Epidemiological Pattern of Diseases and Risk Behaviors of Pilgrims

Vol. 83 N°.l& 2,2008
/ Egypt Public Health Assoc
Epidemiological Pattern of Diseases and Risk
Behaviors of Pilgrims Attending Mina Hospitals,
Hajj 1427 H (2007 G)
Nahla K. R. Ibrahim
Epidemiology, Department of Epidemiology, High Institute of Public Health,
Alexandria University
ABSTRACT
Hajj is a unique Islamic ritual where around 2.5 million Muslims gather
annually in the Kingdom of Saudi Arabia. The objective of this work was to
determine epidemiological pattern of diseases and risk behaviors of pilgrim
patients during Hajj 1427 H. A cross sectional study was conducted at two
randomly chosen Mina hospitals and a total of 248 patients were selected
using systematic random sample method. Results show that about two-fifths
(39.1%) of patients had chronic diseases and only 34.4 % received health
education before Hajj. The commonest patients' complaints were cough,
dyspnea and fever (28.2 %, 27.4% and 25 % respectively). Acute respiratory
infections and gastrointestinal illnesses were the commonest diagnosed
diseases. Analgesics and antibiotics were the most commonly prescribed
drugs. Regarding risky behaviors, 24.6 % of pilgrims were unvaccinated
against meningococcal meningitis, 87.9 % didn't wear protective masks and
43.1 % had their hair shaved or cut by re-used razors or scissors. Pilgrims
who followed organized camps and who received health education before
hajj conducted significantly lower risky behaviors compared to others.
Recommendations: Intensified health education campaigns should be
conducted for all pilgrims in their mother countries & KSA. Surveillance of
behavioral risk factors, formulating intervention strategies and proposing
new policies and regulations are urgently needed.
Key words: Hajj, epidemiology, diseases, risk, behaviors.
INTRODUCTION
Every year around 2.5 million Muslims from more than 140
countries around the world gather annually in the Kingdom of
Corresponding Author:
Nahla Khamis Ragab Ibrahim
Epidemiology, Department of Epidemiology
High Institute of Public Health, Alexandria University
Email:nahlakhamis@yahoo.com
/ Egypt Public Health Assoc
Vol. 83 N°. 1&2,2008
Saudi Arabia to perform the sacred ritual, the fifth pillar of
Islam, Hajj. u-5> It is the largest annual gathering of its kind in
the world. <® Pilgrims (Hajjes) vary considerably in their sociodemographic characteristics, health related behavior, underlying
health status and medical needs. <5« 7>
Pilgrims can be divided into two groups; the first which
represents the majority, consists of those who join organized Hay
groups (Hamla), and the second consists of those who do not join
organized Hajj groups. This group resides on the street and is
therefore given the name "Muftaresheen". It is expected that
these Hajjes will face numerous difficulties. ®
During HafJ, the extreme congestion of people and vehicles &
poor behaviors increase the risk of spread of many epidemics &
other health problems, w Non-communicable health risks
associated with the Hajj are mainly related to heat exhaustion,
heat stroke and physical injuries. In addition, the physical
exertion, overcrowding and high prevalence of pre-existing health
conditions favor the spread of communicable diseases. <6)
Infection hazards at the Hajj have domestic and
international ramifications as Muslim pilgrims return home.*10*11)
Most of the infections likely to occur during the pilgrimage are
preventable. Acute Respiratory Tract Infections (ARIs) have high
secondary attack rates and thus there is great potential for its
spread among the Hajjes. <10> In addition, epidemiological studies
also showed that hajj pilgrimage plays an important role in
meningococcal infections outbreaks.*1'12) Overcrowded conditions,
high humidity and dense air pollution all contribute to
occurrence of carrier rate as high as 80 %. When carrier rate
become so abnormally high, outbreak become a real public
health threat.*13) Following several outbreaks of meningococcal
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disease among pilgrims, the Saudi authorities now require
medical certification of quadrivalent vaccine (A, C, W135, and Y)
before obtaining Hajj Visa. & 6« i3>
One of the rites of Hajj for men is to have their head shaved
(although many also cut the hair, which is acceptable). Although
the Saudi authorities provide licensed barbers with a new blade
for each pilgrim, <4> other opportunistic barbers in makeshift
centers may not conform to such standard and most of them use
the same razor blade for many different people before discarding
it. <4* 6> This practice puts pilgrims at risk of acquiring hepatitis B,
C and HIV infections. <4- 6» 14*15> Pilgrims need to be made aware of
this and should insist that a new razor blade is used. (15>
During the Hajj days, too many Hajj pilgrims get medical
problems ranging from minor flu to major illnesses.*5) Planning
for health care requires knowledge of the pattern of diseases and
risky behaviors of people during Hajj.f2) There is lack of
comprehensive epidemiological studies on diseases and
behaviors during Hajj. The objective of the work was to
determine epidemiological pattern of diseases and risk behaviors
of pilgrim patients during Hajj 1427 H. (2007 G).
