Eastern Mediterranean La Revue de Santé de Health Journal la Méditerranée orientale

Vol. 19 Supplement 2 r r ½:n”üÐØ{_UÐPL HnšUÐ{dœCÐ

Supplement on Mass Gatherings

Contents

Preface ...... Si Editorials Hajj and the significance of mass gatherings Ziad A. Memish ...... S5 Health preparedness and legacy planning at mass gatherings in the EMR: a WHO perspective Nicolas Isla and Isabelle Nuttall ...... S7 Research articles 6TJOHIFBMUIFEVDBUPSTUPJNQSPWFLOPXMFEHFPGIFBMUIZCFIBWJPVSBNPOH)BKK  QJMHSJNT A. Turkestani, M. Balahmar, A. Ibrahem, E. Moqbel and Z.A. Memish...... S9 1BĨFSOPGNPSCJEJUZBOENPSUBMJUZJO,BSCBMBIPTQJUBMTEVSJOH"TIVSBNBTTHBUIFSJOHBU,BSCBMB *SBR  F. Al-Lami, A. Al-Fatlawi, P. Bloland, A. Nawwar, A. Jetheer, H. Hantoosh, F. Radhi, B. Mohan, M. Abbas, A. Kamil, I. Khayatt nda H. Baqir ...... S13 Preparedness and health risks associated with Moulay Abdellah Amghar moussem .PSPDDP m M. Youbi, N. Dghoughi, M. Akrim, A. Essolbi, A. Barkia, A.I. Azami, A.T. Fleischauer, D. Schneider and A. Maaroufi ...... S19 Public health surveillance at a mass gathering: ursPG#BCB'BSJE 1BLQBĨBOEJTUSJDU 1VOKBC 1BLJTUBO %FDFNCFS S. Hassan, R. Imtiaz, N. Ikram, M.A. Baig, R. Safdar, M. Salman and R.J. Asghar ...... S24 .BTTHBUIFSJOHJO"RBCB +PSEBO EVSJOH&JE"M"EIB  S. Abdullah, G. Sharkas N. Sabri, I. Iblan, M. Abdallat, S. Jriesat, B. Hijawi, R. Khanfar and M. Al-Nsour ...... S29 Patterns of diseases and preventive measures among domestic hajjis from Central, [complete republication] Fahad S. Al-Jasser, Ibrahim A. Kabbash, Mohammad A. AlMazroa, Ziad A. Memish ...... S34 Review 1VCMJDIFBMUIDPOTJEFSBUJPOTGPSNBTTHBUIFSJOHTJOUIF.JEEMF&BTUBOE/PSUI"GSJDB .&/" SFHJPO M. AlNsour and A. Fleischauer ...... S42

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Editorial Hajj and the public health significance of mass gatherings Ziad A. Memish 1

