Author(s): Salim Parker, Joanna Gaines

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 make Hajj at least once in their lifetime. Hajj takes place from the 8th through the 12th 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 ≈11 days earlier each successive year. In 2021, for example, Hajj took place from July 17–22, but in 2022, Hajj occurred from July 7–12. Muslims can perform Umrah, the “minor pilgrimage,” any time of the year; unlike Hajj, Umrah is not compulsory.

Normally, ≈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) attend. In a typical year, >11,000 pilgrims travel from the United States. Due to the coronavirus disease 2019 (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. In both 2020 and 2021, because no cross-border entry into the country was permitted, KSA limited Hajj pilgrims to residents of Saudi Arabia.

Performing the Pilgrimage

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

Day 1

On the first day of Hajj (8th day of Dhul Hijjah), hajjis travel by foot or by bus ≈5.5 miles (9 km) 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 ≈7.75-mile (12.5-km) trip by foot, shuttle bus, or train to the Plain of Arafat (Map 10-03 [all distances shown are approximate]). During the summer months, daytime temperatures can reach 122°F (50°C). 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. After sunset, pilgrims begin the ≈6.5-mile (10.5-km) 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.

Day 3

At sunrise on the 10th day of Dhul Hijjah, pilgrims collect small pebbles to carry to Jamaraat, the site of multiple deadly crowd crush disasters. At Jamaraat, hajjis throw 7 tiny pebbles at the largest of 3 white pillars—the stoning of the effigy of the Devil. Afterwards, 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 750,000 people, performing tawaf can take hours. In addition to tawaf, pilgrims have the option of performing sa’i, walking (sometimes running) 7 times between the hills of Safa and Marwah, then drinking water from the Well of Zamzam. Hajjis can travel between Safa and Marwah via air-conditioned tunnels, which have separate sections for walkers and disabled pilgrims. At the end of the day, pilgrims return to Mina (via Jamaraat) 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. Although not required, some hajjis include a trip to Medina, where they visit the Mosque of the Prophet, home to the tomb 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.

Required Vaccines

Current Hajj vaccination requirements are available from the Embassy of the Kingdom of Saudi Arabia in the United States. As part of the Hajj and Umrah visa application process, KSA requires 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).

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. 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 and 2022, 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.

All travelers going to Saudi Arabia 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 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 best. 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 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.

Bloodborne 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 bloodborne 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 all travelers to KSA, particularly health care workers or other caretakers participating in Hajj, be up to date with routine immunizations, including hepatitis B vaccine.

Enteric Infections & Diseases

Diarrheal disease is common during Hajj. During the pretravel consultation, inform travelers about prevention, oral rehydration strategies, proper use of antimotility agents, and self-treatment of travelers’ diarrhea (TD) with antibiotics. Most TD in hajjis is bacterial (≤83%), with smaller proportions caused by viruses and parasites. More information on TD can be found in Sec. 2, Ch. 6, Travelers’ Diarrhea.

The World Health Organization recommends that travelers visiting farms, or other areas where animals are present, practice general hygiene measures, including avoiding contact with sick animals and regular handwashing before and after touching animals. Travelers should avoid consuming raw or undercooked animal products, including milk and meat.

Respiratory Infections & 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 fully vaccinated against seasonal influenza. Behavioral interventions, including regular handwashing with soap and water, properly wearing a facemask, cough etiquette, and, if possible, physical distancing and contact avoidance, 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 and Middle East respiratory syndrome (MERS). At the time of writing, no Hajj-associated cases of COVID-19 or MERS have been reported. Many pilgrims come from areas highly endemic for tuberculosis (TB); some arrive for Hajj with active pulmonary disease. Educate pilgrims about the risk for TB, and instruct them to follow up with their doctor if they develop symptoms of active TB.

Middle East Respiratory Syndrome

MERS, caused by the Middle East respiratory syndrome coronavirus (MERS-CoV), was identified in Saudi Arabia in 2012 (see Sec. 5, Part 2, Ch. 14, Middle East Respiratory Syndrome / MERS). Domestic cases in and around the Arabian Peninsula and exported cases, including in the United States, have ranged from mild to severe; ≈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. Advise travelers to keep their skin dry, 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 the tops of their feet uncovered; while most hajjis perform tawaf in their bare feet, encourage travelers with diabetes to wear appropriate, protective footwear.

Vectorborne Diseases

Aedes mosquitoes, vectors for dengue, and Anopheles mosquitoes, vectors for malaria, are present in Saudi Arabia. Travelers should follow mosquito bite prevention measures outlined in Sec. 4, Ch. 6, Mosquitoes, Ticks & Other Arthropods. 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 no malaria transmission, and prophylaxis against malaria is neither recommended nor required for pilgrims.

Environmental Hazards & Risks

Animal Bites

Pilgrims bitten by animals should seek immediate medical attention to address any potential rabies exposure (see Sec. 4, Ch. 7, Zoonotic Exposures: Bites, Stings, Scratches & Other Hazards, and Sec. 5, Part 2, Ch. 18, Rabies).

Climate & Sun Exposure

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 Sec. 4. Ch. 2, Extremes of Temperature). Travelers are particularly at risk when Hajj occurs during summer months; the average high temperatures during June–September are ≥110°F. High temperatures combined with high humidity can lead to a heat index indicative 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 ≈35–40 miles (≈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 dark. 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. 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.

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. Emphasize the importance of wearing durable and protective footwear to reduce the incidence of minor foot trauma, which can lead to infections.

Menstruation

Muslim law prohibits a person 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 & 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 formerly makeshift accommodations.

Traffic-Related Injuries

As in other countries, motor vehicle crashes are the primary safety risk for US travelers to KSA. Remind Hajj pilgrims of the importance of seatbelt use in any vehicle, including buses (see Sec. 8, Ch. 5, Road & Traffic Safety). 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. 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 & 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 health care workers are typically in attendance, and medical services are offered free of charge to all pilgrims. For safety reasons, KSA advises that children, the frail elderly, seriously ill, and pregnant people postpone Hajj and Umrah.