MATERIAL AND METHODS
After obtaining approvals, a cross sectional study was
conducted in Mina, a holy place where all pilgrims camp for 5
days from 8 to 13 Dull Hijjah. The study populations were
patients attending two randomly selected Mina hospitals (Mina al
Tawarri & Mina El- Jesser). Patients were chosen using
systematic random sample technique, where every 10 to patient
attended the selected hospitals, speaks Arabic or English, and
accepted to participate in the study was included. The patients
or their accompanying persons were interviewed using a pre-
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Vol. 83 N°.l&2,2008
designed structured questionnaire for obtaining information
about patient's personal & socio-demographic characteristics
such as age, sex, nationality, level of education and occupation.
Type of accommodation during Hajj either in organized camp
(Hamla) or non-organized Hamla (Muftareesh) was inquired
about. If the patient didn't follow an organized camp, cause of
none-joining camp, place of accommodation and problems
encountered during Hajj were also inquired about. Past history
of chronic medical conditions was obtained. The main presenting
patient's complaints were taken. In addition, Hajj health-related
behaviors were inquired about. For example, receiving
immunization with quadrivalent meningococcal vaccine, amount
of drinking water per day, hours of sleeping, hand hygiene,
wearing protective face mask or identified wrist bandage &
method of hair shaving or cutting,
Physicians were observed during examining and prescribing
drugs for the patients. The diagnosis and the prescribed
medications were recorded
The data was checked, coded, and analyzed using the
Statistical Package for Social Sciences (SPSS) version 13. Mean,
standard deviation, x? and Fisher's Exact test were calculated.
All values deemed statistically significant to p < 0.05.
RESULTS
The total number of pilgrims interviewed during the study
amounted to 248 patients. About three-fourths (73.4 %) of them
performed Hajj for the first time with mean age of 40.12 +17.6
years.
Table (1) portrays that about one- third of Hayes aged less
than 30 years or 50 years and above. The male to female ratio
was 1:1.2. Concerning the nationality, 38.3% were Saudi while
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34,3 % were from the other Arab countries. More than half (53.6
%) of patients had less than secondary education and 13.7 % of
them were manual workers. It is also apparent from the table
that more than one- fourth (26.6 %) of patients didn't join an
organized Hamla. About two-fifths of Hajjes (39.1 %) suffered
from chronic disease.
Table (1): Characteristics of the Sample of Pilgrim Patients who
Attended Mina Hospitals during Hajj 1427 H
Characteristics
Age:
< 30 years
30- <40
40-<50
50 and more
Sex:
Male
Female
Nationality:
Saudi
Other Arab countries
South East Asian& Indian Subcontinent
Other African countries
Iran, Turkey
Europe
Educational level:
Less than secondary
Secondary and above
Occupation:
Manual
Clerical
Technical
Professional
Housewife (Females)
Not working or student
Residence:
Saudi Arabia
International
Chronic disease:
Present
Absent
Residence during HaJJ:
Organized Camp (Hamla)
Non-organize camp (Muftarsheen)
Total
Number
%
81
42
47
78
32.7
16.9
18.9
31.5
113
135
45.6
54.4
95
85
45
14
8
1
38.3
34.3
18.1
5.7
3.2
0.4
133
115
53.6
46.4
34
37
17
21
82
57
13.7
14.9
6.9
8.5
33.0
23.0
129
119
52.0
48.0
97
151
39.1
60.9
182
66
248
73.4
26.6
100
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Regarding t h e type of chronic diseases, it was found that
11.7 %,
6 %, 5.6,
% and 10.1 % of pilgrims suffered
from
bronchial a s t h m a , diabetes mellitus, hypertension and multiple
chronic diseases respectively while 5.7 % suffered from other
diseases.
Concerning
pilgrims
who
didn't join
organized
camps
(Muftasheen), 89.4% of t h e m mentioned that the reason for non
joining Hamla w a s financial. About two-fifths of t h e m (39.4%)
stayed on t h e streets, 36.4 % resided on a tent for more t h a n one
person, 15.1 % o n mountain a n d 9.1 % on a tent for one person.
