Effect of use of Face mask on Hajj related Acute Respiratory Infection among Hajjis from Riyadh - A Health Promotion Intervention study

Every year about two millions Muslims from all around the world perform the pilgrimage (hajj) to the holy city of Makkah in Saudi Arabia. The unavoidable closeness of hajjis during the performance of hajj rites and in the residential area facilitates the spread of infections, particularly Acute Respiratory infections (ARI).

This study was a three pronged group randomized intervention trial aiming to investigate the effect of health education (HE) for use of face mask with provision of free face mask; or HE for face mask alone; as compared to non-intervention group regarding utilization of face mask during hajj. Another objective was to assess the effect of the use of face mask during hajj on preventing ARI, during and immediately after hajj, among domestic hajjis from Riyadh.

The study population was domestic hajjis from Riyadh who went for hajj during hajj season 1424H (January-February 2004). Two stage stratified random sampling technique was done to recruit the study population; where Hamlas (organized hajj groups) were the primary sampling unit and hajjis within the hamlas were the secondary sampling unit. A list of domestic hamlas issued by the ministry of hajj was procured. These hamlas were divided into categories (A, B, C, D, and E) according to the proximity of their rented Mina tents to the Jamarat. Category A tents were the closest and with the highest rent, while Category E were the furthest with the lowest rent, and usually used by non-Arabic speaking expatriates. Within each category (A, C, D); 3 Hamlas were randomly selected (there was no domestic category B Hamla in Riyadh, and domestic Hamlas category E were excluded due to communication barriers), and then were randomized into three intervention groups. The first group was provided with face mask health HE message leaflets and free face masks, the second group was provided with the face mask HE education message leaflets only, while the third (control) group were not provided with either HE or face mask. ARI was defined as any person suffering from at least one of the constitutional symptoms (fever, headache, myalgia) along with one of the local symptoms (runny nose, sneezing, throat pain, cough with/without Sputum, difficulty in breathing) developing after reaching Makkah for the Hajj.

A structured questionnaire with two parts was designed for data collection. The first part was self-administered, filled by hajjis from all the selected hamlas at the time of registration, immediately before departure to Makkah. This section included written consent, telephone contact number, demographic data and inquiry about chronic health problems. The second part was filled by the investigation team via telephone interviews one week post hajj, asking hajjis about their use of face mask; where and how often they used it, symptoms of ARI with date of onset, whether or not they had consulted medical services, and how many days their symptoms kept them out of work. Assessment of compliance to Mask wearing depended only on subjective questionnaire responses. Wearing the mask sometimes and always wearing the mask were both considered as compliant during analysis. Those who never used the mask were considered as non-compliant.

A total of 995 Hajjis participated in this study; 257 (26%) were provided with face mask HE message leaflets and face masks, 292 (29%) were provided with the HE message leaflets only, while the third (control) group 446 (45%) were not provided with either HE or face masks. There were 570 (57%) males with mean age of 35.3 years (SD ±11.72), and 425 (43%) females with mean age 34.7 years (SD ±13.71). Illiterate or little formal education Hajjis constituted 8%, 18% had intermediate and high school education respectively, 43% with university level, and 9% with higher education level. Of the total were 259 (26%) with chronic illness; of those 64 (25%) were diabetic, 36 (14%) asthmatic, and 50 (19%) with hypertension. There were 9% daily smokers, 9% ex-smokers, and 80% non-smokers.

All Hajjis left Riyadh on the 7th of Thul-hijjah, 50% by bus and 50% by airplane, coming back between the 12th and 16th of the month.

Among the no-intervention group 33.6% hajjis used face mask during hajj, among HE alone group 51.7% used faced mask and among HE with free face mask group 81.3% used face mask. As compared to no-intervention group odds ratio of complying with mask wearing in the HE alone group was 2.11 (95% CI 1.56-2.86) and in the HE with free face mask group was 8.59 (95% CI 5.93-12.44). When this association was controlled for the potential confounding effect of age, gender and educational status of the hajjis, the odds ratio became some-what stronger and remained statistically significant. (Table 1)

Among the total participants 255 (25.6%) developed ARI within one week of returning from hajj. However, no association was observed between compliance with face mask wearing and developing ARI (OR 0.97, 95% CI 0.73-1.28).

Acute respiratory infections (ARI's) have been considered low priority health problems because of their low mortality, despite their high morbidity rates.[1,2] A previous study conducted by the Field Epidemiology Training Program among domestic hajjis from Riyadh during hajj season of 1423H (2003G) reported that almost 40% of domestic hajjis developed ARI during hajj or within one week of their return back home.[3] ARI can affect the ability of hajjis to successfully complete their hajj rites and also increases the load on health facilities in both the holy places and the hajjees place of origin. Post hajj symptoms of ARI prevent hajjis from returning back to work, thus decreasing their productivity, and costing the country a considerable amount of money.

A simple prevention method against ARI that can break the cycle of disease transmission is using a simple face mask. Their regular use has been associated in previous studies with a substantial decrease in ARI incidence.[4] The previous FETP study also reported that the use of face mask was associated with lower ARI attack rates, at least among males.[3] This study has been successful in exhibiting that both the mask promotion intervention significantly increased the face mask usage, and as expected free distribution of mask along with HE pamphlets produced a remarkable change in mask usage. However, the observation that no association was found between face mask wearing and ARI, tone down the applicability of this finding as such and highlight the need of in-depth analysis of the data or conducting another study with more objective measurement of ARI.