Mass gatherings (MG) refer to groups localized in their geographical distribu- countries, pushing the Hajj congrega- of people measured in the thousands, tion. Research has shown that emerging tion towards the 3 million mark. The some definitions suggest 25 000 and infectious diseases have roughly quad- sheer dimensions of Hajj demand above [1,2]. MG present unique health rupled over the past 50 years, and extraordinary imagination and agility challenges distinct from the average pathogens that originate in wild animals from planners. population cohort of the same size. (wildlife zoonoses) account for the ma- Because of the wide global attend- Within the context of an exploding jority of such diseases. Further, the fre- ance, international partnerships and global population, widely accessible air quency of infectious disease emergence collaborations in this process are in- travel and unprecedented frequency correlates highly with human popula- creasingly necessary, as countries send- of MG, health issues relating to MG tion density, the density of mammalian ing pilgrims ensure their fitness for are more commonly encoun- species and human population growth. travel and, later, continue to monitor tered. Safeguarding individual and mass Some data exist indicating that emerg- the impact of the returning pilgrims to health at such gatherings is termed ing diseases (specifically zoonoses) are their countries of origin. The scale and public health security [3]. more likely to be seen in tandem with diversity of Hajj presents an enormous MG-related is an emerg- progressive global warming [6]. public health security challenge to Saudi ing in global epidemiol- The role played by travel, migra- Arabian authorities who, as functionar- ogy and while an extensive body of tion, trade and human exchanges in the ies to the Custodians of the two holy information and experiences now propagation of epidemic infectious dis- sites (Makkah Al Mukarramah and exists, not all are published and acces- ease is well known. Almost one billion Medina Al Munnawarah) must provide sible to MG planners and public health people cross international borders each extensive, multi-faceted programmes to administrators,and vital information year. In 2008, there were 924 million serve the “Guests of God” [8]. awaits dissemination [4]. Infectious dis- international arrivals, 16 million more Because of this remarkable scale, eases have long played a substantial part than 2007 [7]. Travel-related infection and its annual occurrence, preparations in shaping human history and continue is reaching previously uncharted di- for the public health safety and security to be an issue of pressing concern. In mensions of scale and complexity and of this event are extraordinarily challeng- this era of the “flat world”, globaliza- it is the Hajj experience that provides ing, requiring an intensely collaborative tion facilitates the spread of numerous invaluable insights in predicting travel- approach. Multiple domestic agencies infectious agents to all corners of the related health challenges. must work together to prepare for Hajj planet. No locale is too remote for a Hajj is the largest and most long- within a matter of months. While most threatening pathogen, be West Nile standing annual MG event on earth. It MG of this scale have the greater part of Virus arriving in the United States or is the site of some of the greatest crowd a decade to prepare, Saudi Arabia read- Rift Valley Fever reaching the Arabian densities known to man. Following an ies itself for the massive influx within a Peninsula [5]. exponential rise in the past decade, Hajj mere 11-month lead time demanding Public health risks focus on infec- is now the most internationally, ethni- precision in organization and the surge tious agents both specific to humans cally, demographically and clinically deployment of massive semi-perma- (which are broadly and uniformly diverse assembly today. The numbers nent infrastructures and manpower. distributed) and zoonoses (infectious of non-Saudi pilgrims attending the Such efforts are accomplished agents transmitted from animals to Hajj routinely exceed 2 million people, through intense inter-Ministry col- humans) which tend to be far more travelling to Makkah from over 180 laboration. Saudi authorities, including

1Deputy Minister of Health for Public Health, Director of the World Health Organization Collaborating Centre for Mass Gathering Medicine & Professor, College of Medicine, Al Faisal University, Riyadh, Kingdom of Saudi Arabia (Correspondence to: [email protected]).

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the Ministry of Health (MOH), the authorities must safeguard Hajj for mil- health security for such a massive gath- Ministry of Hajj, the Ministry of Inte- lions annually while at the same time ering [9]. rior (MOI), the Saudi Red Crescent carefully controlling its access to main- Given the complex, multi-factorial and other government health sectors, tain public health safety and security. elements that comprise the prepara- including the Saudi Arabian National Note must be made of the im- tion for Hajj, Hajj medicine clearly falls Guard Health Affairs, the Ministry of portant work facilitated by the Saudi within the realm of public health secu- Defence and Aviation (MODA) and immigration authorities which safe- rity and must be recognized as such. the Security forces, come together guards public health, possibly one of Further, because of the Kingdom’s with a common focus of public health the largest public health interventions ability to effectively surge public health security. Collectively these agencies today. Saudi Arabia provides visas to resources at short notice, it is in a po- have accumulated decades of experi- every eligible pilgrim, setting an an- sition to make a unique contribution ence managing Hajj from every aspect, nual quota of 1000 visas per million to other gatherings facing bioterror- whether it be management and repa- populations for every country. Access ism or disaster preparedness demands triation of the sick at Hajj, anticipating to all holy sites is strictly limited to visa through exchange of information and crowd turbulence or handling the ar- and permit holders. The visa applica- experiences. Surge capacity is integral rival of over a million and a half head of tion process facilitates enforcement to public health security in which the cattle for ritual sacrifice. of basic public health requirements Kingdom has exceptional experience. With over 1.3 billion Muslims by specifying visa eligibility based on It is for those reasons that Saudi Arabia globally, many more seek to make Hajj evidence of mandatory immunization was recognized and acknowledged to than can be safely accommodated. In (including against polio and yellow fe- be a World Health Organization Col- a delicate choreography of diplomacy ver for pilgrims arriving from countries laborating Centre for MG Medicine in and service, Saudi Arabia must balance with active disease and meningococcal September 2012 tasked with training, the dual roles of both Custodian to the disease for all pilgrims, all important research and providing guidance and Holy Sites and Guardians to the Guests causes of disease at Hajj). Immigration advice to MG administrators across the of God. Representatives of the Saudi thus becomes a tool facilitating public globe.

