Head-Shaving Practices of Barbers and Pilgrims to Makkah, 1998

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Head-shaving practices of barbers and pilgrims to Makkah, 1998

Head shaving is potentially a risk factor for transferring infections, especially bloodborne diseases. Hundreds of thousands of pilgrims (Hajjees) have their heads shaved within.hours in a well-defined area. Conceivably, the hygienic be havior of Hajjees and the practices of barbers could make head shaving during the pilgrimage to Makkah (Hajj) an optimum focal setting for the worldwide spread of serious bloodborne diseases such as hepatitis B virus (HEV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV). We studied the head shaving practices of barbers and Hajjees to identify unsafe practices and to deter mine what steps are necessary to prevent or reduce the transmission of blood borne diseases among Hajjees. We observed 23 nationalities to determine the percentage who had completely shaved their heads. We used a two-stage cluster sampling to select and interview 298 Hajjees who had their heads shaved with razor blades, and visually checked their scalps for visible cut wounds. We covertly observed 196 illegal barbers as they worked (Figure 1). Then, according to a standard checklist, asked them about infectious diseases that could be transmitted by head shaving. We also in spected their hands for visible cut wounds. The proportion of Hajjees who had their heads shaved exceeded 90% among those from Eritrea, Egypt, Mauritania and Pakistan, whereas the proportion of head-shaving Hajjees was quite low among those from Tunisia and Syria. About 61 % (95% Confidence Interval [CI] 55:..(6) ofHajjees had cuts to the scalp (a mean of 2.6 per Hajjee, maximum of 18 cuts). Of all Hajjees, 1.3% indicated they had a history of hepatitis. Out of 196 barbers observed, 23% (95% CI 17- 30) had uncovered hand wounds, 21% (95% CI 16-28) used the same blade for more than one shave, and 82% (95% CI 76-87) threw at least one used blade on the ground. The mean (±SD) time for a single head shave was 5± 1.8 minutes (range 2-10 minutes). Seventy-four percent ofHajjees (95% CI 66-77) and 20% of barbers (95% CI 6-15) were not aware of any health problems that could be caused by shaving with used razor blades. Head-shaving practices of Hajjees did not vary with their (Continued on page 18)

Index - Hajj Issue

Head-shaving practices ...... 18 Behavioral Risk Factors for disease during Hajj ...... 19 Risk factors for hip fractures among pilgrims ...... 21 Malaria among pilgrims ...... 22 SEB Arabic pages ...... 24 25 Notifiable disease reports ...... ~ 26, 27 Calendar...... 28 Head-shaving practices of barber~ and pilgrims

