This article aims to support pharmacists providing general travel advice to patients undertaking pilgrimage, current vaccination advice on vaccine preventable diseases and precautionary measures for diseases that are non-vaccine preventable

The Hajj is the annual pilgrimage to Mecca performed at least once in a lifetime by Muslims. The timing of the Hajj is based on the Islamic lunar calendar. In 2019, it is expected to fall between 9th to 14th August.

Umrah is a shorter, non-compulsory pilgrimage that can be performed at any time of the year.

Every year more than four million pilgrims from around the world converge on Saudi Arabia for both the Hajj and Umrah season¹. The health risks can become more acute when large numbers of travellers visit the country and converge in a single area.

All pilgrims should ensure that they are up-to-date with UK routine vaccination schedule immunisations including measles, mumps and rubella (MMR), diphtheria, tetanus, polio (Td/IVP) and meningitis ACWY.  Travellers on extended journeys (longer than four weeks) or those visiting friends and relatives might want to consider vaccinations against hepatitis A and B and rabies.

Numark members requiring further information on assessing a patient’s travel risk can access Numark’s Pharmacy Excellence module on Travel Risk Assessment.

Numark can also support you to set up a vaccination service for visitors to Hajj and Umrah, to provide the required vaccinations as indicated below – for more information click here.  

Meningococcal Meningitis

During the Hajj, carrier rates for meningococcal disease rise to a level as high as 80%¹ due to intense overcrowding, high humidity and dense air pollution. When rates of carriage rise to this level, the risk for meningococcal outbreaks becomes a real concern.

All travellers visiting this country for the purposes of Hajj or Umrah, or for seasonal work in Hajj areas (in Mecca and Medina along the west coast) require vaccination against ACWY meningococcal meningitis.

Transmission

Meningococcal infection is transmitted is by droplet or aerosol spread of nasal/pharyngeal secretions of infected individuals or asymptomatic carriers. Close/prolonged contact is required for transmission - kissing, sneezing, coughing or living in close contact.

The meningococcal bacterium can be commensal of the upper respiratory tract allowing asymptomatic carrier states.

Vaccination

The Saudi Arabia Ministry of Heath requires all adults and children over the age of two years arriving for pilgrimage to produce a certificate of vaccination with a quadrivalent polysaccharide conjugate vaccine against meningitis (Nimenrix® or Menveo®) which has been issued within the last five years and  no less than 10 days prior to arrival in Saudi Arabia.  The quadrivalent vaccine is protective against the most likely serotypes encountered during travel, A, C, W-135 and Y.

Vaccination against meningococcal group B is offered as part of the UK childhood vaccination schedule at 2, 4 and 12 to 13 months and serogroups  A,C,W and Y in the UK childhood vaccination schedule at around 14 years of age.

Poliomyelitis

Polio has largely been eradicated in the Western World. However, due to poor uptake of the polio vaccine, circulating polio virus is present in third world countries.

The Saudi Arabian Ministry of Health insists that pilgrims arriving from countries that have wild polio virus circulating (e.g. Afghanistan, Democratic Republic of Congo, Mozambique, Niger, Nigeria, Pakistan, Myanmar, Papua New Guinea, Somalia, South Sudan, Syrian Arab Republic and Yemen) or vaccine-derived poliovirus (cVDPV2) and from countries at risk of polio reintroduction are required to submit a valid polio vaccination certificate and will also receive one dose of oral polio vaccination at the border points on arrival regardless of their age or vaccination history.

There is no risk of polio in Saudi Arabia itself.

Transmission

The virus causes an acute enteroviral infection. Severe infection may cause permanent paralysis. Poliomyelitis is spread by the following:

• Human faecal-oral route.
• Poor sanitation.
• Viral shedding from throat or faeces may be prolonged after infection.

Vaccination

Polio vaccine in the form of inactivated polio virus is normally only given as a component of combination vaccines in the UK immunisation schedules and cannot be obtained separately.

The recommended combination vaccine containing inactivated polio for primary immunisation or booster doses for individuals 10 years or older is Revaxis®. UK pilgrims who have completed a primary course of polio vaccination as part of the normal immunisation schedule may still need vaccination.

Pilgrims should ensure that they are up to date with all their recommended immunisations under the UK vaccination schedule. However a booster in the form of tetanus/diphtheria and inactivated polio vaccine (Td/IPV) is recommended if it has been more than ten years since the last dose.

