Advising Hajj and Umrah travellers in general practice

Hajj is the annual pilgrimage to Makkah (Mecca), Islam's holiest city, in the Kingdom of Saudi Arabia (KSA). It is a mandatory religious duty that all Muslims are expected to carry out at least once in their lifetime, provided they are physically and financially capable of undertaking the journey (All-Party Parliamentary Group on Hajj and Umrah, 2019).

The Hajj is one of the largest global gatherings of its kind (TravelHealthPro, 2019) and is the fifth pillar of Islam. Hajj is performed during a 5-day period from the 8th through the 13th of Dhul-Hijjah, the 12th month of the Muslim lunar calendar (Muslim Council of Britain, 2018). Consequently, the date of Hajj changes every year. The approximate dates for the Hajj this year are 28 July to 2 August 2020 (Foreign and Commonwealth Office, 2020).

Umrah is a smaller pilgrimage, consisting of abbreviated rites that can be completed in half a day (McLoughlin, 2019). Umrah can be performed at any time of year and, unlike Hajj, is not compulsory (US Centers for Disease Control, 2019).

Until the introduction of modern transport, most Muslims outside the Middle East had little expectation of completing the Hajj. Before the mid-1950s, numbers of overseas pilgrims rarely exceeded 100 000. Yet by the early 2000s, the total number of pilgrims in KSA passed the 2 million mark, reaching a peak of just over 3 million in 2012 (McLoughlin, 2019).

Currently, it is estimated that each year approximately 3.7 million pilgrims participate in the Hajj (Foreign and Commonwealth Office, 2020), with pilgrims attending from over 183 countries (US Centers for Disease Control, 2019). British Muslims have been travelling to Makkah and Madinah (Medina) from the UK in their hundreds and thousands since the 1960s and 1970s. The number of UK pilgrims has risen from 573 in 1969 to around 25 000–27 000 in recent years. Therefore, the UK, along with France, represents the joint highest number of western pilgrims. About 100 000 British Muslims also travel annually for Umrah (McLoughlin, 2019).

The influx of large numbers of people to mass gathering events may give rise to specific public health risks (World Health Organization [WHO], 2020). Crowded conditions increase the risk of exposure to infections, including meningitis (TravelHealthPro, 2019). Contagious diseases spread quickly, particularly during Hajj and Ramadan. Flu, colds and respiratory problems are very common. During the period of Hajj and for Umrah, pilgrims must have a valid certificate of vaccination against the ACWY strains of meningitis (Foreign and Commonwealth Office, 2020). Pneumonia is one of the most common causes of hospital admission in pilgrims. Many pilgrims come from highly endemic TB areas; some arrive for Hajj with active disease. Pilgrims should be educated about this risk and advised to seek medical advice for any respiratory symptoms they experience (US Centers for Disease Control, 2020) while travelling or if they develop symptoms after they return home.

Every year the Ministry of Health (MoH) of KSA issues the requirements and recommendations for entry visas relevant to pilgrims and seasonal workers who intend to visit KSA during the forthcoming Hajj and Umrah season. Requirements and recommendations may differ from year to year, so practice nurses should make sure they are using up-to-date information (TravelHealthPro, 2019; WHO, 2019a).

Coronavirus disease 2019 (COVID-19)

On 31 December 2019, a cluster of pneumonia cases were reported to WHO from Wuhan, Hubei Province in China. In January 2020, the Chinese authorities reported a new (novel) coronavirus as the cause of this outbreak. The associated illness is now referred to as novel coronavirus disease 2019 (COVID-19). Current evidence indicates that COVID-19 causes mild disease (respiratory symptoms or mild pneumonia) in about 80% of cases and most people recover. Severe pneumonia, which can be fatal, has been reported. However, the majority of severe illnesses and deaths have occurred in the elderly and those with chronic underlying health conditions. As of 25 March 2020, more than 416 916 cases of COVID-19 have been reported worldwide. The number of reported COVID-19 cases is rapidly increasing in all EU/EEA countries and the UK (European Centres for Disease Control and Prevention, 2020). The situation is evolving, so practice nurses should ensure they are using up-to-date information.

As of 17 March 2020, the Foreign and Commonwealth Office now advise British people against all non-essential travel worldwide. This advice takes effect immediately and applies initially for a period of 30 days. The COVID-19 pandemic has led to unprecedented international border closures and other restrictions. All countries may restrict travel without notice (Foreign and Commonwealth Office, 2020a).

