Mass gathering and globalization of respiratory pathogens during the 2013 Hajj

Abstract

Every year, more than 10 million pilgrims arrive in the Kingdom of Saudi Arabia for the Hajj or Umrah. Crowding conditions lead to high rates of respiratory infections among the pilgrims, representing a significant cause of morbidity and a major cause of hospitalization. Pre- and post-Hajj nasal specimens were prospectively obtained from a paired cohort (692 pilgrims) and from nonpaired cohorts (514 arriving and 470 departing pilgrims) from 13 countries. The countries of residence included Africa (44.2%), Asia (40.2%), the United States (8.4%) and Europe (7.2%). Nasal specimens were tested for 34 respiratory pathogens using RT-PCR. A total of 80 512 PCRs were performed. The prevalence of viruses and bacteria increased, from 7.4% and 15.4% before the Hajj to 45.4% and 31.0% after the Hajj, respectively, due to the acquisition of rhinovirus, coronaviruses (229E, HKU1, OC43), influenza A H1N1, Streptococcus pneumoniae, Haemophilus influenzae and Staphylococcus aureus. We did not identify Middle East respiratory coronavirus carriage. At arrival, the prevalence of several viruses was clearly dependent on the pilgrim's country of origin. After Hajj participation, these viruses were isolated among pilgrims from all countries, with few exceptions. No significant differences were observed between paired and nonpaired cohort results. Our results strongly suggest that, given the particularly crowded conditions during the rituals, an international mass gathering such as the Hajj may contribute to the globalization of respiratory pathogens after the cross-contamination of pilgrims harbouring pathogens that easily spread among participants. Influenza and pneumococcal vaccination, face mask use and hand hygiene should be considered in the context of the Hajj.

Indian Medical Mission at Hajj-2016: Mass-Gathering Medicine Perspectives, Challenges, and Opportunities in a Mission Posture

“…Two MERS hospitalizations and zero deaths were reported during Hajj 2014. 15 Hajj also has the distinction of having the best mass gathering preparedness effort in the world; nevertheless, the history of Hajj is replete with disasters and accidents leading to mass mortality. 37 Mass gathering medicine at Hajj is backed by robust public health policies encompassing a multi-sectoral risk mitigation, intervention, coordination, cooperation, and communication strategy in international dimensions.…”

“…[3][4][5]23 Emerging diseases such as Ebola, MERS, Alkhumra viral hemorrhagic fever, Rift Valley fever, and unidentified imported diseases having intercontinental implications challenge global public health security during Hajj. 1,15,18 Overcrowding increases the risk of transmission of respiratory pathogens such as human rhinovirus, respiratory syncytial virus, MERS and non-MERS Corona virus (229E, HKU1, NL63, OC43), influenza A H1N1, influenza B, adenovirus, multidrug resistant tuberculosis (MDRTB), and Streptococcus pneumoniae in an environment of "Hajj cough" in mass gathering Hajj rituals. 5,10,16,17,19,24 A significant difference has been seen in pre-and post-Hajj carriage rates of Influenza A and B, rhinovirus, and non-MERS coronaviruses.…”

“…3,5,39 Quality and preparedness interventions should incorporate pneumococcal vaccinations for the elderly; objective scoring systems such as the Acute Physiology and Chronic Health Evaluation IV for elderly pilgrims; third party medical audits for resources, protocols, patient comfort and security; facility worthiness for geographic, social, environmental, and technological phenomena; and evaluation of contingency plans. 15,40,41 Clientele interventions targeted at patient education towards choosing to perform Hajj at a younger age, selfWhat Is Already Known? Mass-gathering medicine at Hajj is plagued by issues of healthcare accessibility, on-site treatment, evacuation, response to disasters and public-health emergencies; emanating challenges in interdependent dimensions of health and human support systems.…”

“…Thus, they face serious complications or polymicrobial infections mandating tertiary care referrals and/or evacuation from Saudi Arabia to their residence in India. [15][16][17][18] The average length of secondary care admission was 3.6 days. [19][20][21] Healthcare for pilgrims from all countries is completely sponsored by Saudi Arabia through 141 Hajj medical centers and 100 ambulances; however, there are limitations in bed availability, ambulance transfers, and the daily follow-up of transferred patients.…”

Operations Throughput as a Determinant of Golden-Hour in Mass-Gathering Medicine

“…Sometimes, visit come at the cost of leaving the medical facility without a doctor. In any resource limited scenario, most patients who deserve time, access definitive-care beyond the golden-hour [7,8,25,26].…”