Amani S. Alqahtani

Vaccinations against respiratory tract infections at Hajj

The transmission of respiratory tract infections (RTIs) is very high among the Hajj congregation in Mecca, Saudi Arabia. Despite recommendations for vaccinations, pilgrims remain at increased risk of RTIs. In this paper we systematically reviewed available studies assessing the uptake and effectiveness of vaccinations against RTIs among Hajj pilgrims and enumerated important demographic factors, if described, associated with vaccine uptake. Of the 42 included studies, 29 reported on the uptake and effectiveness of influenza vaccine among pilgrims, eight studies reported the uptake of other vaccines, notably pneumococcal, diphtheria and bacillus Calmette-Guérin vaccines, and the remaining five studies described both influenza and non-influenza vaccines. The uptake of seasonal influenza vaccine ranged from 0.7% to 100% across the study populations, with coverage highest in the elderly and those with pre-existing co-morbidities. The effectiveness of influenza vaccine was variable across studies but was significantly effective against laboratory-confirmed influenza (risk ratio 0.56; 95% CI 0.41-0.75; p <0.001) in pooled metadata from six studies. Uptake of diphtheria and pneumococcal vaccines was low, and the only study reporting pertussis among Hajj pilgrims found the presence of pre-Hajj immunity to be significantly protective against disease. Despite favourable evidence of effectiveness, our review shows variable uptake of vaccines across a number of studies with few data available on the uptake of non-influenza vaccines. Mixed-method studies are needed to gauge knowledge, attitudes and practices of Hajj pilgrims regarding vaccination, and randomized controlled trials are required to confirm the efficacy of vaccines and improve uptake in this vulnerable travelling population.

Australian Hajj pilgrims' knowledge, attitude and perception about Ebola, November 2014 to February 2015.

Upon return from Hajj 2014, 150 Australian pilgrims were interviewed about their understanding of the Ebola epidemic. Most (89%, 134/150) knew of the epidemic before travelling and 60% (80/134) of those knew Ebola transmits through body fluids. Pilgrims who received pre-travel health advice were more conscious of Ebola (69% vs 31%, p = 0.01) and adhered better to hand hygiene after touching an ill person (68% vs 31%, p < 0.01). Mass media was the main information source (78%).

Australian Hajj pilgrims’ knowledge about MERS-CoV and other respiratory infections

Dear Editor,With the intense crowding in mass gatherings such as Hajj,there is a high risk of acquisition of airborne in-fections with the potential for its transmission in the pilgrims’country of origin(Memish Z A,et al.,2014).The risk of importing serious infections from Hajj has escalated since the emergence of the Middle East respiratory syndrome coronavirus(MERS-CoV)in Saudi Arabia and other neighbouring countries from September2012.Active surveillance of Hajj pilgrims in 2012 and 2013

Exploring barriers to and facilitators of preventive measures against infectious diseases among Australian Hajj pilgrims: cross-sectional studies before and after Hajj

Summary Objective For reasons that have yet to be elucidated, the uptake of preventive measures against infectious diseases by Hajj pilgrims is variable. The aim of this study was to identify the preventive advice and interventions received by Australian pilgrims before Hajj, and the barriers to and facilitators of their use during Hajj. Methods Two cross-sectional surveys of Australians pilgrims aged ≥18 years were undertaken, one before and one after the Hajj 2014. Results Of 356 pilgrims who completed the survey (response rate 94%), 80% had the influenza vaccine, 30% the pneumococcal vaccine, and 30% the pertussis vaccine. Concern about contracting disease at Hajj was the most cited reason for vaccination (73.4%), and not being aware of vaccine availability was the main reason for non-receipt (56%). Those who obtained pre-travel advice were twice as likely to be vaccinated as those who did not seek advice. Of 150 pilgrims surveyed upon return, 94% reported practicing hand hygiene during Hajj, citing ease of use (67%) and belief in its effectiveness (62.4%) as the main reasons for compliance; university education was a significant predictor of hand hygiene adherence. Fifty-three percent used facemasks, with breathing discomfort (76%) and a feeling of suffocation (40%) being the main obstacles to compliance. Conclusion This study indicates that there are significant opportunities to improve awareness among Australian Hajj pilgrims about the importance of using preventive health measures.

Risk factors for severity and mortality in patients with MERS-CoV: Analysis of publicly available data from Saudi Arabia

To date, Middle East respiratory syndrome coronavirus (MERS-CoV) has affected over 1600 individuals in 26 countries across the globe, claiming 40% lives and thus poses a great public health challenge to the Middle East and elsewhere. Risk factors for mortality and severity among MERS patients are poorly understood. To address this, the author analysed a large dataset from Saudi Arabian Ministry of Health (MOH) in order to explore key risk factors for mortality and severity, and found that people with certain co-morbid conditions (diabetes, hypertension, renal disease, malignancy, miscellaneous conditions) were at particularly higher risk of dying or suffering severe outcome of MERS-CoV.