References

1. Arbon P, Bridgewater FHG, Smith C. Mass gathering med- 6. Blancou J et al. Emerging or re-emerging bacterial zoonoses: icine: a predictive model for patient presentation and factors of emergence, surveillance and control. Veterinary Re- transport rates. Prehospital and , 2001, search, 2005, 36(3):507–522. 16:150–158. 7. United Nations World Tourism Organization. UNWTO world 2. Mitchell JA, Barbera MD. Mass gathering medical care: a tourism barometer (2009) (http://unwtp.orh/facts/eng/pdf/ twenty-five year review. Prehospital and Disaster Medicine, barometer/UNWTP_barom09_1_en_excrept.pdf, accessed 1 1997, 12:72–79. October 2013). 3. Ahmed QA, Barbeschi M, Memish ZA. The quest for public 8. Ahmed QA, Memish ZA. Hajj medicine for the Guests of God: health security at Hajj: the WHO guidelines on communica- a public health frontier revisited. Journal of Infection and Public ble disease alert and response during mass gatherings. Travel Health, 2008, 1:57–61. Medicine and Infectious Disease, 2009, 7:226–230. 9. Memish ZA, Al-Rabeeah AA. Health conditions of travellers to 4. Memish ZA et al.Emergence of medicine for mass gather- Saudi Arabia for the pilgrimage to Mecca (Hajj and Umra) for ings: lessons from the Hajj. Lancet Infectious Diseases, 2012, 1434 (2013). Journal of Epidemiology and Global Health, 2013, 12:56–65. 3:59–61. 5. Balkhy HH, Memish ZA. Rift Valley fever: an uninvited zoono- sis in the Arabian peninsula [Review]. International Journal of Antimicrobial Agents, 2003, 21:153–157.

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Editorial Health preparedness and legacy planning at mass gatherings in the EMR: a WHO perspective Nicolas Isla 1 and Isabelle Nuttall 2

As more countries commit to hosting that public health authorities can use Saudi Arabia, Public Health England large, international mass gatherings, before planning an event. This man- in the United Kingdom, the Institute health preparedness planning is requir- date was provided by a decision at of Public Health of Vojvodina in Serbia ing more research and collaborative the 130th Executive Board Meeting in and the Disaster Research Centre and efforts. A growing body of researchers January 2012 advising the Secretariat to, Flinders University in Australia are cur- and policy-makers view mass gatherings among other activities, “multisectoral rently Collaborating Centres. as important opportunities for positive guidance on planning, management, WHO is also working closely with legacy for the community and visitors. evaluation and monitoring of all types international sporting federations, such This special edition of the Eastern Medi- of mass gathering events with specific as the International Olympic Commit- terranean Health Journal is a good exam- emphasis on sustainable preventive tee, to encourage knowledge transfer ple of a respected scientific publication measures including health education between successive hosts and to make . offering its pages to researchers to share and preparedness” In response, WHO health preparedness a central pillar of their experiences studying small, medi- has developed a three-point strategy for any event. um and large events; religious, sporting supporting countries with mass gather- Health planning, however, is only ing health planning: and cultural events; one-off events and one component of the complex cho- events that recur in the same location r Capacity development and support reography of preparedness that needs year after year. This work, and the work for Member States and host organi- to be undertaken. WHO's efforts to of others, will help future hosts to assess zations – protecting public health at support health authorities in mass options, to adapt and build existing sys- mass gatherings gathering health planning is in line with tems and to evaluate their effectiveness r Establishment of governance, re- the all-hazard and whole-of-society through the acquired experience and sources, tools and methodologies approaches driving public health risk mounting evidence generated by past r Shaping the discipline: leadership management under the International organizers. and communication. Health Regulations(2005). Mass gath- The Eastern Mediterranean Region WHO has worked with organizers erings, which are most often bound by (EMR) is host to some of the world’s of some of the largest events including immutable time frames, known years in largest mass gatherings. Each year the the London Olympics and the 2012 advance, are test-beds for achieving bet- Kingdom of Saudi Arabia welcomes UEFA European Football Champion- ter integration between sectors that can upwards of 3 million pilgrims from ship in Poland and Ukraine, Hajj and be applied in other public health con- around the world; the Formula 1 motor the World Youth Day. In addition, texts and emergencies. Furthermore, racing championship is being held in over the past year, a network of Col- WHO has developed a framework for two EMR countries in 2013 and Qatar laborating Centres on mass gatherings legacy research based on four areas of is set to host the FIFA World Cup in has been established to act as regional health system improvement: 2022. There are a large number of other hubs for best practice in mass gathering r improved medical and hospital ser- mass gatherings in the Region of all health preparedness planning. These vices sizes and purposes, each with their own Collaborating Centres are working with r strengthened public health system specific risks. WHO Regional and Country Offices The World Health Organization to promote public health planning and r an enhanced living environment (WHO) continues to build an inter- positive legacy development as a key r increased health awareness. disciplinary mass gathering programme area of investment for mass gathering WHO has worked with a number of that offers guidance, tools and expertise organizers. The Ministry of Health of countries in the EMR including with the