Figure (1) shows t h a t the main problems encountered by
Muflasheen were overcrowding, offensive odors,
overcrowded
WC's a n d lack of hygienic food (26.1%, 16.9% , 9.2% and 3 . 1 %
respectively). On the other h a n d , 4 4 . 6 % mentioned thai Ihey
suffered from more than one problem.
44.6
50
40
30
20
10
0
26.1
—_
16.9
9.2
—,
A
Jt&
,<?
cf
&
■••• •■"•■• • • - »
^
*PV
>
^
c?
3.2
i
^
<X
x>
<?
^
v»*
^
c
Problem
Figure (1): Problems Encountered among Pilgrims Who didn't Join
Organized Camp (Muftasheen)
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Table (2) shows patients' complaints, physicians' diagnosis
and prescribed drugs for Hajjes. Cardiorespiratory symptoms as
cough, dyspnea and chest pain were presented by 28.2%, 27.4%,
and 15.3/ of patients respectively.
Table (2): Pilgrims' Complaints, Diagnoses and Prescribed Drug of
Patients who Attended Mina Hospitals during Hajj 1427 H
Symptoms
Cough
Dyspnea
Fever
Abdominal pain
Headache
Running nose
Chest pain
Diarrhea
Vomiting
Pain, swelling of feet
Coma
Itching of the skin
Constipation
Physicians' diagnoses:
Respiratory tract infection
Gastrointestinal illnesses
Cardiovascular disease
Injury, trauma
Musclo-skeletal
Fracture
Abscess
Chronic disease
Skin disease
Urinary tract infections
Neurological disease
Suspected meningitis
Heat related problems
Prescribed drugs:
Analgesics
Antibiotics
Anti-tussives
Ventilator (Nebulizer)
I.V. fluid
Anti- histaminic
Anti-spasmodic
Anti-hypertensive
Hypoglycemic
No.
70
68
62
53
48
41
38
34
34
20
9
6
5
Prevalence (%)
28.2
27.4
25.0
21.4
19.4
16.5
15.3
13.7
13.7
8.1
3.6
2.4
2.0
74
28
25
22
18
16
10
7
6
4
4
3
1
29.8
11.3
10.0
8.9
7.3
6.5
4.0
2.8
2.4
1.6
1.6
1.2
0.4
147
70
48
37
33
31
26
15
8
59.3
28.2
19.4
14.9
13.3
12.5
10.5
6.0
3.2
N.B. Bach inquiry is separately taken
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Vol. 83 AK 1 & 2,2008
Gastrointestinal complaints as abdominal pain was
encountered among 21.4%, while both vomiting and diarrhea
were found among 13.7 % of patients. On the other hand, coma
occurred among 3.6 % of Hajjes.
Regarding physicians' diagnosis, it was found that ARIs,
gastrointestinal illnesses, and cardiovascular diseases were the
commonest diagnosed conditions among pilgrim patients (29.8%,
11.3 % and 10.0 % respectively). On the other hand, the least
diagnosed cases were cases with urinary tract infections (UTIs),
neurological diseases, suspected meningitis and heat related
problems.
The number of prescribed drugs ranged from 0-5 drugs and
the average number of drug per encounter was 1.5 drugs.
Analgesics were the commonest prescribed drugs (59.3%),
followed by antibiotics (28.2%) and anti-tussives (19.4%).
Table (3) shows the relationship between the type of
accommodation in Mina and health-related behaviors done by
hajjes. It is apparent from the table that risky behaviors were
much lower among pilgrims who joined organized Hamla
compared to Muftarsheen. Meningococcal vaccine coverage rate
was 75.4 % (88.5 % for those who joined Hamla compared to
only 39.4 % among Muftasheen). A highly statistical significant
difference is found (x2= 62.87, p <0.000). Similarly, 74.2 % of
Hajjes who followed Hamla had their hair shaving or cut by unused or own blades or scissors compared to only 9.1 % among
Muftasheen. A highly statistical significance difference is present
(x2= 83.64, p <0.000). The same was also seen regarding wearing
face mask, wrist bandage, and other health related behaviors.
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Table (3): Relationship Between Type of Accommodation and Healthrelated Behaviors of Pilgrim Patients Attending Mina
Hospitals
p ^ ^ ~
Accommodation
Following organized
camp
No
1 Yes
II Behavior
^"^--^^
%
%
No.
No.
