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Behavioral Risk Factors for Diseases during Hajj 1428 H.

Certain behaviors among hajjis are influenced by their personal habits, educational background, and traditional beliefs. The fact that many come from countries endemic for numerous infectious diseases, their varying age distribution and nutritional states, in addition to being exposed to overcrowding and strenuous physical effort, render hajjis extra vulnerable to disease and may aggravate underlying medical conditions. The objective of this study was to estimate hajjis disease related Behavioral Risk Factors (BRF) during Hajj 1428 (2007) and compare them with the findings of earlier studies conducted by the Field Epidemiology Training Program (FETP).
A cross-sectional survey was conducted among hajjis in Mina. Single stage stratified random cluster sampling based on geographical mapping was done. The self-administered questionnaire used in 1422 H was reviewed and modified in light of the findings of the previous studies.
A total of 1706 hajjis participated in the study, with a mean age of 42.2 years. Of the total, 89.5% were male. The participants belonged to 29 nationalities; 33% were domestic hajjis, 54% of whom were Saudis; 61.3% were performing Hajj for the first time, and 42% had arrived to the hajj area just one week prior to our study.
Of the total hajjis, 19.7% kept food stored for over two hours before consumption. Hamla was the main source of cooked food in Mina. In the 24 hours prior to the survey, hajjis had eaten 3 or more meals in Arafat and Mina (42.3% and 56%, respectively), and only 16.4% had drank more than 2 liters of fluid; 24.9% from water coolers or water tankers, and 72.6% from plastic bottles or plastic bags.
Among male Hajjis, 48.5% had shaved their heads by razor blades, 25.4% had used hair trimmers or machines, and 20.6% had used scissors. Among those who had cut or shaved their heads, only 39.1% had it done by professional barbers, 6% used razor blades that had been used by other hajjis, and the rest had their hair cut or shaved by non professional barbers, mostly other hajjis (39.6%).
The mean number of sleeping hours in the previous 24 hours among hajjis contacted on the 10th of Dhul Hijjah was 4.5 hrs (corresponding to Arafat/Muzadalifa days), which rose to 6 hrs among those contacted on the 11th.
Hajjis suffering from acute or chronic problems were 56.6% and 32.2% respectively. Among those with chronic diseases, 73.9% had brought their medications with them.
Of all the hajjis, 84.4% had been vaccinated against meningococcal meningitis (MCM). However, only 53.5% had been vaccinated during the recommended period (10 days – 3 years before arrival to Hajj). The best vaccination coverage within the recommended period was among Iranian and South East Asian Hajjis (84% and 77% respectively), while the lowest was among domestic Hajjis (47%). Within domestic hajjis, only 38% of Saudis had received the vaccine within the recommended period. Some of the hajjis had been vaccinated against other diseases, including Influenza (38.0%), yellow fever (15.4%), cholera (13.9%), and poliomyelitis (11.6%).

Editorial note:

The first study investigating hajjis’ BRF was conducted by the FETP in 1418 H,1 followed by a second study in 1422 H.2 Since that time, however, there have been a number of changes during hajj, in terms of health care facilities, health education messages, food and water sanitation, major changes in the structure of Jamarat, possible changes in hajjis’ awareness, in addition to the change in climate in the recent hajj seasons. Results of this study showed considerable improvement in certain health behaviors when compared with the earlier studies, while others remained relatively unchanged or showed some signs of deterioration.

