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Behavioral risk factors for disease during Hajj: the second survey

During the Islamic pilgrimage to Makkah (Hajj) of 1417 (1997), the Saudi Arabian Field Epidemiology Training Program (FETP) conducted a major survey to assess behavioral risk factors (BRF) for several important diseases and conditions among the pilgrims (Hajjees). At Mina, a holy place near Makkah, where more than 2 million Hajjees camp for at least 3 days, 1101 Hajjees completed a self-administered questionnaire that was translated into 10 major languages. A similar survey was conducted this past year during Hajj 1418 (1998) to validate the results of the first BRF survey, assess current interventions, and to suggest designing additional feasible, relevant, and culturally acceptable intervention programs.
Accordingly, the map of Mina was used to divide the camping area into 4 equal zones, then further subdivided into 475 equal areas. Of those 475 equal areas, we randomly selected 61 clusters proportionate to the number of areas in each zone using a two-stage cluster sampling. A total of 1613 Hajjees from 53 nationalities were interviewed, 20-30 Hajjees per cluster.
Hajjees were grouped according to their nationalities as determined by the Ministry of Hajj: Gulf Cooperation Council countries (GCC), Other Arab countries, South Asia (Indian subcontinent, ISC), Southeast Asia (SEA), Sub-Saharan Africa (SSA), Iran, the Former Soviet Union (FSU), Turkey, the Americas, the European countries, Australia and Other Western countries.
Of the total of 1613 respondents, 71% were performing Hajj for the first time and 15% were residents of the Kingdom of Saudi Arabia (KSA).
Risky behavior for food poisoning included bringing foods from home countries (37%) and eating food from street vendors (33.9%). Heat stroke prevention included using umbrellas (59%). Of all Hajjees, 3-5% moved between the holy places on foot.
Nineteen percent lost their way in Mina for a median of 2 hours, drank a median (interquartile range) of 2500 (1500-3750) ml of fluids, and slept for a median of 6 hours per day. After completing Hajj rites, 56% (95% CI 54-59) had their heads shaved with razor blades and 25% (95% CI 21-29) put themselves at risk of bloodborne disease by reusing razor blades used by other Hajjees. Hajjees also risked injuring themselves by hanging on the backs of buses 12% (95% CI 10-13). The main BRF are summarized in Table 1.

Editorial note:

Hajjees come to KSA from more than 140 countries around the world with varying disease profiles [1]. Surveillance of BRF can provide the basis for both launching and evaluating programs designed to reduce the prevalence of unhealthy behaviors. Surveillance data are necessary for formulating intervention strategies, justifying resources to support these strategies, and proposing new policies or regulations. Also, data allow monitoring of trends in health behavior [2].
The results of this survey were consistent with a previous report and indicate the need for simple, innovative cross-cultural educational programs aimed at reducing BRF among religious visitors.
The variation in the meningococcal vaccine (MCV) coverage rates demonstrates the need for continuous effort to maintain high coverage, probably through the constant release of reminders emphasizing strict adherence to the visa issuance policy for religious visitors. Rapid mini-surveys are needed to identify Hajjees from countries with relatively low MCV coverage early enough to launch mass catch-up vaccinations in KSA.
The reasons for bringing foods were not ascertained; however, it is conceivable that Hajjees brought their favorite items thinking the food might be difficult to find or too expensive to buy in Makkah. Also, perhaps Hajjees brought ready-to-eat foods such as canned foods, because cooking facilities were not readily available and they wanted to save time by not cooking. Canned foods are usually safe. However, in the absence of adequate refrigeration and re-heating facilities, leftover canned foods can be potentially hazardous. The major factor that contributes to outbreaks of food-borne disease in developed countries is holding cooked foods at an ambient temperature for several hours [3].
The results of this survey show there is a remarkable variation in the proportion of Hajjees who had their heads shaved during Hajj. Hajjees should be the center of all interventions as it would be difficult to supervise the large number of licensed and unlicensed barbers (such as fellow Hajjees), whose main goal is to make as much money as possible during Hajj.
Heat exhaustion during Hajj is the leading cause of morbidity among Hajjees and accounts for 70% of all hospital admissions [4]. The etiology of heat exhaustion is multi-factorial; well-established risk factors have been elucidated. Conceivably, a multitude of interventions is needed. Some risk factors for heat exhaustion are inescapable (crowding, especially at Al Jamarat, and the desire of Hajjees to visit landmarks at Mina and Arafat); whereas some other risk factors are modifiable, such as increasing the daily intake of fluids. Interventions need to address Hajj and Hajj guides (Mutawifs); many interventions might start in the home country of each Hajjee.
Health education is the key element in all interventions to prevent Hajj related health problems [5]. Exposure of Hajjees to intensified sessions in health education regarding different aspects of Hajj-related illnesses could start even before Hajjees depart from their home countries. Then, language would not be a barrier, as health educators would be using the Hajees' mother tongue. Health education could continue throughout the journey to Makkah. At that time, Hajjees would probably be more attentive and responsive than when they receive health education after arrival to Makkah. Nevertheless, the Mutawifs could still play an important role in health education for Hajjees inside their camping sites.
  1. Ministry of Health. Annual health reports. 1996 (1416 H); 269-79.
  2. Frazier EL, Franks AL, Sanderson LM. Behavioral risk factor data: using chronic disease data; a handbook for public health practitioners. U.S. Department of Health and Humans Services.
  3. Bryan FL, Teufel P, Riaz S, et al. Hazards and critical control points of street vended Chat, a regionally popular food in Pakistan. J Food Prot 1992;55:708-13.
  4. Ministry of Health. Health services for pilgrims to Makkah. Ministry of Health annual reports 1992-1994. Ministry of Health. Saudi Arabia.
  5. Green LW, Simons-Morton DG. In: Holland WW, Deteles R, Konx G, Fitzsimons B, Gardner L. Oxford textbook of public health, 2'd Ed. Oxford University Press, 1991:181-95
Table 1: Main differences between the 1997G (1417H) and 1998G (1418H) BRF surveys
1997G (1417H)
1998G (1418H)
Vaccination against meningococcal meningitis (MCV)
88% (87-90%)
-MCV: Low coverage among Hajjees from FSU (76.4%), Turkey (68.3%). For international Hajjees, 89.9%, domestic Hajjees, 79.7%.
Risk factors for heat associated illnesses:
Used umbrellas
-Umbrella usage: almost all Hajjees from Iran (94.9%), half from GCC, SSA, and ISC stated never used umbrellas during Hajj
Moved at least 6 km by foot
-Walking: mostly those from ISC, SSA, and Arabs from countries other than GCC
Carrying heavy load
30% (24.5-35.6%)
Median fluid intake(in ml) in 24 hours
-Fluids: American, European, Australian, Turkish Hajjees drank a median of 3000 ml or more.
Lost way in Mina
-Lost way: Median duration of 2 hrs (IQR 1-4 hrs).
Visited Jabal Ar-Rahma
Prayed - Namira Mosque
Wore identity wrist band
Had head shaved
56.4% (54-59%)
-Head shaved: Turkish (3.4%) and SEA (12.3%) Hajjees least likely. More than 80% of Hajjees from ISC, UK, Iran had heads shaved.
Food hygiene and safety:
Brought food from home (canned/dried/other)
-Food: GCC, SSA, and Iranian Hajjees least likely to bring (12-18%); Hajjees from Turkey, FSU, SEA brought mostly dried foods (65-86%).
Bought food from street vendors
Visited health facility at least once
Received health education before arrival
* This question was not asked.
** Hajjees brought more than one food item