Seasonal Influenza

Seasonal influenza vaccine is recommended for all pilgrims, especially those at increased risk of complications such as pregnant women, children over 5 years old, the elderly and those with chronic chest or heart disease, diabetes or immunosuppression.

The new winter season influenza vaccines are available from early September so pilgrims planning to undertake the Hajj in the following year should ensure they are vaccinated during the preceding flu season as this may still confer some protection.

Hepatitis A

Hepatitis A is spread through contaminated food and water or by person-to-person via the faecal-oral route, particularly where sanitation or personal hygiene is poor. In Saudi Arabia the prevalence of hepatitis A is considered low to moderate so vaccination needs only to be considered for travellers who are at a higher risk of infection such as those traveling to rural areas or those unable to guarantee proper hygiene with food and water.

Travellers should be given advice on food hygiene measures, ensuring food is cooked thoroughly and only using bottled water.

Hepatitis B

The virus is found in body fluids and can be transmitted either through the skin with the use of contaminated medical instruments, injected drug use, tattooing or by sexual contact. One of the Hajj rites for men is head shaving. The Saudi authorities provide licensed barbers who use a new blade for each pilgrim; however unlicensed barbers may not comply with this^3.

Pilgrims should avoid shaving with a previously used blade and could consider taking a disposable razor for their own personal use during this rite.

Diphtheria

A diphtheria booster is recommended if it has been more than ten years since the last dose. Diphtheria is spread via respiratory droplets or by close contact with infected persons or contaminated objects.

Transmission is more likely in poorer socioeconomic areas and particularly where there is over-crowding such as during the Hajj.

Measles, Mumps and Rubella

Rubella and measles seem to be resurgent recently, principally due to a decrease in vaccination uptake². Confirmation of previous vaccination status is needed to assess a patient’s risk and determine if immunisation is needed prior to travel to protect against infection during the pilgrimage.

Two previous doses of MMR will confer immunity.

Yellow Fever

The Saudi Arabian Ministry of Health requires travellers from countries endemic with yellow fever to have a valid yellow fever vaccination certificate.

Pilgrims travelling directly from the UK to Saudi Arabia will not need certification or vaccination. However, travellers who stop over or visit countries where yellow fever is endemic must seek vaccination and have the corresponding certificate. This includes anyone who has transited for more than 12 hours through an airport of a country with a risk of yellow fever transmission. Country-specific information can be found on the public access website Fit for Travel.

There is no risk of contracting yellow fever in Saudi Arabia itself.

Middle East Respiratory Syndrome Coronavirus (MERS-CoV)

MERS-CoV is a relatively newly discovered coronavirus that causes illness ranging from common cold symptoms to pneumonia and acute respiratory distress syndrome. It was first identified in Saudi Arabia by Dutch researchers in 2012.

MERS-CoV is highly pathogenic and as of the end of April 2018 a total of 2206 cases have been reported to the World Health Organisation (WHO) with at least 787 related deaths (35% of confirmed cases)³.

Signs and symptoms

MERS-CoV has an incubation period of between two and fourteen days meaning that pilgrims travelling for two weeks or less may present with symptoms shortly after their return home.

Most cases present with fever and respiratory symptoms however renal failure, diarrhoea and severe febrile illness have been observed in immunocompromised individuals.

The most common symptoms are:

• Fever
• Cough
• Shortness of breath

Most people returning from Saudi Arabia with respiratory symptoms will most likely be suffering from the common cold virus, however if symptoms worsen or shortness of breath develops they should be referred for investigation. All patients who have recently visited Saudi Arabia and reporting respiratory symptoms should be encouraged to inform their GP of their recent travel.

Transmission

Even though the majority of cases to date have occurred in the Arabian Peninsula and particularly in Saudi Arabia⁴, in 2017 when the Hajj took place between 30th August and 4th September there was no reported increase in travel-related cases of MERS-CoV.

Since 2012 MERS-CoV has been reported in 27 countries². Cases of MERS-CoV have been exported to countries outside of the Middle East with the most recent being identified in Malaysia in January 2018 with a Malaysian Umrah pilgrim who had visited a camel farm whilst in Saudi Arabia^1.