II Received Meningococcal Vaccine—
Yes
161 88.5
26
39.5
No
22
40
64.5
11.5
|| Wear face mask
15.4
Yes
28
2
3.0
No
154 70.6
64
97.0
Wear wrist bandage
Yes
i4t 79.1
8
12.1
No
20.9
38
58
87.9
II Hair Shaving or cut
135 74.2
6
9.1
I Unused or own blades / scissors
|| Reused or other's blades / scissors
47
25.8
90.9
60
|| Hand Hygiene:
||
Frequent washing
75
41.2
3
4.5
||
Infrequent or no
107 58.8
63
95.5
|| Sleeping hours / day
||
> 6 hours
76
41.8
5
7.6
1
^ 6 hours
61
92.4
106 63.5
B| Amount of water/day
< 1 Liter
129 70.9
25
37.9
||
< 1 Liter
53
29.1
41
62.1
|| Carry luggage during hajj
22.7
171 94.0
15
No
11
51
77.3
6.0
II Yes
|| Go to Manasek:
||
By Bus or car
172 94.5
6
9.1
10
5.5
|
On back of buses and on foot
60
90.9
182
100
66
100
I Total
!
I
I
I
Total
X2
(P)
No.
%
187
62
75.4
24.6
(0.000) 1
30
218
12.1
87.9
(0.004) 1
152
96
61.3
38.7
(0.000) 1
141
107
56.9
43.1
(0.000) 1
78
170
31.5
68.5
(0.000)*
81
167
32.7
67.3
25.73
154
94
62.1
37.9
(0.000) 1
186
62
75.0
25.0
131.1
(0.000) 1
178
70
248
71.8
28.2
100
(0.000) 1
62.87
6.92*
91.64
83.64
(0.000) 1
22.41
174.4
mtSSSSSSSSSSmi
• Fishefs Exact test
It is apparent from table (4) that receiving health education
before Hajj resulted in lowering the rate of risky behaviors. The
rate of meningococcal vaccine coverage was 87.5 % among those
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who received health education compared to only 66.7 % among
those who didn't take the educational advice. About one-fourth
of those who received education were protective mask during
doing Haft rituals compared to only 3.5 % of those who didn't
receive educational advice. On the other hand, only 7.7 % of
those received health education carried their luggage during
Manasek compared to 37.5 % of those who didn't receive
education (x2= 28.61, p <0.000).
Table (4): Relationship Between Receiving Health Education before Hajj
and Health-related Behaviors of Pilgrim Patients Attending
Mina Hospitals
||^--^.
Received H.E
Health Education
X2
Total
No
II Behavior
^^""^^^^^
(P)
No.
%
No.
%
No.
%
II Yes
No
91
13
87.5
22.6
96
48
66.7
77.4
187
62
75.4
24.6
(0.000)* |
jl Yes
H No
25
79
24.0
36.2
5
139
3.5
63.8
30
218
12.1
87.9
24.02 ||
(0.000)* ||
82
22
78.8
21.2
70
74
48.6
51.4
152
96
61.3
38.7
23.26 11
|| Un-used or own instrument
| Used or non-own instrument
|| Hand Hygiene:
I
Frequent washing
1
Infrequent or no
I Sleeping hours / day
I
> 6 hours
1
< 6 hours
|| Amount of water/day
82
22
78.8
21.2
59
85
41.0
59.0
141
107
56.9
43.1
(0.000) 11
61
43
58.7
41.3
17
127
11.8
88.2
78
170
31.5
68.5
61.47 ||
(0.000)* ||
48
56
46.2
53.8
33
111
22.9
77.1
81
167
32.7
67.3
(0.000)* 1
II
< 1 Liter
I
< 1 Liter
87
17
83.7
16.3
67
77
46.5
53.5
154
94
62.1
37.9
35.36 ||
(0.000)* ||
11 Received Meningococcal Vaftciael
II11 Wear face mask
14.13 II
II Wear wrist bandage
Yes
II No
II11 Hair Shaving or cut
(p.000)* ||
35.31 ||
14.82 ||
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Table(4):Cont.
|P^Z~^
Accommodation
BSiaesaassassssasssBsssssBS
Following organized
camp
Yes
No
II Behavior
^**"^^^^ No.
%
%
No.
II Carry luggage during hajj
No
96
92.3
90
62.5
|
Yes
7.7
8
54
37.5
|| Go to Manasek:
||
By Bus or car
94
84
58.3
90.4
10
41.7
II
On back of buses and on foot
6.9
60
1 Total
1
———
* Significant
104
100
144
100
Total
(P)
No.