The Foreign and Commonwealth Office also advise that, as of 16 March 2020, the KSA authorities have announced measures aimed at limiting the spread of COVID-19. These include:

• All travellers arriving into KSA are required to enter quarantine facilities for 14 days
• The temporary suspension of entry to KSA for the purpose of Umrah and/or visiting the Prophet's Mosque in Medina. This suspension applies to British Nationals
• The temporary suspension of flights and sea routes.

On 14 March 2020 the KSA authorities announced the suspension of international flights. Restrictions have also been placed on some land border crossings. Pilgrims should keep up-to-date with information from their airline or tour operator on the impact on any existing travel plans.

There has been an increase of COVID-19 cases in the region. Travellers may be questioned about travel history on arrival into KSA and should comply with any additional screening measures put in place by the authorities Travellers to KSA should contact their airline or tour operator before travel. Questions about travel restrictions to Saudi Arabia should be addressed to the nearest KSA Embassy or Visit Saudi: https://help.visitsaudi.com/hc/en-us/categories/360001818700-Visa-Information (Foreign and Commonwealth Office, 2020b).

Middle East respiratory syndrome coronavirus

A respiratory illness called Middle East respiratory syndrome (MERS) coronavirus (MERS Co-V), which can cause severe illness and death, was identified in KSA in 2012. Currently, the majority of cases have been reported in the Arabian Peninsula and in particular in KSA. Most human MERS-CoV cases have been linked to human-to-human infections in health care settings. Current scientific evidence suggests that dromedary camels are a major reservoir host for MERS-CoV and a source of human infection. However, the exact role of camels in MERS-CoV transmission and the exact routes of transmission are unknown (WHO, 2019b)

MoH KSA recommends all pilgrims comply with the following advice (TravelHealthPro, 2019):

• Wash hands with soap and water or a disinfectant, especially after coughing and sneezing, after using toilets, before handling and consuming food, and after touching animals
• Use disposable tissues when coughing or sneezing and dispose of dirty tissues in a bin
• Avoid close contact with people who appear ill and avoid sharing their personal belongings
• Avoid contact with camels in farms, markets or barns
• Avoid drinking raw milk or eating meat that has not been thoroughly cooked.

Meningitis

Outbreaks of meningitis have been associated with the Hajj in the past, with epidemics of both group A and W meningococcal disease. Proof of vaccination against A, C, W and Y serogroups is now a visa entry requirement for pilgrims and seasonal workers travelling to Saudi Arabia (Public Health England, 2016).

In 2000, over 400 cases of serogroup W disease were reported. In this outbreak, cases were identified in pilgrims and their close contacts across at least 16 countries worldwide. To obtain a visa for entry into KSA, all those planning Hajj or Umrah, or who undertake seasonal work, are required to submit proof of vaccination with quadrivalent meningitis (ACWY) vaccine with a vaccination certificate. Pilgrims and seasonal workers must carry vaccination certificates with them for inspection by KSA authorities at the point of entry (TravelHealthPro, 2019). The pre-Hajj/Umrah travel consultation also gives practice nurses a chance to check routine immunisations are in date, offer any recommended travel vaccines and discuss appropriate travel health prevention strategies. Ensuring that UK pilgrims are aware of current Foreign and Commonwealth Office and KSA travel recommendations during the current COVID-19 outbreak is also a part of this process.

Food and water hygiene

Diarrhoea is common during Hajj and the pre-travel consultation should include discussions about prevention, self-oral rehydration strategies and proper use of anti-motility drugs (US Centers for Disease Control, 2020).

Heat

Heat and humidity can have an impact on pilgrims, especially those from cooler climates (such as the UK) who may be unused to, and unprepared for, extreme high temperatures. Travellers are particularly at risk when Hajj takes place in the summer; average temperatures in KSA between June and September can be above 43°C. The combination of high temperature with high humidity can lead to extreme heat conditions, with the associated risk of heat exhaustion and heatstroke. High temperatures can also exacerbate chronic conditions. Pilgrims should be advised to stay well-hydrated, wear sunscreen, and seek shade or use umbrellas (US Centers for Disease Control, 2020).

Physical fitness

The Hajj is physically demanding and should only be undertaken by those fit enough to perform the rites (Ministry of Hajj, Kingdom of Saudi Arabia, 2017). Pilgrims should be advised to ensure that they are physically fit before travelling, as Hajj is challenging and involves walking great distances in hot weather (TravelHealthPro, 2019). Most international pilgrims fly into Jeddah or Medina and take a bus to Mecca. Pilgrims then travel by foot or bus approximately 5 miles, to the tent city of Mina, the largest temporary city in the world (US Centers for Disease Control, 2020).