Pilot use of a novel smartphone application to track traveller health behaviour and collect infectious disease data during a mass gathering: Hajj pilgrimage 2014

Abstract This study examines the feasibility of using a smartphone application (app) to conduct surveys among travellers during the Hajj pilgrimage, where the use of apps has not been evaluated for infectious disease surveillance. A longitudinal study was conducted among pilgrims at the Hajj 2014 using an iPhone app with separate questionnaires for three study phases covering before, during, and after Hajj. Forty-eight pilgrims from 13 countries downloaded the app. Respondents were aged between 21 and 61 (median 36) years and 58.5% (24/41) were male. Of these, 85% (41/48) completed the first phase, 52% (25/41) completed both the second and third phases, and 25 of these reported meningococcal vaccination, with 36% (9/25) receiving other vaccines. All (25) reported hand hygiene use and 64% (16/25) wore a facemask at some point during the pilgrimage. Four (6%) reported close contact with camels. Respiratory symptoms commenced from the 4th day of Hajj, with sore throat (20%) and cough (12%) being the most common. Three participants (12%) reported respiratory symptoms after returning home. Conducting a prospective survey using a smartphone app to collect data on travel-associated infections and traveller compliance to prevention is feasible at mass gatherings and can provide useful data associated with health-related behaviour.

Australian Hajj pilgrims' infection control beliefs and practices: Insight with implications for public health approaches

BACKGROUND Hajj is one of the largest annual mass gatherings around the world. Although the Saudi Arabian health authority recommends vaccination and other infection control measures, studies identified variable uptake of these measures among pilgrims, and the reasons behind this variability remain unclear. This qualitative study aimed to addresses this knowledge gap. METHODS In-depth interviews were conducted with pilgrims over 18 years of age. RESULTS A total of 10 participants took part in the study. There was low perception of the potential severity of respiratory conditions and the need for influenza vaccination during Hajj. Different attitudes were found by age group with elderly participants believing that they were under Allahs protection, and were fatalistic about the risk of illness. While younger participants described the impact infections would have on their worship. Facemask use was infrequent with discomfort; difficulty in breathing and a feeling of isolation were commonly cited barriers to use of facemasks. Participants accepted and trusted preventative health advice from travel agents and friends who had previously undertaken the Hajj more so than primary care practitioners. CONCLUSIONS This study extended our understanding of how health beliefs influence uptake of preventive measures during the Hajj, and the gaps in the provision of Hajj-specific health information to pilgrims.

Mandating influenza vaccine for Hajj pilgrims

www.thelancet.com/infection Vol 16 June 2016 633 The risk of acquisition and trans mission of respiratory tract infections including infl uenza is considerably enhanced among attendees of the Hajj pilgrimage. Infl uenza vaccine has been recommended by the Saudi Ministry of Health since 2005 for all pilgrims, particularly for those at increased risk of severe disease. The Saudi Ministry of Health is now seriously considering mandating infl uenza vaccine for all pilgrims, and the Saudi Thoracic Society has already urged consideration of a “strict vaccination strategy” for Hajj and Umrah visitors. Pooled estimates from observational studies indicate that infl uenza vaccine is eff ective against laboratory-proven infl uenza among Hajj pilgrims. A more stringent policy to ensure vaccination is justifi ed, but the challenges of such measures need to be carefully considered before making a compulsory recommendation for all Hajj pilgrims. First, the issue of vaccine availability for pilgrims before Hajj needs to be addressed. Hajj takes place on specifi c dates of the lunar calendar, which is 10–11 days shorter than the Gregorian calendar. Therefore, Hajj will occur in all seasons over the years, whereas infl uenza vaccine is available only during autumn and winter months of the southern and northern hemispheres. So, vaccine will not be available for some pilgrims if the Hajj dates correspond with spring or summer season of their countries. This has happened recently in France; none of the pilgrims from Marseille could receive infl uenza vaccine before the Hajj 2013 and 2014 since it was unavailable immediately before Hajj. A great number of pilgrims would thus be unable to meet a mandatory requirement. Second, to overcome the issue of unavailability due to seasonal shift, the Saudi Thoracic Society suggested that the southern hemisphere vaccine be used for pilgrims arriving from the northern hemisphere (evidence D, the committee’s expert opinion), but the logistics of such a policy are not outlined. It is unclear how a tailormade vaccine for a specifi c season and hemisphere could be made available for the population of the other hemisphere; since infl uenza is an RNA virus that mutates rapidly, the vaccine might be ineff ective, and whether the strategy is going to be benefi cial or sustainable should be formally explored. A detailed analysis of data on circulating infl uenza strains globally and at the Hajj found that strain mismatch is frequent, and there are instances of drift occurring between the vaccine strains and the circulating strains of the same hemisphere even before the end of the season. Therefore, the feasibility and usefulness of the Saudi Thoracic Society recommendation to use cross-hemisphere vaccine is uncertain for the moment. Third, although the vaccine uptake among overseas pilgrims has been improving, the uptake among domestic pilgrims has remained suboptimal. Except for the pandemic year when the vaccine uptake exceptionally rose to over 90%, infl uenza vaccine coverage among Saudi pilgrims has ranged between 0·7% and 10·5%, which is much lower when compared with the uptake in overseas pilgrims. Likewise, the uptake among Saudi health-care workers at Hajj is also low. The mandatory vaccination is most justifi ed for the high-risk domestic pilgrims and health-care workers during the winter season (when a vaccine is available). Fourth, there are examples of improving infl uenza vaccine uptake among Hajj pilgrims without mandating it. For instance, infl uenza vaccine uptake has reached and remained 80% or more among Australian Hajj pilgrims primarily with support and recommendation from Hajj tour group leaders. Misperceptions and not being aware of the vaccine availability are important reasons for not receiving vaccination (>75%) among Hajj visitors. Therefore, dispelling myths surrounding vaccinations would be an important step to improve vaccination uptake among Hajj pilgrims. Finally, from the example of meningococcal vaccine, it is apparent that a mandatory policy is not always practical. For instance, many domestic and some overseas pilgrims miss out meningococcal vaccine, although it is mandatory. Even the meningococcal vaccine uptake among domestic health-care workers in Haji is low. Also, mandatory polices for infl uenza vaccine for other populations (eg, health-care workers), have been controversial. In conclusion, infl uenza vaccine is highly commendable for Hajj attendees, including health-care workers, but a mandatory vaccination policy might not be practical. Continuous surveillance of infl uenza, and evaluation of the uptake and eff ectiveness of vaccination in Hajj pilgrims is required to inform a practically feasible policy. Mandating infl uenza vaccine for Hajj pilgrims

