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H ajj – the of - archetype of a mass gathering (Poster NECTM 7) Prof. Dr. Günt er Schmolz, MD, MSc, member of the board, German Society for Travel Medicine

Muslims have to respect five pillars of : Shahadah (profession of faith) – sala’at() - ( purification , tax for the poors) – saum () – (annual pilgrimage) The Noble Qur’ân, surat 2, al - baqarah ( ‘ the cow ’ ) 196 : ” And perform properly (i.e. all the ceremonies according to the ways of ), the Hajj and ‘ (i.e. the perennial pilgrimage to Makkah) for ” . Every about 2 - 3 Mio Muslims follow th is demand of Muhammad . Th e extremely diverse population from about 185 countries perform s the same activities within 6 days in a state of purity and holiness ( ) . Many of these people w ere not able to afford their attendance before getting old and are restricted in their health . The s ecurity of the pilgrims and their health care is a huge challenge for Saudi Arabian authorities. During the hajj , pilgrims often neglect obvious and hidden health risks.

The main ho ly sites of the hajj Possible and probable health risks

Mina: Communicable diseases Thousands of t ents  Malaria , and other VBD to accommodate a million people  Hepatitis A, E  Cutaneous leishmaniosis  I nvasive meningococcal meningitis  Tuberculosis Plain of Arafat:  Influenza Pilgrims pray from  Gastro enteritis, diarrhea noon to sunset and  Po liomyelitis climb the mountain Non - communicable diseases Jamarat:  Sunstroke/heat exhaustion/cramps Stoning  Circulatory collapse , coronary the syndrome  R enal failure  Panic attack and other psychiatric disorders M ecc a Gr eat :  Exacerbation of preexisting diseases seven walks around like diabetes or coronary heart disease the holy shrine Kissing of the stone Other risks  Road accidents Sa f a – Marwah run s  Stampede in Reminiscence of  Injuries , for example by falling down and Ismael  Acts of terrorism

Measu res of health care, Obligatory vaccination s: - A ir - conditioned rooms , sun protection - Gate control (Jeddah, Great Mosque prevention and precaution - meningococcal meningitis ACYW - E verywhere offering drinking water - Extended presence of police, fire

to minimize health hazards - poliomyelitis - M obile hospitals Brigade, security staff - YF of people from endemic regions - A mbulances - F ireproof tents in Mina ( invests billions Recommended vaccinations - > 20.000 members of medical staff - D eveloped public transport system of d ollars p.a. since decades ) - Influenza, dPT, HepA, measles, PNC - I ntensive care and dialysis units - C ompulsory vis a contingents

A ssessment of persistent health risks of the holy sites and the route s to get there ; legend: 0 = no risk, + = little risk, ++ = moderate risk,+++ = high risk Estimated C ommunicable diseases Non - Communicable diseases violence Stampede Acts of health ri s ks I njuries terrorism Holy sites Malaria , Tuberculosis Invasive Gastro - Exacerb Panic Heart Heat ex - along the Hajj other Mening o enteritis ation of attacks, attacks, haustion, route VBD - coccal diarrhea diseases psychiatr. collapse sunstroke disease disorders Stay in Mina 0 - + + - ++ 0 - ++ ++ + - ++ + + + + (+) (+)? Plain of Arafat 0 - + (+) 0 - + (+) ++ - +++ + - ++ ++ - +++ ++ - +++ + + (+)? Jamarat - Bridge 0 - + + 0 - + + + ++ - +++ ++ - +++ ++ ++ ++ - +++ + - ++? Great Mosque 0 - + + - ++ 0 - + + + - ++ ++ - +++ ++ - +++ ++ + - ++ ++ ++? Saf a - Marwah 0 - 0 0 – (+) 0 - + 0 - + 0 - + 0 (+) (+) (+)? Public routes 0 - + - 0 + + + + - ++ + - ++ + - ++ (+) (+) Results: Hajj, o bligatory pilgrimage of the Islamic world, reveals a of different risks to health. The knowledge of the rites , holy site s and the health state of the traveler will allow adequate advice to travel medicine staff

Figure: R oute of h a jj (CDC) ; P ctures: M inistry of H aj (SA) ; R eferences: The Noble Qu r ’ â n (Darussalam) , Schmolz G , Hadsch (FTR 2009:117 - 124 ), ECDC: Rapid risk assessment for the hajj ( 10.08. 2017) , WHO - WER