%
186
62
75.6
25.0
28.61
(0.000)*
178
70
71.8
28.2
30.62
(0.000)* 1
248
100
sagsag
DISCUSSION
In modern health care system continuous measurement and
monitoring of clinical data comprise the basis of documentation
for the quality of care. <1G) The present study revealed that the
leading causes of morbidity among Hajjes were respiratory arid
gastrointestinal illnesses. These findings coincide with results of
study conducted by reviewing records of Hajjes attended Mina
Primary Health Care Centers, w Similar results are also reported
from other studies.*16^) On the other hand, Khan et al. (2006)
found that cardiovascular diseases were the commonest
morbidity that necessitated admission to a tertiary care hospital
in Mecca. <18> The discrepancy between the current study and
previous one may be attributed to differences in the type of
patients or health care settings, as Khan's study was conducted
among patients admitted in a tertiary care hospital and twothirds of them were referred from other facilities (severer cases).
(18)
Hajj represents a major c&Ilmge to the Saudi Ministry of
Health in addressing infection control at this big gathering, uo)
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The present study demonstrated that the prevalence of ARIs
among pilgrim patients was 29.8%. This may be attributed to
overcrowding, congestion and also because this Hajj occurred
during winter months when respiratory diseases are more
frequent. This result agrees with that of a study conducted
among 250 personnel serving Hajj medical mission at Al-Hada
and Taif Armed Forces Hospitals (the rate of ARIs was 25.6%) <19)
ARIs were also found among 26 % of patients in a study during
Hajj 1420 H.(20> The most common diseases among Iranian
pilgrims during the 2 recent Hajj journeys were also ARIs. <21)
Another cross-sectional study found that pneumonia was
responsible for 22% of admission to ICU of Mina and Arafat
hospitals during Hajj 1424H. & On the other hand, a higher ARIs
cumulative incidence rate (39.8%) was reported from a cohort
study done among hajjes from Riyadh governorate.*10* This higher
rate may be attributed to differences in the study designs; as
pilgrims from Riyadh's study were followed up during the period
from 8 Dhu al-Hijja to 27 Dhu al-Hijja. <10>
Cough, dyspnea and fever were the commonest complaints
of patients in the present study. On the other hand, Khan et al.
(2006) reported that dyspnea, chest pain, cough and fever were
the most common symptoms.<18) These disagreements may be
also due to differences in type of patients and study settings.
Travelers commonly face diarrhea, being the most commonly
reported medical problem when visiting developing nations.f13>
Results of the current study showed that 13.7 % of pilgrims
complained from diarrhea which goes on line with results
reported among patients from different Gulf countries who
attended clinics of Gulf Cooperation Council States' Hajj Medical
Mission (GCCSHM). UT>
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In the present study urinary problems and heat disorders
constituted only 1.6 % and 0.4 %, which coincide with results of
GCCSHM study. (17> These low rates may be because Hajj in
these two studies didn't occur during summer months.
In the present study trauma was found among 8.9 % of
patients. Madani et al. (2004) found that trauma accounted for
6.4% of causes of admissions to ICU. ®
As regards chronic diseases, results of the current study
showed that diabetes mellitus and hypertension were reported by
6 % and 5.6 % of pilgrims respectively. Khan et al. (2006)
reported higher rates (31.9% and 37.2 % respectively).(18> Th^se
discrepancies may be attributed also to differences in type of
patients and health care facility.
Regarding drugs, results of the present study revealed that
analgesics, antibiotics and anti-tussives were the most
commonly prescribed drugs which coincide with results of a
study conducted among patients attending GCCSHM Clinics. (17>
Analysis of results of the present study showed that 26.6 %
patients didn't join organized camp (Muftarsheen). The majority
of them explained that the most common reason for not joining
Hamla was financial. This goes on line with result of Fatani et al.
(2001) <8> Muftarsheen in the present study faced many problems
(overcrowding, offensive odors, overcrowded WC's, and lack of
hygienic food) which also coincide with results of Fatani et al.
(2001) In addition, the majority of them mentioned that their
sleeping hours during Hajj were less than 6 hours/ day which
coincide with results of the previous study. Muftarsheen in the
two studies also conducted significantly higher rates of risky Hajj
health related behaviors compared to other hajjes. In the current
study, only 75.4 % of hajjes received meningococcal vaccine
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(87.5 % among those joined organized Hamla versus 66.7 %
among Muftrasheen). On the other hand, higher vaccination
coverage rate (89.8%) was reported from a study conducted
during Hajj 1422H. The cause of lower vaccination coverage in
the present study may be attributed to lower percentage of
pilgrims who joined Hamla in the present study (73.4%)
compared to the study of 1422 H study (94.4 %).») Organized
Hamla usually require a valid meningococcal vaccine certificate
for obtaining Hajj permission and joining the camp.