Medical conditions

Pilgrims with pre-existing medical conditions should discuss the suitability of their planned pilgrimage carefully with their doctor and/or specialist. If taking regular prescribed medicines, pilgrims should ensure they have enough supplies to cover their trip, with extra in case of delays. Pilgrims should also carry copies of their prescriptions. MoH KSA advises that pilgrims and relevant officials in countries of origin consider the physical ability and health conditions of individuals applying for Hajj and Umrah. Muslims with severe medical conditions, such as terminal cancer, advanced cardiac, respiratory, liver or kidney diseases, and senility are exempt from these religious duties (TravelHealthPro, 2019).

Pregnant women, babies and young children

MoH KSA currently recommends that pregnant women and young children postpone the performance of the Hajj and Umrah rituals for their own safety (TravelHealthPro, 2019).

Realistically, if pregnant women or families with babies or young children are determined to undertake Hajj or Umrah, they will travel. Practice nurses can inform pilgrims of the official KSA recommendations and give the best advice. However, if a traveller is determined to undertake Hajj or Umrah, even if current RSA recommendations advise postponing, it is appropriate to offer advice and suitable vaccines.

Further advice about pregnant women travellers, including information about offering vaccines in pregnancy can be found in TravelHealthPro's Pregnancy factsheet (https://travelhealthpro.org.uk/factsheet/45/pregnancy).

Meningitis ACWY vaccines can be given to babies under the age of 1 year, if indicated for travel (Public Health England, 2016).

Currently two conjugated meningitis ACWY vaccines: Menveo® and Nimenrix® are available in the UK. As of March 2017, Menveo® has a marketing authorisation for use in children from 2 years of age, and Nimenrix® has a marketing authorisation for use in children from 6 weeks of age.

TravelHealthPro's guidance on travelling with children is available here: https://travelhealthpro.org.uk/factsheet/82/children

Pilgrims with disabilities or special health needs

The KSA authorities advise that Muslims with disabilities can perform Hajj if adequate preparations are made. They also state that it is imperative that individuals with disabilities thinking of performing Hajj should consult in detail with their travel agent before making a booking (Ministry of Hajj, Kingdom of Saudi Arabia, 2017).

As with all travellers, pilgrims with disabilities or special needs should ensure they have all appropriate vaccines prior to travel. If they are taking regular medicines or use specialist equipment, they should check that they can bring their medication and equipment into KSA. Transport, accessibility to accommodation, venues and local environment, medical requirements and equipment and travel health insurance should all be researched before leaving. They should also ensure they have a back-up plan if they become seriously ill, or their journey is delayed or cancelled or their luggage, medication or equipment is lost (TravelHealthPro, 2018).

Pilgrims with disabilities should be prepared for different standards of accessibility and accommodation to those in the UK (Foreign and Commonwealth Office, 2020).

Medical care

Healthcare facilities in major cities are of a high standard in KSA. Most towns have a health centre or basic hospital. Serious cases may require a transfer by ambulance or by air to hospitals in a major city that might be some distance away. All pilgrims should be advised to ensure they have adequate travel health insurance and accessible funds to cover the cost of any medical treatment and repatriation (Foreign and Commonwealth Office, 2020).

Malaria

Public Health England advise that there is no malaria risk in the cities of Jeddah, Makkah (Mecca), Medina, Riyadh and Ta'if or in Asir province in areas above 2000 metres. There is a low risk of malaria in the south western provinces, along the border with Yemen. This includes parts of Asir province below 2000 metres. Currently Public Health England recommend bite avoidance only for most travellers to these low malaria risk areas in Saudi Arabia. (Public Health England, 2019).

Practice nurses should ask if pilgrims are planning further travel before or after Hajj or Umrah to malaria risk areas either in KSA or other countries. If travel to a malaria risk regions is declared, appropriate malaria prevention advice should be offered (TravelHealthPro, 2019). TravelHealthPro's Country Information pages can be accessed to check malaria risk at onward destination countries: https://travelhealthpro.org.uk/countries

Safety

Trauma is a major cause of injury and death as Hajj is associated with dense crowding, which in the past has led to crush disasters and stampedes. Thousands of pilgrims were killed during a crush at Mina in 2015, making it the deadliest Hajj on record. Death usually results from asphyxiation or head trauma. Large crowds limit the movement of emergency medical services, making prompt rescue and treatment difficult (US Centers for Disease Control, 2020).