1Technical Officer, Global Alert and Response Operations, Global Capacities, Alert and Response, World Health Organization, Geneva, Switzerland. 2Director, Global Capacities, Alert and Response, World Health Organization, Geneva, Switzerland.

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Ministry of Health of Iraq with which and water safety, risk communication, in planning a mass gathering. This col- a workshop on mass gathering health coordination, preparedness and social lection of papers will provide a sense preparedness was held in Amman in mobilization. Likewise, WHO is cur- of the research being undertaken in October 2012. An international team rently working closely with Ministry of the EMR to better understand the of experts from WHO and a repre- Health of the Kingdom of Saudi Arabia risks associated with mass gatherings sentative from Public Health England to manage risks associated with the and potential solutions to prevent and worked with responsible health au- emergence of the Middle East Res- mitigate these risks during the event thorities from the Ministry of Health piratory Syndrome Coronavirus in the and achieve a long-term benefit from and District Health authorities from context of Hajj. the experience. WHO will continue to Karbala to improve health prepared- From the articles in this special edi- work closely with any Member State ness in the areas of on surveillance, pre- tion on mass gathering, the reader will on mass gathering health preparedness hospital casualty management, food understand the complexity involved and planning.

Information sources

1. Resolutions and Decisions, Annexes. Executive Board, 130th 3. Global Alert and Response (GAR).Communicable disease alert Session, Geneva, 16–23 January 2012 (http://apps.who.int/gb/ and response for mass gatherings. Key considerations [web- ebwha/pdf_files/EB130-REC1/B130_REC1-en.pdf#page=17, page] (http://www.who.int/csr/mass_gathering/en/index. accessed 7 October 2013). html, ,accessed 7 October 2013) 2. Global Alert and Response (GAR).Communicable disease alert 4. International Health Regulations [webpage] (http://www. and response for mass gatherings [webpage](http://www. who.int/topics/international_health_regulations/en/, ac- who.int/csr/mass_gatherings/en/, accessed 7 October 2013). cessed 7 October 2013).

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Using health educators to improve knowledge of healthy behaviour among Hajj 1432 (2011) pilgrims A. Turkestani,1 M. Balahmar,2 A. Ibrahem,2 E. Moqbel 2 and Z.A. Memish 3

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ABSTRACT The main objective of this study was to assess the short-term effect on health knowledge among pilgrims after being provided specific health education messages.A random sample of 6 entry-point buses was selected. A self-administered questionnaire was used to assess knowledge before and after intervention; 278 pilgrims completed the questionnaire.There was a significant increase in the proportion of participants who answered all questions correctly after the educational intervention (P<0.05). Almost all respondents stated that they benefited from the health education and that the health educator was successful in delivering the messages. Only 19 (7.2%) reported that they had already received relevant health education messages prior to their arrival in Saudi Arabia. Before the intervention just 50% of the respondents knew that safe shaving prevents dissemination of bloodborne diseases; this rose to 84.7% after the intervention. Direct health education to pilgrims is effective in improving short-term health knowledge.

