Head shaving is potentially a risk factor for transferring infections, especially bloodborne diseases. Hundreds of thousands of pilgrims (Hajjees) have their heads shaved within hours in a well-defined area. Conceivably, the hygienic behavior of Hajjees and the practices of barbers could make head shaving during the pilgrimage to Makkah (Hajj) an optimum focal setting for the worldwide spread of serious bloodborne diseases such as hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV). We studied the head-shaving practices of barbers and Hajjees to identify unsafe practices and to determine what steps are necessary to prevent or reduce the transmission of blood-borne diseases among Hajjees.
We observed 23 nationalities to determine the percentage who had completely shaved their heads. We used a two-stage cluster sampling to select and interview 298 Hajjees who had their heads shaved with razor blades, and visually checked their scalps for visible cut wounds. We covertly observed 196 illegal barbers as
they worked (Figure 1). Then, according to a standard checklist, asked them about infectious diseases that could be transmitted by head shaving. We also inspected their hands for visible cut wounds.
The proportion of Hajjees who had their heads shaved exceeded 90% among those from Eritrea, Egypt, Mauritania and Pakistan, whereas the proportion of head-shaving Hajjees was quite low among those from Tunisia and Syria. About 61% (95% Confidence Interval [CI] 55-66) of Hajjees had cuts to the scalp (a mean of 2.6 per Hajjee, maximum of 18 cuts). Of all Hajjees, 1.3% indicated they had a history of hepatitis. Out of 196 barbers observed, 23% (95% CI 1730) had uncovered hand wounds, 21% (95% CI 16-28) used the same blade for more than one shave, and 82% (95% CI 76-87) threw at least one used blade on the ground. The mean (±SD) time for a single head shave was 5+1.8 minutes (range 2-10 minutes).
Seventy-four percent of Hajjees ( 95% CI 66-77) and 20% of barbers (95% CI 6-15) were not aware of any health problems that could be caused by shaving with used razor blades. Head-shaving practices of Hajjees did not vary with their educational level. About one-fourth of Hajjees from western countries and sub-Saharan Africa were relatively more aware of potential transmission of HIV/AIDS by barbers, compared with only 4-12% of Hajjees from other countries. Hajjees aged 50 years or younger were relatively more concerned with transmission of HIV, whereas older Hajjees were more concerned about transmission of skin diseases.
Editorial note:
There is no place on earth where hundreds of thousands of people have their heads shaved within a few hours in a very limited geographical area as during Hajj. Similarly, every year large numbers of Muslims perform Umra, worship in Haram, the Holy Mosque. The uncertainty of disease profiles of the unequivocally diverse population of Hajjees, the poor hygienic behavior of Hajjees, and the practices of barbers shown in this study are disturbing. There is an obvious increased potential risk for bloodborne diseases among Hajjees as well as between Hajjees and barbers.
A further risk is presented with the data on the fate of used razor blades, showing that 82% of the barbers threw used blades on the ground after shaving rather than using garbage cans. This presents the hazard of foot injury to Hajjees, as many of them lose their slippers in the crowds that form after finishing Al Jamarat (pebble throwing).
The Saudi Ministry of Health (MOH) is aware of the public health consequences of unsafe head-shaving practices, and has spared no effort to constantly upgrade the facilities available to the Hajjees in order to provide adequate health care for them. Included in MOH plans for a
safe Hajj is the wide distribution of illustrated, health education materials translated into 10 main languages. About 700 barber chairs were placed around the Al Jamarat area (Figure 2). Nevertheless, the difficulty in communicating with Hajjees makes it very difficult obviously to ensure that all Hajjees practice head-shaving safety as only 14% of the Hajjees actually asked the barber to change the blade before shaving
An appropriate intervention should be fourfold: availability of safe razor blades, health education, presence of affordable head-shaving services, and close supervision of barbers. Hajjees need to be educated to treat razor blades used for head shaving as if they were using disposable syringes.
It is recommended to have each razor blade and its holder packed in a plastic bag; each Hajjee should be told to make sure the plastic bag is opened in front of him. Used razor blades should be considered potentially infective and must be handled with extraordinary care to prevent un-intentional injuries. They must be placed into puncture-resistant containers located as close as practical to the area in which they are used [1]. We also recommend establishing an official shaving area at each camp with qualified barbers and a group of Hajjees (Hamlah) responsible for ensuring hygiene and good practice.
References
- Lakshman S. Rules of infection control. International Dental Journal 1993; 43:578-584