(Continuedji-om page 17) jees, the poor hygienic behavior of safe Hajj is the wide distribution of educational level. About one-fourth of Rajjees, and the practices of barbers illustrated, health education materials Hajjees from western countries and shown in this study are disturbing. translated into 10 main languages. sub-Saharan Africa were relatively There is an obvious increased poten About 700 barber chairs were placed more aware of potential transmission tial risk for bloodborne diseases around theAi Jamarat area (Figure of HIVI AIDS by barbers, compared among Hajjees as well as between Ha 2). Nevertheless, the difficulty in with only 4-12% of Hajjees from jjees and barbers. communicating with Hajjees makes it other countries. Hajjees aged 50 years A further risk is presented with the very difficult obviously to ensure that or younger were relatively more con data on the fate of used razor blades, all Hajjees practice head-shaving cerned with transmission of HIV, showing that 82% of the barbers safety as only 14% of the Hajjees ac whereas older Hajjees were more con threw used blades on the ground after tually asked the barber to change the cerned about transmission of skin dis shaving rather than using garbage blade before shaving eases. cans. This presents the hazard of foot An appropriate intervention should injury to Hajjees, as many of the them be fourfold: availability of safe razor -Reported by: Mr. Ahmed A. Al lose their slippers in the crowds that blades, health education, presence of Saiamah and Dr. Hassan E. Ei form after finishing Al Jamarat affordable head-shaving services, and Bushra, Dr. Abduiaziz Ai Mazam, Dr. (pebble throwing). close supervision of barbers. Hajjees Abdullah Ai Rabeah, Mr. Ahmed Ai The Saudi Ministry of Health need to be educated to treat razor Rasheedi, Mr. Mohammed Ai-Sayed, (MOR) is aware of the public health blades used for head shaving as if Dr. Nasser AI-Hamdan, Dr. Mo consequences of unsafe head-shaving they were using disposable syringes. hammed Ai-JeJri (Saudi Arabian practices, and has spared no effort to It is recommended to have each ra Field Epidemiology Training Pro constantly upgrade the facilities zor blade and its holder packed in a gram) available to the Rajjees in order to plastic bag; each Hajjee should be provide adequate health care for told to make sure the plastic bag is Editorial note: There is no place on them. Included in MOH plans for a (Continued on page 25) earth where hundreds of thousands of Figure 1: Hajjee having head shaved by illegal barber during Hajj people have their heads shaved within a few hours in a very limited geographical area as during Hajj. Similarly, every year large numbers of Muslims perform Umra, worship in Haram, the Holy Mosque. The un certainty of disease profiles of the un equivocally diverse population of Haj- Glossary of terms Hajj- Islamic pilgrimage to Makkah Hajjee- Muslim pilgrims Hijiran calendar- The Muslim lunar year of 12 months calculated from the actual sighting of the moon. 1418H (Hijiran)=1998G (Gregorian) 10 Duhl Hijja- the Feast of Sacrifice Figure 2: Legal barber chairs at AI Jamarat during Hajj Day (April 7, 1998) Ramadan- The Muslim Holy Month of fasting Hajj season- 4-month period between Ramadan and Dhul Hijja Hamlah- Organized pilgrim group Haram-The Holy Mosque, Makkah Umra-Traveling to worship in H aram Zamzam- The Holy Well, Makkah Mutawif- Saudi Muslim guide Al Iamarat-Area near Makkah used for pebble throwing Masha'ar-The holy city of Makkah and related holy places of Mina, Arafat and Muzda1ifa

Page 18 Saudi Epidemiology Bulletin, Vol 5, Nos 3 & 4, 1998 Malaria among pilgrims to Makkah, 1998