Risk assessment

A Hajj and Umrah travel risk assessment should incorporate vaccine, safety, food and water hygiene advice. This should be based on contemporary UK best practice recommendations for the personal protection of individual pilgrims and UK public health considerations. This is to protect the health of individual pilgrims and to prevent disease outbreaks related to Hajj and Umrah in both the KSA and the UK. Current UK and KSA recommendations must be taken into account and be tailored to the individual's specific requirements. Practice nurses must be aware of any recent changes to KSA requirements and inform pilgrims of any travel prohibitions that may be in place.

Conclusion

Prospective Hajj and Umrah pilgrims may only be aware of the KSA meningitis ACWY vaccine requirement. They may attend the surgery requesting this vaccine, without understanding that it is recommended, not only as a visa entry requirement, but also for their own personal protection and to protect their community after they return to the UK. A conjugated meningitis ACWY vaccine is the preferred vaccine. This is because it not only protects pilgrims against serious infection, but also prevents them carrying meningococcal bacteria back to the UK (TravelHealthPro, 2019). The Hajj and Umrah pre-travel consultation provides an opportunity to advise on other health issues, as well as meningitis. This now includes the KSA's recent suspension of Umrah for UK nationals. UK residents seeking advice may have dual nationality and may be planning to travel despite the current KSA suspension for UK nationals.

COVID-19 is a rapidly changing situation and practice nurses should keep up to date with current advice for travellers to Hajj and Umrah.

Individuals make their own choices, which may not necessarily reflect the advice provided by the practice nurse or the current KSA requirements and recommendations. The practice nurse's role is to ensure pilgrims are aware of any current outbreak and health recommendations associated with Hajj and Umrah and to help them make informed choices. If a traveller chooses to try and travel, practice nurses can still support this decision and offer appropriate advice and vaccines. This is to ensure the individual, and/or their family is protected. This does not mean that practice nurses are taking responsibility for decisions made by the pilgrim. Rather, the practice nurse is offering the best protection and advice, with decisions taken by an individual.

KEY POINTS:

• Due to concern about COVID-19, the Kingdom of Saudi Arabia (KSA) have temporarily suspended entry into KSA for the purpose of Umrah and/or visiting the Prophet's Mosque in Medina for certain travellers. This includes UK nationals
• KSA guidance, requirements and recommendations, including suspending entry for some pilgrims, may change at short notice
• KSA authorities' recommend that pregnant women and young children should postpone performance of Hajj and Umrah
• Pilgrims may also be visiting friends and family in other locations and could be at risk of malaria if they are planning onward travel

CPD reflective practice:

• How could you advise a female pilgrim in the first trimester of pregnancy if she is determined to complete Hajj? What specific advice and vaccines would you offer her?
• A male patient in his early 70s has recently been diagnosed with chronic obstructive pulmonary disease (COPD). He asks advice about his planned Hajj trip later this year now he has finally retired. You discuss current KSA recommendations for those with underlying medical conditions. However, he does not feel that postponing is an option, as it is his lifetime ambition to complete Hajj. What advice and vaccines can be offered?
• A mother brings in her 8-week old baby boy for his first dose of routine childhood vaccines. While you are chatting, she mentions that next week the whole family are going to KSA for Umrah. She is breastfeeding and thought she could not have any vaccines. She is not willing to cancel, as this trip has been organised by her extended family. She then mentions that after Umrah, the family will be flying to visit her family in Pakistan. What advice and vaccines can be offered?
• How will the current temporary suspension of entry into KSA for Umrah for UK nationals affect these travellers? What sources of information should they be directed to?

Resources:

• Foreign and Commonwealth Office. Travel and health advice for Hajj pilgrims: https://www.gov.uk/government/news/travel-and-health-advice-for-hajj-pilgrims
• Foreign and Commonwealth Office. Foreign Travel Advice – Saudi Arabia: https://www.gov.uk/foreign-travel-advice/saudi-arabia
• Public Health England. Coronavirus (COVID-19): latest information and advice: https://www.gov.uk/guidance/wuhan-novel-coronavirus-information-for-the-public
• Royal Embassy of Saudi Arabia: https://www.mofa.gov.sa/sites/mofaen/Pages/Default.aspx
• TravelHealthPro: Novel coronavirus (COVID-19): general advice for travellers: https://travelhealthpro.org.uk/news/499/novel-coronavirus-covid-19-general-advice-for-travellers
• TravelHealthPro: Country Information Pages Saudi Arabia: https://travelhealthpro.org.uk/country/191/saudi-arabia
• TravelHealthPro: Middle East respiratory syndrome coronavirus: https://travelhealthpro.org.uk/disease/124/middle-east-respiratory-syndrome-coronavirus
• TravelHealthPro. Risk Assessment/Risk Management checklist: https://travelhealthpro.org.uk/factsheet/61/risk-assessment--risk-management-checklist