L'éducation sanitaire pour améliorer les connaissances des pèlerins de la Mecque en 2011 (Hajj 1432) sur les comportements favorables à la santé

RÉSUMÉ L'objectif principal de la présente étude était d'évaluer l’effet à court terme de certains messages d’éducation sanitaire sur les connaissances des pèlerins en matière de santé. Nous avons choisi comme échantillon aléatoire les personnes présentes à bord de six bus à l’entrée du site. Pour évaluer les connaissances avant et après l’intervention, nous avons utilisé un questionnaire auto-administré, que 278 pèlerins ont rempli. Le pourcentage de participants ayant répondu correctement à l’ensemble des questions était significativement plus élevé après l’intervention d’éducation sanitaire (P < 0,05). Presque tous les participants ont affirmé que cette intervention leur avait été utile et que l’éducateur avait bien fait passer les messages. Seules 19 personnes (7,2 %) ont déclaré qu'elles avaient déjà reçu des informations pertinentes en matière d’éducation sanitaire avant d’arriver en Arabie saoudite. Avant l’intervention, seuls 50 % des participants savaient qu’un rasage sans risque contribuait à prévenir la propagation des maladies à transmission hématogène ; ils étaient 84,7 % à le savoir après l’intervention. Communiquer des messages d'éducation sanitaire directement aux pèlerins est efficace pour améliorer les connaissances à court terme en la matière.

1Department of Public Health, Mecca Regional Health Directorate, Mecca, Saudi Arabia. 2Department of Preventive Medicine, Jeddah Health Directorate, Jeddah, Saudi Arabia. 3Department of Public Health, Ministry of Health, Riyadh, Saudi Arabia (Correspondence to Z.A. Memish: [email protected]).

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Introduction r Encourage medical students to ac- This method of health education tively take a health education role was intended to provide more effective Health education has been described during the Hajj. health education. The executive com- as a process by which individuals or Both objectives were achieved mittee of the Hajj recommended study- groups learn to behave in a manner con- through inviting medical and health ing this new educational approach to ducive to the promotion, maintenance science students to voluntarily enrol determine its effectiveness. Therefore, or restoration of health[1].Communi- in an HEA team. Volunteers agreed to the main objective of this study was to cation in relation to health education undergo a training programme focus- assess the short-term effect on health involves various modes, e.g. lectures, ing on communication skills, the ethics knowledge among pilgrim after they discussions, symposia, posters, public of volunteer work and the important had been given specific health educa- address, and radio and television mes- health messages to be delivered to ar- tion messages. sages. Each mode has its own merits, riving pilgrims. The messages were basi- drawbacks and scope of effectiveness. cally designed to cover issues related to Messages may also have to overcome healthy behaviour during the perfor- Methods communication barriers (e.g. physio- mance of the Hajj, for example, personal logical, psychological, environmental hygiene, measures protective against Through a pre- and post-intervention and cultural). The effectiveness of a infectious respiratory droplets, avoid- study design, a random sample of 6 particular mode of health education ing exposure to direct sun, and proper buses was selected from a total of about 300 buses on the last day of work in the varies according to the setting in which ways of using razors. This programme Pilgrims City at King Abdul Aziz Inter- it is delivered[2,3]to a specific group benefited by making use of the students national Airport. Sample size was calcu- [4]. It has been observed that different in Mecca who are often fluent in foreign lated to find a difference of at least 20% methods may be especially suitable for languages in addition to Arabic. in improvement of level of knowledge different groups of people depending In Hajj in 1431 AH (2010 CE), of the participants after conducting the upon their age, sex, educational quali- the HEA programme was extended to intervention. Considering a confidence fication, background and the nature of cover pilgrims arriving at King Abdul level at 95% and a power of 80%, the their employment [1]. Aziz International Airport, 19 km north estimated sample size was 244; this was The Hajj has become the epicentre of Jeddah, the main aviation entry port for pilgrims. The messages were deliv- increased to 300 to compensate for of the mass migration of millions of expected missing data. Since each bus Muslims of various ethnic diversities. ered to them in the Pilgrim’s City, just outside the Hajj terminal, while they accommodated about 50 pilgrims on No other mass gathering can compare average, 6 buses were adequate to satu- in scale or in regularity[5]. The prepared- waited aboard buses that would trans- port them to the holy places. Challenges rate the estimated sample size,giving a ness plans made before the Hajj season total of around 300 pilgrims. The re- ensure the optimum provision of health to providing the training included the preoccupied state of pilgrims while sponse rate was 92.7%: 278 completed services for pilgrims to Saudi Arabia, questionnaires returned. and have been set up to minimize dis- completing their registration formalities The total number of pilgrims ease transmission both during their stay on arrival. During Hajj 1432 AH (2011 aboard these buses was 300. The in the country and upon their return CE), analysis of passenger flow within health educators boarded the buses, home[6].Health education is one of the Pilgrim’s City showed that loading a bus takes about 4–6 minutes for pil- described the purpose of the study, and principal services provided for pilgrims grims and up to 20–25 minutes for their then invited pilgrims to participate. from their arrival. Health education of luggage. This meant that the pilgrims Those who agreed were asked to fill pilgrims, through the Health Educa- waited in the stationary buses for about out a self-administered questionnaire tion Ambassadors (HEA) programme, 20 minutes while waiting for luggage (pre-test). The questionnaire had been which was launched as an innovative arrival and loading, prior to departure. designed and validated for a similar approach in 1428 AH (2007 CE), is This was determined to be the ideal time trial carried out the previous year for one of the principal activities supporting to deliver health messages. The HEA the local authority to assess the knowl- those plans. volunteers were organized into teams edge of pilgrims about healthy behav- The HEA module aimed at achiev- of 2: one volunteer was responsible for iour during Hajj (unpublished report). ing 2 specific objectives: conveying messages aided by a picto- Reliability was assured by Cronbach’s r Provide effective health education rial chart while the other distributed a alpha test which gave a value of 0.88; to pilgrims in their mother tongue at copy of the multilingual health message this is considered an acceptable reli- their dormitories in the holy places. pictorial leaflet to each pilgrim. ability level.

