Behavioral risk factors for pilgrims to Makkah, 1997

For five days every year, more than two million Muslims gather in a 10square-kilometer area to perform the rites of the Hajj, the Islamic pilgrimage to Makkah. These pilgrims (Hajjees) encompass many diverse nationalities (more than 140 countries) with different languages, habits and lifestyles. The disease profile of Hajjees varies according to their home countries, economic and educational levels, age distribution (middle age or the elderly), knowledge of and attitudes toward personal hygiene, and underlying chronic diseases. There are histories of disasters and outbreaks of infectious disease during Hajj that could be in part attributed to unhealthy behavior of Hajjees.

To reduce the occurrence of serious Hajj-related illnesses, the Saudi Ministry of Health (MOH) has developed a number of programs to modify some risky behaviors of Hajjees. In 1997, we assessed behavioral risk factors (BRF) for several important diseases and health conditions to assess current intervention programs, to design additional intervention programs, and to serve as a baseline for future similar monitory BRF surveys.

Hajjees live in Mina for at least three days in camps spread over the whole area of Mina. Each nationality has its own camps, composed of groups of tents attached to one another. Each camp accommodates 2,800 to 4,000 Hajjees. To obtain our sample, we subdivided a map of Mina into 475 equal areas. From those areas, we randomly selected 44 clusters proportionate to the number of areas in each zone using a two-stage cluster sampling; 30-40 Hajjees were interviewed in each cluster.

We used a pre-tested self-administered questionnaire that had been translated into 10 languages. We also sought information on selected behaviors predisposing to the major Hajj-related illnesses and the sociodemographic factors that influence them, including use of identifying wristbands, vaccination against meningococcal meningitis, and risk factors for heat exhaustion or heat stroke, food poisoning and blood-borne diseases. The point prevalence of selected acute illnesses and some chronic diseases was calculated. Hajjees were asked whether they had received health education on ways to prevent the most common health problems. We assured each Hajjee that the information was confidential and did not ask for either names or passport numbers.

Out of 1,101 respondents (37 nationalities), 63% were performing Hajj for the first time. Almost three-quarters (74%) joined organized Hajj missions; 27% were residents of Saudi Arabia.

Identifying wristbands were worn by 57% of respondents. For prevention of meningococcal meningitis, 90% (95% CI 88-91) had received the required vaccination.

Risky behavior for food poisoning included bringing foods from their home countries (39%) and eating food from street vendors (27.3%). However, 1.6% (95% CI 0.9-2.6) had eaten no meal during the 24 hours preceding the survey.

Heat stroke prevention included the use of umbrellas (51%). Of all Hajjees, seven to nine percent moved between holy places (three journeys within 24 hours, a total of 30 kilometers) on foot, and 22% lost their way in Mina for a median of three hours; drank a mean (±SD) of 2670 +58.2ml of fluids, and slept for a median of six hours per day.

After completing Hajj rites, 36% (95% CI 33-39) shaved their heads with razor blades and 21% (95% CI 17-26) put themselves at risk of bloodborne disease by using razor blades previously used by other Hajjees. In addition, 23% (95% CI 1924) had cut wounds in their feet. Hajjees put themselves at risk of injury by hanging on the back of buses (6.4%, 95% CI 4.9-8.2), and 13% (95% CI 11-15) had severe hits with pebbles thrown at the Jamarat. The BRF were more common among domestic Hajjees.

Table 1 summarizes some of the differences in selected BRF among Hajjees.

Scarcity of data has restricted the scope of public health programs aimed at reduction of BRF among religious visitors, especially domestic Hajjees. Such programs require continuous revisions and evaluations. This survey would be the baseline for future surveys providing epidemiologic data needed for evaluating current public health programs, monitoring changes in behavioral

risk factors, identifying emerging public health problems and developing appropriate and relevant interventions. Behavioral risk factors could be modified or avoided; if they are not, the results could be a costly burden to the health services.

Strict regulations helped in having high coverage with MCV, and it is possible that similar regulations on importation of foods, the presence of street vendors, etc., could help to prevent foodborne diseases. In addition, certain nationalities need special intervention programs

The Hajjees from Southeast Asia demonstrated safe behaviors. Arabs (both from Saudi Arabia and from other GCC countries) are at risk for heat exhaustion because they travel by land, rarely use umbrellas, and have less exposure to health education. Head-shaving remains an important risk factor for bloodborne diseases, especially among pilgrims from Sub-Saharan Africa, the GCC countries and South Asia.

Half of the Hajjees with diarrhea and cough utilized PHCCs. The fires that swept Mina that year could explain the high incidence of cough. It was estimated that there were 100,000-150,000 diabetic Hajjees, and special programs may be required for their care. The use of identification wristbands needs promotion.