The Lancet
Nov 21, 2009  Volume 374  Number 9703  Pages 1723 – 1792
http://www.thelancet.com/journals/lancet/issue/current

Hajj and 2009 pandemic influenza A H1N1
The Lancet

More than 2·5 million Muslims from over 160 countries will be going on Hajj—a pilgrimage to Mecca, Saudi Arabia—this year during Nov 25—30. Such a mass gathering, with up to seven people per m2, increases the risk of spreading infectious diseases, particularly the 2009 pandemic influenza A H1N1.

In The Lancet today, Ziad Memish and colleagues report several recommendations, based on the current status of this pandemic, for provision of the best health services to pilgrims and to keep disease transmission to a minimum among pilgrims and their contacts at home. These recommendations—which are to be put into practice before and during this year’s Hajj—were made after a consultation in Jeddah during June 26—30, 2009, between global agencies at the invitation of the Saudi Arabian Ministry of Health. They are grouped according to screening and isolation; surveillance, epidemiology, and informatics; laboratory testing; infection control; and treatment of the 2009 pandemic influenza A H1N1 infection.

The most important recommendation is that people at risk of infection—such as those older than 64 years, children younger than 5 years, pregnant women, and immunosuppressed individuals—should not go on Hajj this year. However, because Hajj is one of the five pillars of Islam and should be done at least once in a Muslim’s lifetime, individuals will probably not want to postpone after they have spent much time saving money and planning for this purpose. Some of the other recommendations, such as isolation of pilgrims with influenza-like illness, might not only deter individuals from reporting their illness but will undoubtedly also cause them distress and difficulty reuniting with their companions. Improvement of hand hygiene for infection control might be more acceptable than some of the other recommendations because pilgrims should wash before they pray.

These recommendations are a starting point, but they will need to be assessed. Some recommendations might need to be adjusted or discarded as the pandemic develops. However, pandemic influenza A H1N1 alone is understandably unlikely to dissuade many Muslims from going on Hajj.

Establishment of public health security in Saudi Arabia for the 2009 Hajj in response to pandemic influenza A H1N1

ZA Memish, SJN McNabb, F Mahoney, F Alrabiah, N Marano, QA Ahmed, J Mahjour, RA Hajjeh, P Formenty, FH Harmanci, H El Bushra, TM Uyeki, M Nunn, N Isla, M Barbeschi, the Jeddah Hajj Consultancy Group

Public Health
Establishment of public health security in Saudi Arabia for the 2009 Hajj in response to pandemic influenza A H1N1
ZA Memish, SJN McNabb, F Mahoney, F Alrabiah, N Marano, QA Ahmed, J Mahjour, RA Hajjeh, P Formenty, FH Harmanci, H El Bushra, TM Uyeki, M Nunn, N Isla, M Barbeschi, the Jeddah Hajj Consultancy Group

Summary
Mass gatherings of people challenge public health capacities at host locations and the visitors’ places of origin. Hajj—the yearly pilgrimage by Muslims to Saudi Arabia—is one of the largest, most culturally and geographically diverse mass gatherings in the world. With the 2009 pandemic influenza A H1N1 and upcoming Hajj, the Saudi Arabian Ministry of Health (MoH) convened a preparedness consultation in June, 2009. Consultants from global public health agencies met in their official capacities with their Saudi Arabian counterparts. The MoH aimed to pool and share public health knowledge about mass gatherings, and review the country’s preparedness plans, focusing on the prevention and control of pandemic influenza. This process resulted in several practical recommendations, many to be put into practice before the start of Hajj and the rest during Hajj. These preparedness plans should ensure the optimum provision of health services for pilgrims to Saudi Arabia, and minimum disease transmission on their return home. Review of the implementation of these recommendations and their effect will not only inform future mass gatherings in Saudi Arabia, but will also strengthen preparedness efforts in other settings.