Behavioral Risk Factors for Diseases during Hajj 1422 H, (2002 G)

The pilgrimage to Makkah (Hajj) is an annual congregation of more than 2.3 million Muslim Pilgrims (hajjis) with different nationalities, languages, life styles, level of education, and health status. This study was conducted to estimate the disease related behavioral risk factors (BRF) among hajjis during Hajj 1422H (2002G) and to study the changes in BRF of hajjis observed in an earlier study conducted in 1418 H(1998 G) by the Field Epidemiology Training Program, Riyadh.[1]

A cross-sectional survey was conducted among hajjis while staying in Mina using a self-administered questionnaire. Sampling was done by a three stage simple random cluster sampling technique based on geographical mapping, with 50 clusters of 30 hajjis each. The self-administered questionnaire used in 1418 H was revised in light of the experience of the previous studies and translated into 12 languages. A team of physicians and health inspectors collected the data in Mina on the 10th and 11th of Thul-Hijjah, in accordance with the laid down sampling plan.

A total of 1374 hajjis participated in the study, with a mean age of 43 years. Of the total, 86.4% were male and 13.6% were female. The participants belonged to 22 nationalities, which were categorized into eight regional groups for presentation of data. Only 18.8% were domestic hajjis, among them 66.7% were Saudis.

Out of the total hajjis, 68.6% were performing Hajj for the first time. The majority (76.1%) of hajjis in the study had arrived in Makkah by air, while 22% arrived by land and the rest by sea. Out of the total hajjis, 94.4% performed Hajj with Hamla (organized group).

Of all the hajjis, 89.8% were vaccinated against meningococcal meningitis. The coverage of meningitis vaccine among international hajjis and domestic hajjis was 90.4% and 87% respectively. The lowest coverage of meningococcal vaccine was observed among hajjis from Malaysia (45.6%) and Iraq (58.3%). Out of the hajjis vaccinated against meningitis 2.1% had received meningitis vaccine in the Saudi ports. Only 66% of all vaccinated hajjis were vaccinated at least 10 days before arrival to Makkah. Some of the hajjis were vaccinated against other diseases including cholera (11.1%), typhoid (9%), and influenza (10.2%).

Out of the total hajjis 16.9% kept leftover food stored for more than two hours, 49.3% of hajjis from Turkey, 36.5% of Algerians, 32.7% of Egyptians and 29.2% of Australians, compared to only 7.6% of hajjis from Saudi Arabia.

Out of the total hajjis surveyed 71% had drank less than 2 liters of fluid in the 24 hours prior to the survey. Regarding the sources of the drinking water, 49.1% reported drinking water from water coolers available in the camps, 54.4% from bottled water, 4.8% from the plastic bags, 7% from the water tanker, 3.4% from the toilets or wadu taps, and 2.2% from other sources like Zamzam water.

Out of all hajjis 13.6% lost their way in Mina and 6.6% lost their way in Arafat. Among the hajjis who had lost their way, 69.5% reported losing their way for 1-4 hours and 19.5% for over 5 hours.

Most of the hajjis moved between the holy places by cars or buses. About 15% walked between the holy places, mostly those from Indian Subcontinent (ISC), SubSaharan Africa (SSA), and Arabs other than those from Gulf Cooperation Council (GCC). Among hajjis who walked between the holy places, 10.1% reported carrying heavy loads during the journey. While moving between the holy places, 10.8% of all hajjis (especially those from Arab countries other than GCC, ISC, Turkey) traveled on the roof of the vehicles, and about 1.3% of all hajjis hanged on the side of the vehicles.

Out of total male Hajjis 50.7% used razor blades to shave their head, 30.9% used scissors, 14.9% used hair trimmers and 3.5% had not cut or shaved their hair by the time of survey. The SEA hajjis (15.4%) used razor blades least, while the ISC hajjis (78.7%), Iranian hajjis (73.2%), SSA hajjis (68.5%) and Saudi hajjis (61.8%) used them more frequently. Out of total hajjis who used the razor blade for shaving only 1.9% of them shaved their head with used razor blades. Around one third of the hajjis (30.2%) had their head hit by pebbles thrown at Al-Jamarat sites; 26.2% had light hits while 4% had severe hits.

