The Hajj to Makkah is one of the largest yearly religious mass gatherings worldwide, with more than 2 million people from more than 184 countries. The proximity between pilgrims due to the crowded accommodation, congregation, and prayers creates an ideal environment for transmission of infectious diseases. However, through decades of managing millions of pilgrims, Saudi Arabia has established sophisticated public health planning and surveillance systems.

Pre-Hajj public health preparedness

To minimize the health risks to the pilgrims, the Saudi Ministry of Health liaises with governments of all countries from which pilgrims visit Makkah throughout the year. A proactive public health program is initiated before each Hajj, with focus on prevention and surveillance of health hazards and health-care provision during the pilgrimage. Before each Hajj, the Saudi Ministry of Health disseminates the health requirements for issuance of travel visas and provides advice about public health guidelines to prevent the spread of respiratory and gastrointestinal infections. This advice is re-enforced with widespread health education and prevention campaigns through reading materials, travel agents, pilgrims’ group leaders, and media communication during the Hajj.

Infectious disease alert and response

The Saudi Government’s success in alert and response planning for infectious diseases is attributable to a multidisciplinary group of experts from various government sectors who are involved in the advance planning of health services, logistical support, and communications for the Hajj. Continuous monitoring of emerging infectious diseases ensures that, for example, infection with the Middle East respiratory syndrome corona-virus (MERS-CoV) in an individual is not transmitted to other pilgrims, thereby avoiding a worldwide epidemic. Input about outbreak management and emerging diseases is provided by WHO, the European Center for Disease Prevention and Control, UK’s Public Health England, and the US Centers for Disease Control and Prevention through the Saudi Public Health Directorate of the Ministry of Health.

Advance planning

Early preparations for Hajj are undertaken by the Saudi Ministry of Hajj and Ministry of Health, which usually begins soon after the end of the previous Hajj. Information from monitoring and evaluation of the prevalence and emergence of infectious diseases globally, regionally, and locally is considered to develop the public health program for alert and response for the next Hajj.

Gastrointestinal infections

To alleviate the hazard of gastrointestinal infections, inspections of all main water supply sources and water tanks at various locations in Makkah are done throughout the year. A thorough survey is done of kitchen workers at hotels and hospitals to identify potential carriers of gut pathogens and to ensure standards of food hygiene are maintained. As a precaution, the Ministry of Health strongly enforces the regulation that pilgrims are not allowed to bring fresh food or agricultural products into Saudi Arabia.

Vector-borne diseases

For Hajj, vector control programs are intensified, and the Ministry of Health liaises closely with other entities to coordinate and assess pest control, identify the zones and density of mosquitoes, and undertake insecticide spraying campaigns. Specific teams spray housing units earmarked for pilgrims who come from dengue-endemic areas, with long-lasting pesticide before the arrival of the pilgrims. The teams also spray government departments, and all field accommodation used by pilgrims such as tents at the holy sites. Also, insecticide is sprayed aerially over Arafat and Mina. In accordance with the international health regulations, all aircraft and ship carriers are required to provide an official valid carrier sanitation certificate to verify that insecticide spraying was done before arrival at the port.

Vaccination requirements

To keep the health risks to pilgrims to a minimum and to prevent importation or acquisition of communicable diseases during travel, the Ministry of Health issues its own health regulations, which are updated every year. Before an entry visa for Hajj can be issued, pilgrims are required to meet these health regulations. In addition, the immunization status of each pilgrim is checked and, if relevant, appropriate vaccines and antibiotics are administered in clinical examination rooms and holding areas at the main hubs of the international airport terminals for the Hajj.