women postpone Hajj and Umrah.