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The intervention included the with disposable tools prevents dis- as that of mutawefs (guides), about health education messages provided semination of some bloodborne dis- the HEA programme was assessed through the HEA programme using eases (e.g. HIV and hepatitis B) before during previous Hajj seasons (un- a pictorial chart as well as the distribu- intervention;this rose to 84.7% after published report), but the impact of tion of pictorial pamphlets. This was the educational intervention (Table these messages on the knowledge of followed by assessment of knowledge 1). pilgrims was not assessed. Our find- using the same questionnaire (post- Almost all pilgrims (99.6%) agreed ings showed significant improvement test). the HEA programme aboard the buses in the short-term knowledge level Data were verified, assessed for was beneficial, with 98.9% evaluating among intervention recipients. This quality, then analysed using SPSS, ver- the health educator as successful in effect has been established in previous sion 16.0. delivering the health education mes- studies in similar settings, including sages. India [1] and Saudi Arabia [4];the authors recommended that health Results When asked about the importance of receiving health education messag- education-focused programmes es in their home countries before de- should be conducted in small groups, The response rate for completion of preferably via specific topic lectures. the pre-intervention questionnaire parting to the Hajj, the overwhelming The low rate for receiving pre- was 92.7% (n = 278) and 89.3% (n majority of the participants (92.4%) = 268) for completion of the post- supported the idea. However, only departure health education messages intervention questionnaire. The 7.2% (n =19) stated that they had al- among those affluent enough to af- proportion of pilgrims giving cor- ready received relevant health educa- ford to travel by air and participate rect answers showed a significant tion messages in their home country. in the Hajj indicated a notable lapse increase on the post-test (Table 1) in pre-travel preparation in the study (P < 0.05). While around two-thirds population, and a need for home of respondents (69.1%) indicated Discussion country educational interventions. that pilgrims,whether healthy or sick, The limited time available to con- should consult a before This study showed that using the duct the current health education departing for the Hajj, the figure was educational intervention improved intervention presented a significant more than 80% after the intervention. short-term knowledge in the popula- limitation. It was conducted on the Similarly,before the intervention just tion studied. last day that pilgrims were arriving at over two-thirds (68.7%) said that Volunteers have been document- King Abdul Aziz International Airport, toothpaste is the only item that can be ed to be effective health education and most were Arabic speakers. This shared between 2 or more individu- providers[7].The HEA programme population was not representative of als; this increased to 94.4% after the depends on volunteers from various all pilgrims. Also, it was not possible to intervention (Table 1). medical faculties and health institutes obtain directly-paired responses from The greatest improvement in in the Mecca region; their enthusi- each of the pilgrims, and statistical knowledge was seen for the item astic participation was essential to analysis was therefore based on the relating to shaving: only half of the the health education programme. overall percentages of pre- and post- respondents knew that safe shaving Student volunteer opinion, as well test correct questionnaire responses.