High vaccination coverage against MCM has to be maintained to avoid outbreaks during Hajj.3 During this hajj season, an overall vaccination proportion of 84.4% was observed. Hajjis should be vaccinated at least 10 days and not more than 3 years before travelling to Hajj in order to produce adequate immunity.3 Only 53.5% of hajjis had been vaccinated during the recommended period, and this low coverage was observed among all groups except Iranians (85%). Unfortunately, Saudi hajjis had the lowest MCM vaccination coverage within the recommended period (39%). This indicates a deficiency in knowledge of the proper timing for MCM vaccination among a large number of hajjis.
The current Saudi Hajj rules enforce that hajjis perform Hajj attached to Hamlas. Furthermore, bringing food from outside the Kingdom is not permitted and cooking is prohibited in Mina. The study showed that hamlas were the main source of cooked food for hajjis, which is an improvement from previous studies. Hajjis also had a problem of food storage and maintenance of proper food environment, which is a major contributor to food poisoning.4 The proportion of hajjis keeping their food over 2 hours was similar to the two earlier studies.1,2
Eighty three percent of hajjis reported drinking under two liters of fluid in the 24 hours preceding the survey, which may lead to dehydration and its complications.5 The fact that 37% of hajjis were not satisfied with toilet facilities may have contributed to their drinking fewer amounts of fluids.
About half of the hajjis had used razor blades to shave their heads. Head shaving exposes hajjis to scalp wounds. Over a quarter of hajjis who got their head shaved were aware of having at least one cut wound on their scalps. This creates the risk of transmission of blood-borne diseases.3 It was alarming to find that that the proportion of hajjis who got their heads shaved with used razor blades had increased in comparison with the earlier studies, from 1.9% to 6%; in addition to another 11.6% who were not aware whether the razor blades they had used had been previously used. This reflects a decrease in awareness of the danger of using used blades. Also, only one third of hajjis reported having been educated to avoid shaving by a used razor blade.
In this study, hajjis suffering from one or more chronic diseases increased to 32.2%, and 16.5% of those with chronic diseases had not brought their medications. Old age and chronic diseases are both major risk factors for morbidity and mortality during hajj, particularly if hajjis are not taking their regular medications. This can lead to an increased workload on the Saudi health facilities.3
While comparing the results of our studies with the earlier BRF studies, there were improvements in some variables, such as the increase in proportion of hajjis for whom Hamla was the main source of cooked food, where sealed plastic bottles / bags were the main source of drinking water, getting hair cut by a professional barber, use of face mask, and receiving both influenza and cholera vaccination. Also, there was a decrease in the proportion of hajjis suffering from feet wounds. However, there was a deterioration in some behaviors, such as a decrease in the number of meals per day, the proportion of Hamlas with accompanied doctors, the proportion of hajjis with chronic diseases who had brought their medication, MCM vaccination coverage; and an increase in the proportion of hajjis who shaved their head with used blades and those hit by pebbles at Jamarat.
However, when making comparison with earlier BRF studies, it has to be kept in mind that the current study adopted a weighted mechanism to ensure that study participants represented the true proportion of hajjis according to their geographical grouping among the total hajjis for this year, adjusting for sampling and differential response rate issues. This was not done in the earlier studies, which may cause problems of differential response rates and proportionate sampling. The proportions of behaviors observed in this study, although more valid and representative of the study population are,therefore, strictly incomparable with the earlier studies, but would help make more valid comparisons with future studies of this type.
The majority of Hajj related illnesses relate to modifiable behaviors. Health education is the key element to prevent hajj-related health problems, which should commence even before the hajjis depart from their home countries. Strengthening the vaccination program against MCM is required. For international hajjis, it was recommended to increase coordination with Hajj authorities in different countries to ensure 100% vaccination coverage among their hajjis, especially focusing on hajjis from non-GCC Arabs countries and from meningitis belt countries; and ensuring the accurate timing of vaccination. For domestic hajjis, MCM vaccination coverage can be increased by strengthening local health education campaigns, and making proper timing of vaccination as part of the requirements for obtaining the Hajj license. Health education campaigns for hajjis in the coming years should be strengthened, focusing on MCM vaccination and its proper timing, eating proper number of meals, while observing food hygiene, drinking adequate amounts of fluids, avoiding used razor blades, bringing medication and medical reports if possible from home countries, injuries prevention, importance of using the face mask, and avoiding crowding. The number of licensed barbers and barbershops should be increased. Toilet facilities should be improved. It is suggested to repeat this study in 3-4 years to evaluate changes in behavior of hajjis.


1. Al-Rabeah AM, El-Bushra HE, Al-Sayed MO, Al-Saigul AM, Al-Rasheedi AA, Al-Mazam AA, et al. Behavioral risk factors for diseases during Hajj to Makkah, 1998. Saudi Epidemiol Bull 1998; 5 (3,4): 19,20.

2. Almaghderi Y, Aljoudi A. Behavioral Risk Factors for Diseases during the Pilgrimage to Makkah 1422 H/2002 G [Dissertation]. Riyadh: King Saud University and Saudi Epidemiology Field program 2002.

3. Shafi S, Memish Z, Gatrad A, Sheikh A. Hajj 2006: communicable disease and other health risks and current official guidance for pilgrims. Hajj 2006: communicable disease and other health risks and current official guidance for pilgrims. Euro Surveill 2005; 10(12): E051215.2.

4. National Travel Health Network and Centre (NaTHNaC). Prevention of Food and Water Borne Diseases. 2006 [cited 3/10/2007] available from URL:

5.Guyton AC, Hall JE. The body fluids compartments: Extracellular and intracellular fluids; interstitial fluids and edema. In: Guyton AC, Hall JE. Textbook of Medical Physiology. 10th ed. Philadelphia: W B Saunders; 2000: 297-303.

Table 1: Comparison of study findings with the previous BRF studies conducted in 1418 H and 1422 H.

1428 (%)
1422 H study
1418 H study
1422 (%)
1428% -1422%
1418 (%)
1428% -1418%
First time in hajj
Food in Mina from Hamla
Eating ≥ 3 meals in Arafat
Eating ≥ 3 meal in Mina
Left food > 2 hours
Water from plastic bottles/ bags
Fluid intake >2 L
Razor blade for head shaving
Shaving in barber shop
Razor blade sharing
Accompanying doctor in Hamla
Using facemask during hajj
Feet wounds during hajj
Chronic disease
Brought medication with them
Hit by pebbles at Jamarat