Exposure to camels is a recognised risk factor for developing MERS-CoV although the route of transmission from animals to humans is not fully understood. Dromedary camels are a major reservoir host for MERS-CoV and an animal source of infection in humans. Strains of MERS-CoV that are identical to human strains have been isolated from dromedaries in several countries, including Egypt, Oman, Qatar, and Saudi Arabia.

The virus does not pass easily from person to person unless there is close contact, such as providing unprotected care to an infected patient. Human to human transmission has been limited to date, and has been identified among family members, patients, and health care workers.

Public Health England advises that the risk of UK residents travelling to the Middle East contracting the virus remains low⁵. Travellers returning from this region are advised to report severe respiratory symptoms that include shortness of breath within two weeks of returning.

Prevention

There is no vaccine available to prevent MERS-CoV.  The risk associated with MERS-CoV to the general UK population remains extremely low and the risk to travellers to the Arabian Peninsula and surrounding countries remains very low and there are currently no travel restrictions in place. Travellers can be given the following advice to reduce their risk of contracting MERS-CoV:

• Wear facemasks, especially when in crowded places. Replace the facemask with a new one according to the manufacturer’s instructions.
• Wash hands with soap and water or disinfectant, especially after coughing and sneezing.
• Use disposable tissues when coughing or sneezing and dispose of them appropriately.
• Avoid hand contact with the eyes, nose and mouth.
• Avoid direct contact with those showing symptoms of respiratory or other infection.
• Practice good food safety - avoid undercooked meat or food prepared under unsanitary conditions, wash fruit and vegetables with bottled water properly before eating them and avoid unpasteurised milk or milk products, including camel’s milk.
• Maintain good personal hygiene.
• Avoid contact with animals.

Malaria

The malaria risk is present throughout the year in the provinces of Jazan, Aseer, Najaran and other areas, but the number of cases is very small.

Many Hajj pilgrims travel between the cities of Mecca and Medina. The risk of malaria is low in both cities and antimalarial prophylaxis is not advised although pilgrims who are outdoors or walking at night are advised to take strict mosquito bite avoidance precautions such as wearing suitable clothing and using insect repellents.

Travellers’ Diarrhoea

Diarrhoeal illnesses are transmitted by the consumption of contaminated food or water. Dehydration can occur with diarrhoea and this is of particular risk in hot weather and to babies, infants, the elderly and those with chronic medical conditions.

Pilgrims are advised to consider food and water hygiene precautions and to take oral rehydration therapy and anti-diarrhoeal medication such as loperamide.

Heat and Sun

Daytime temperatures in Saudi Arabia, even in the winter months, can reach over 30°C. The Saudi Ministry of Health recommends that all pilgrims, especially the very young and old, should drink sufficient fluid and avoid direct sun exposure while performing rituals⁶. Medicines with the potential to exacerbate dehydration such as diuretics may need adjustment by the prescriber before travel.

Sun protection factor (SPF) of 30 or above, with four or five star UVA protection, should be applied liberally to exposed skin every two to three hours. Male pilgrims are not allowed to cover their heads but could use a parasol/umbrella to provide shade from the sun.

Desert sand can reach very high temperatures so good quality footwear is essential to protect their feet from burning. Footwear must be removed during times of prayer so to avoid losing them pilgrims are advised to carry their shoes in a bag.

Pilgrims travelling to the Hajj or Umrah in Saudi Arabia are at increased risk of certain diseases due to the congregation of large numbers of people amongst other factors. They should research their trip well in advance and seek advice about the health risks at least four to six weeks before travel.

Pharmacists should assess travellers for their individual risk and advise accordingly on the health risks and necessary vaccinations. In some cases vaccination is required for certification purposes for visa entry.

Further information can be found on the NHS Fit For Travel page.  

1 The Hajj: communicable and non-communicable health hazards and current guidance for pilgrims

2 World Health Organisation News Release 13th November 2014; WHO warns that progress towards eliminating measles has stalled

3 WHO – Update on MERS-CoV regional assessment

4 WHO –Frequently asked questions on MERS-CoV

5 PHE risk assessment of MERS-CoV (Feb 2018) 

6 Ministry of Health, Kingdom of Saudi Arabia. Health Regulations. Health Requirements for Travellers to Saudi Arabia for Pilgrimage to Makkah (2018/1439H Hajj)