Table 1 Knowledge of Hajj pilgrims arriving at King Abdul Aziz International Airport regarding healthy behaviour before and after a health education intervention, 1431 AH (2010 CE) Questionnaire item Pre-intervention Post-intervention % correct % correct Consulting a physician before travelling to the Hajj 69.1 83.6 Items that can be shared by ≥ 2 individuals 68.7 94.4 Health behaviour on coughing or sneezing 92.4 100.0 must be assured 91.4 97.0 Prevention of sunstroke 89.6 98.9 Frequency of hand-washing 79.1 95.5 Diseases prevented by safe shaving practices 50.0 84.7

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Recommendations intervention actually resulted in any mation provided to foreign travel change in health among pilgrims dur- agencies, additional links to health ing the Hajj and in the following weeks, education posts already provided r The HEA programme should con- compared with those who did not par- within Saudi Arabia, and shared tinue in the coming Hajj seasons with ticipate in the intervention, along with through working with air carriers and the inclusion of pilgrims at other por- the specifics of any diagnosis. charter companies serving Hajj ports tals of entry to Saudi Arabia, especially of entry to provide in-flight health in Prince Mohammed Ibn Abdul Aziz r Methods to provide standardized, education videos. International Airport in Medina. pre-departure, health education to pilgrims scheduled to participate in r Consideration should be given to r A study of wider scope should be the Hajj should be explored. Health investigating methods of educating planned for the next Hajj season. education materials should be pre- those who enter the country using r An additional study would be worth- pared in concert with the Ministry other means of transportation, in- while to determine whether or not the of Health. This could include infor- cluding ships.

References

1. Saha A, Poddar E, Mankad M. Effectiveness of different meth- 5. Memish ZA. The Hajj: communicable and non-communicable ods of health education: a comparative assessment in a scien- health hazards and current guidance for pilgrims. Euro Sur- tific conference. BMC Public Health, 2005, 5:88. veillance : European Communicable Disease Bulletin, 2010, 2. Nishtar S et al. Posters as a tool for disseminating health re- 15:19671. lated information in a developing country: a pilot experience. 6. Memish ZA et al. Establishment of public health security in Journal of the Pakistan Medical Association, 2004, 54:456–460. Saudi Arabia for the 2009 Hajj in response to pandemic influ- 3. Werner RT Sr, Wilson JM. Are health education conferences enza A H1N1. Lancet, 2009, 374:1786–1791. effective? An evaluation of knowledge gain in a three-day in- 7. Haroun HM et al. Assessment of the effect of health education stitute. Health Education, 1981, 12:22–24. on mothers in Al Maki area, Gezira state, to improve homec- 4. Abolfotouh MA. The impact of a lecture on AIDS on knowl- are for children under five with diarrhea. Journal of Family and edge, attitudes and beliefs of male school-age adolescents in Community Medicine, 2010, 17:141–146. the Asir Region of southwestern Saudi Arabia. Journal of Com- munity Health, 1995, 20:271–281.

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Pattern of morbidity and mortality in Karbala hospitals during Ashura mass gathering at Karbala, Iraq, 2010 F. Al-Lami,1 A. Al-Fatlawi,1 P. Bloland,2 A. Nawwar,3 A. Jetheer,1 H. Hantoosh,1 F. Radhi,1 B. Mohan,1 M. Abbas,1 A. Kamil,1 I. Khayatt 1 and H. Baqir 1

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ABSTRACT Religious mass gatherings are increasingly common in Iraq and can harbour considerable public health risks. This study was aimed at determining morbidity and mortality patterns in hospitals in Karbala city, Iraq during the mass gathering for Ashura in 2010. We conducted a cross-sectional study on attendees at the 3 public hospitals in the city. The study period was divided into pre-event, event, and post-event phases. Morbidity and mortality data were obtained from hospital registry books and the coroner’s office. About 80% of the 18 415 consultations were at emergency rooms. Average daily emergency room attendance was higher during the event compared with pre- and post-event phases, while average daily admissions decreased. Compared with the pre-event phase, a 7-fold increase in febrile disorders and a 2-fold increase in chronic diseases and injuries were noted during the event phase. There was no difference between the 3 phases for average daily death rate,nor for cause of death.