The CDC recommendations for the prevention of influenza
include wearing a facemask. Although this may not provide
complete protection from infection, it will reduce the incidence of
infection by preventing droplet inhalation, which is considered
one of the main modes of transmission of most upper respiratory
tract infections (URTIs). 02) i n the present study 87.9 % of hajjis
didn't use the mask. In a study in Riyadh's it was reported that
46.4% of hajjes never used a facemask while 20.4 % used it
sometimes. (1(»
The present work revealed that 61.3 % of pilgrims wore
identified wrist band which is similar to results of previous study
conducted for identifying behavioral risk factors for diseases
during Hajj 1418 and 1419. <23> On the other hand, a higher rate
(73 %) was reported by Turkistani et al.(1995) ^
The hygienic behavior of Hajjes and the practice of barbers
could make head shaving during Hajj an optimum focus of
spread of blood borne diseases. (l5> Results of the present study
showed that 43.1 % of Hajjes had their hair shaved or cut by reused (used by other Hajjis) razor blades or scissors. Another
study found that 25 % of Hajjes reused razor blades used by
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others (23> while a third one reported that 21 % of barbers used
the same blade for more than one head shave. (15>
Health education remains the backbone for preventing most
of Hajj associated diseases. ® During Hajj season Saudi Ministry
of Health in collaboration of Islamic countries and the WHO
carries out the health education. (25> In the present study, strong
associations were found between practicing sound Hajj healthrelated behaviors and receiving health education advice before
Hajj. This coincides with results ?.:other studies. <25-27>
Hand washing is recommended for protection of many
diseases, including influenza, during Hajj. <28) Results of the
present study showed that 58.7 % of hajjes who received health
education advice frequently washed their hands, and this rate
was much lower among those who didn't take the educational
advice. Similar findings were obtained among Hajjes from
different nationalities who received educational advice in Hajj
1999. v®
CONCLUSION
ARIs and gastrointestinal illnesses were the most prevalent
diseases among pilgrims in the current study. Poor Hajj healthrelated behaviors (un-vaccination against meningococcal vaccine,
re-using of hair shaving and cutting tools, and not wearing
protective face masks or identified wrist bandage) were prevailed
among high percentage of pilgrims. Those who didn't join an
organized camp (Muftasheen) or who didn't receive health
educational advice before Hajj were significantly more
susceptible to practice poor Hajj health-related behaviors.
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/ Egypt Public Health Assoc
Vol. 83 N°.l&2,2008
RECOMMENDATIONS
•
Surveillance of behavioral risk factors can provide the basis for
evaluating programs designed to reduce the prevalence of unhealthy risk behavior during Hajj and for
formulating
intervention strategies with proposing new policies and
regulations.
•
Strong efforts should be exerted to stop the problem of "Eftrash"
by intensifying health education on the hazards of staying on
street, application of strong regulations regarding joining
organized Hajj group and decreasing the cost of camps.
•
Exerting continuous efforts to raise the immunization coverage
of meningococcal vaccine to almost 100 % to prevent outbreaks.
•
Hepatitis B vaccination is recommended by CDC for those who
didn't
receive
vaccine
in
the
Expanded
Program
on
Immunization (EPI) and who stay for a period of more than 1
month in SA.
•
Increasing the availability of safe razors blades and sterile head
shaving services is needed. In addition, establishing official
shaving areas at each camp is recommended. In these areas
head shaving should to be done by trained, screened barbers
(free from blood borne diseases), who received health education
on sterile hair shaving and who are licensed and supervised by
Saudi government. Used blades should be placed in punctureresistance containers,
•
Increasing the availability of free face masks and identified
wrist bandages in each camp.
•
Intensifying health education activities before Hajj to raise
awareness of pilgrims about Hajj health related behaviors and
how to avoid conduction of poor behaviors.
30
J Egypt Public Health Assoc
Vol. 83
N°.l&2,2008
Acknowledgements
The author would like to thank the entire group of C3 of the
fourth year medical students during the educational year 2006 2007 for their active participation in the study. Special thanks to
students Mona Al-Khotani and Dania Monagel for their active
contribution to this work. Acknowledgment should be extended
to all doctors and patients who participated in the study.
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