Out of the total hajjis who came with organized groups (Hamla) 64.5% had at least one accompanying doctor in the group. Of all hajjis 29.5% had visited one of the health facilities in the holy places at least once during the Hajj period. The main complaints for which health care was sought included cough and throat pain 67.3%, fever 22.9% and weakness 7.8%.

Of all hajjis, 13.2% were suffering from one or more of the chronic diseases. Out of the total hajjis, 6.8% were suffering from diabetes mellitus, 1.1% from bronchial asthma, 5.3% from hypertension and 2.8% from cardiovascular diseases. Diabetes mellitus and hypertension were more common among hajjis from Europe and Australia. 96.7% of the hajjis with chronic diseases brought their medication with them from their home countries.

Regarding health education, 34.4% had received health messages about not storing food for long periods, 41.3% about not to get their heads shaved by a used blade, 27.5% about using toilets for urination, and 39.9% about the importance of wearing the wrist band during hajj time. The most common place where hajjis received the health messages was Makkah followed by Mina, Airport, and Arafat.

Out of all hajjis 67.5% used the identification/health bands, while only 4.7% of Saudi Hajjis and 35.6% of GCC Hajjis wore such bands. Among those who didn't use the wrist band 7.4% reported not using it because of religious reasons, 26.4% thought that it is not important to use, 7.1% had lost it, while 22.1% had no particular reasons, and 36.9% had never been provided with wrist bands.

In comparison to 1418 H study, this study has shown that there is a statistically significant increase in coming to Makkah by land and with organized groups, getting the food from organized groups in Mina and Arafat, wearing the identification wristband, using facemasks and bringing the medications with them. There is a statistically significantly less hajjis losing their way in Mina, and using a used razor blade for head shaving or using a health facility. Other factors remained practically unchanged.

Hajjis vary in age, nutritional and educational status, underlying chronic diseases, beliefs and lifestyles while being exposed to strenuous physical efforts, irregular diet and unfamiliar landscape, which may lead to increased risk of illnesses. Data on behavioral risk factors of Hajjis are necessary to formulate intervention strategies, justifying resources to support these strategies and proposing new policies or regulations.[2] A number of studies on this aspect have been conducted by the FETP and the last one was in 1998.[1,3]

The results of this study showed considerable improvement in certain health behaviors, while others are relatively unchanged. Meningococcal disease (MCD) is a serious disease, with high epidemic potential and case fatality rate.[4] In the very dynamic population of Makkah, with massive crowding, and a large number of the hajjis coming from endemic areas, result in high chance of outbreaks. Vaccination coverage rate was fairly high this year but the situation of Malaysia and Iraq need special attention. For vaccination to be effective, Hajjis should be vaccinated at least 10 days before arrival to Makkah to perform hajj.[5] In this aspect, the vaccination coverage is low, especially for local and domestic hajjis and hajjis from GCC and other Arab countries. This indicates that a large number of hajjis were not aware about the proper timing for meningitis vaccination before hajj, and the respective health or Hajj departments in their countries had not taken care of this issue properly.

More than half the hajjis had used razor blades to shave their heads during hajj. Head shaving in such circumstances may result in scalp wounds, especially in case of unexperienced barbers or hajjis shaving each other, creating an ideal environment for transmission of blood-borne diseases (e.g. HIV, Hepatitis B&C). The impressive thing is that the proportion of hajjis who got their head shaved with used razor blades had decreased tremendously in comparison with the results of the previous study. This reflects the increased awareness of the people about the danger of using used blades for head shaving.

It is recommended that the Saudi Ministry of Health coordinate with other hajj missions to ensure the timely vaccination of all Hajjis against meningococcal meningitis. Health education should be continued and its scope broadened to cover the issues of adequate intake of water, avoidance of eating non-fresh food, use of face mask and avoiding travel on the roofs of vehicles.