(Continued fi'om page 22) been halted in the eastern and north imply local transmission of malaria the northwest regions and accounts ern parts ofKSA. However, in west in the city of Makkah and surround for over 50% of the malaria cases; ern KSA, there is low incidence of ing holy places. Interruption of whereas, P. malariae is scarce and malaria (1- 3 per 1,000 per year) and malaria transmission in these areas constitutes 1-2% of all the malaria in Tihama, the coastal plains along could be explained by the intensive cases in KSA (2). the Red Sea in southern and south environmental malaria control efforts The governmental malaria control western KSA, medium or high inci and strict malaria control measures project in KSA was initiated in 1952 dence of malaria (more than 3 per instituted just before Hajj season, in with assistance from WHO, mainly 1,000 per year) is reported (2). The the holy places, along the road, and for the protection of the pilgrimage peak of malaria transmission occurs the adjacent valleys that lie between routes. Hajjees are neither screened between October and April and coin Jeddah, the main port of entry of pil for malaria at the entry ports of the cides with the rainy season (70-550 grims (Hajjees), and the city of Kingdom, nor given suppressive mm/year). There is a noticeable de Makkah (4). doses of anti-malarial treatment. Cur cline in incidence of malaria during Despite successful efforts made to rently, most areas are virtually free the summer months (2). interrupt local malaria transmission from malaria with the exception of Ail malaria cases diagnosed during during the Hajj season in the city of the southwestern areas. Central KSA the Hajj period admitted recent travel Makkah and the neighboring holy is non-malarious and only occasional history to, or arrival from malarious places, the continuous influx of reli imported cases are reported every areas within KSA in the 2 weeks that gious visitors and expatriate workers year. Transmission of malaria has preceded the onset of symptoms. The remains a potential source for intro people traveled to malarious areas duction of malaria. The role of illegal such as AI-Leith, AI-Gonfedah, or aliens in reintroducing malaria into Risk factors for Jizan to visit their relatives during a this area can not be ruled out; an in hip fra ctures school vacation or to work in their flux of a large number of illegal im farms in the affected valleys. This migrants changed the epidemiology movement of peoples to and from en of malaria and other diseases in (Continuedfrom page 21) demic areas poses the threat of im Kuala Lumpur, Malaysia (5). It is tions to improve environmental con ported malaria also in Kuwait (3). probable that the unusual heavy and ditions have greatly reduced the inci The majority of non-Saudi cases of prolonged rainfalls in the last 2 years, dence of falls, the prime cause of hip malaria came from East Africa, the during these 4 months, favored in fractures. Indian subcontinent and Yemen, creased breeding of the Anopheles where malaria is known to be en vector and greater transmission of the References: demic. parasite in endemic areas around 1. Cuming RG, Nevitt MC, Cummings Diagnosis of malaria cases among Makkah. SR. Epidemiology of hip fractures. Hajjees during Hajj season does not Epidemiol Rev 1997;19:244-57. References: 2. Cummings SR, Kelsey JL, Nevitt 1. Alrajhi A, Frayha HH. Chloroquine MC, et al. Epidemiology of osteo resistant Plasmodium fa/ciparum: Is porosis and osteoporotic fractures. Head-shaving it our turn? Ann Saudi Med Epidemiol Rev 1985;7:178-208. 1997;17:151-3. 3. Josephson KR, Fabacher DA, practices 2. AI-Seghayer SM. Malaria control in Rubenstein LZ. Home safety and the Kingdom of Saudi Arabia. fall prevention. Clin Ggeriatr Med (Continued from page 18) Saudi Epidemiology Bulletin, 1991 ;7:707-31 . opened in front of him. Used razor 1995;3(1):4. 4. Wolinsky FD, Fitzgerald JF. The blades should be considered poten 3. Hira PR , Behbehani K, AI-Kandari risk of hip fracture among non tially infective and must be handled S. Imported malaria in Kuwait. older adults. Journal of Gerontol with extraordinary care to prevent un Trans R Soc Trop Med Hyg ogy: social sciences 1994; intentional injuries. They must be 1985;79:291-6. 49:S165-75. placed into puncture-resistant con 4. Zahar AR. Malaria status in pil 5. Norton R, Campbell AJ, Lee-Joe T, grimage routes in Saudi Arabia et al. Circumstances of falls result tainers located as close as practical to with special reference to load of ing in hip fractures among older the area in which they are used (1). malaria infection among pilgrims people. J Am Geriatr Soc We also recommend establishing an from various countries arriving in 1997;45: 11 08-12. official shaving area at each camp Saudi Arabia (Jeddah) by sea 6. Tenetti MA, Doucette JT, Claus EB. with qualified barbers and a group of [Abstract]. World Health Organiza The contribution of pred isposing Hajjees (Hamlah) responsible for en tion 1957. Document # EMI and situational risk factors to seri suring hygiene and good practice. Mal. Erad.l13. ous fall injuries. J Am Geriatr Soc 5. Moore CS, Cheong I. Audit of im 1995;43: 1207-13. References: ported and domestic malaria cases 7. Melton LJ III. Epidemiology of hip 1. Lakshman S. Rules of infection at Kuala Lumpur hospital. Br J Clin fractures: implications of the expo control. International Dental Journal Pract 1995; 49: 304-7. nential increase with age. Bone 1993; 43:578-584 1996;18:S121-5.

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