Camel exposure and knowledge about MERS-CoV among Australian Hajj pilgrims in 2014

In this study, the authors evaluated Australian pilgrims’ knowledge and perceptions regarding the risk of MERS-CoV and camel contact at Hajj. Moreover, the authors assessed their practice regarding contact with camels during Hajj. This is the first study which has assessed the actual practice of the pilgrims’ contact with camels during Hajj. This study involved two cross-sectional surveys among Australian pilgrims aged ≥ 18 years, before and after Hajj in 2014. The first survey was conducted 1 month before Hajj among departing pilgrims. Participants were met at weekly pre-Hajj seminars run by travel agents and were invited to take part in the survey. The second survey was conducted immediately after the pilgrims’ return to Australia (post-Hajj study). Participants were recruited in selected Muslim suburbs during community gatherings in mosques or Islamic centres. In conclusion, many Australian Hajj pilgrims are not aware of MERS-CoV in Saudi Arabia, and some of them engage in activities that may put them at risk of MERS-CoV; therefore, there is a need for improved awareness among Hajj pilgrims and other travelers to the Middle East regarding MERS-CoV.

Public response to MERS-CoV in the Middle East: iPhone survey in six countries

Abstract Gulf Cooperation Council (GCC) countries bear the heaviest brunt of MERS-CoV. This study aims to compare public awareness and practice around MERS-CoV across GCC countries. A cross-sectional survey was conducted using the Gulf Indicators (GI) smartphone app among people in the six GCC countries, namely Saudi Arabia, Kuwait, the United Arab Emirates, Qatar, Bahrain, and Oman. A total of 1812 participants recruited. All were aware of MERS-CoV, yet the perception and practice around MERS-CoV varied widely between countries. Over two thirds were either “not concerned” or “slightly concerned” about contracting MERS-CoV; believing that they were under Allah’s (God’s) protection (40%) was the most cited reason. While 79% were aware that the disease can transmit through droplet from infected person, only 12% stated that MERS-CoV transmits via camels; people in Saudi Arabia were better aware of the transmission. Nevertheless, only 22% of respondents believed that camels are the zoonotic reservoir of MERS-CoV. Those who were concerned about contracting MERS-CoV (aOR: 1.6, 95% CI: 1.2–2.1, p <0.01) and those who thought MERS-CoV to be a severe disease only for those with high-risk conditions (aOR: 1.5, 95% CI: 1.1–2.1, p <0.01) were more likely to believe that camels are the zoonotic source. However, residents of KSA (aOR: 0.03, 95% CI: 0.01–0.07, p <0.01), UAE (aOR: 0.01, 95% CI: 0.004–0.02, p <0.01) and Kuwait (aOR: 0.03, 95% CI: 0.01–0.07, p <0.01) were less likely to believe that camels are the main zoonotic source compared to respondents from the other countries. Hygienic measures were more commonly adopted than avoidance of camels or their raw products, yet there was a discrepancy between the countries. This study highlights that despite being aware of the ongoing MERS-CoV epidemic; many people lack accurate understanding about MERS-CoV transmission, prevention, and are not fully compliant with preventive measures.