Tableaux de morbidité et de mortalité dans les hôpitaux de Karbala lors du rassemblement de masse pour l’Achoura, à Karbala (Iraq), 2010

RÉSUMÉ Les rassemblements religieux de masse sont de plus en plus courants en Iraq et peuvent engendrer des risques importants pour la santé publique. La présente étude visait à déterminer les tableaux de morbidité et de mortalité dans les hôpitaux de la ville de Karbala (Iraq) lors du rassemblement de masse pour l’Achoura en 2010. Nous avons mené une étude transversale sur la fréquentation dans trois hôpitaux publics de la ville. La période d’étude couvrait les trois phases suivantes : avant, pendant et après l'événement. Les données sur la morbidité et la mortalité ont été recueillies à partir des registres des hôpitaux et du bureau du médecin légiste. Le service des urgences a reçu près de 80 % des 18 415 consultations. La fréquentation journalière moyenne au service des urgences était plus élevée pendant l’événement qu’avant et après ce dernier, alors que le nombre moyen d’hospitalisations journalières a diminué au moment du rassemblement. On a constaté que, pendant l'événement, les accès de fièvre ont été multipliés par sept, et les maladies chroniques et traumatismes par deux, par rapport à la phase précédant le rassemblement. Il n’y avait pas de différence entre les trois phases pour ce qui concerne le taux moyen de mortalité journalière et les causes de décès.

1Field Epidemiology Training Programme (FETP),Baghdad, Iraq(Correspondence to F. Al-Lami: [email protected]). 2Centers for Diseases Control and Prevention, Atlanta, Georgia, United States of America. 3Ministry of Health, Baghdad, Iraq.

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Introduction Muhammad at the Battle of Karbala rooms (ERs) of these hospitals. Mor- in 61 AH (680 CE). It is attended by tality data were obtained from death Mass gatherings are defined as pre- millions of Muslims from within and certificates issued by the hospitals and planned, public events held for a lim- outside Iraq [15]; all should visit the from the provincial coroner’s office over ited time period and attended by large holy shrines on this day. This can re- the same period. number of people, typically more than sult in extreme crowding, leading to Data were collected on a daily basis 1000, although some suggest more increased risk of stampedes. For cultural using standardized instrument that in- than 25 000 [1,2]. They can be held or religious reasons, some attendees use cluded basic patient demographic data for political, social, religious, sports, and self harm practices such as laceration of and provisional diagnosis or primary other reasons. Comprehensive reviews the scalp using sharp knives, etc. More cause of death. The study period was of mass gathering literature have con- importantly, owing to the high densities divided into three phases: “pre-event” cluded that medical needs were largely of people, international visibility, and (1–14 December), “event” (15–18 determined by the event type and dura- symbolic means through which terror- December), and “post-event” (19–26 tion, attendance, weather, crowd mood ists might amplify the effects of their December). Although Ashura is actu- and density, and other factors [3,4]. action,mass gatherings are often cited ally a 1-day event, people usually attend Mass gatherings can engender a lot as targets for terrorism [16–18]. This 2 days earlier and stay 1 day afterwards. is particularly true for Iraq, which has of societal and governmental concerns For planning purposes, the local gov- experienced a number of terrorist at- and can result in health and socioeco- ernment considers this as the mass tacks, making the prevention of such nomic consequences. They challenge gathering period to take into account attacks the focus of the government public health vigilance and knowledge the arrival and departure of attendees. during mass gatherings. because they increase the epidemiologi- We used the same period to define the cal potential for the spread of disease to Religious mass gatherings follow “event” phase. a maximum, increase the risk of injuries, the Islamic lunar calendar, so the date Because standardized case defini- and exacerbate pre-existing chronic moves forward by 10–11 days every tions or international disease classifica- conditions [5]. Mass gatherings add year, therefore presenting health risks tion standards are not routinely used in burden to the host countries and to trav- associated with seasonal variation [19]. Iraq, we grouped provisional diagnoses ellers’ countries of origin [6–8]. Public The public health impacts associ- into broad syndromic or body-system health systems become strained even ated with mass gatherings are inade- categories. As reliable denominator if they are advanced and effective in quately studied in Iraq. The objective of figures were not available and because preventing and controlling the endemic this study was to describe the pattern of the phases were of different lengths, disease burden and even if the countries morbidity and mortality in Karbala hos- we analysed the data through the 3 have the appropriate resources [9,10]. pitals, with emphasis on emergency at- phases using average daily health-care The mass gathering environment itself tendance, and type of diseases/injuries, contact rates (including hospital admis- also impacts the host population by during Ashura in 1431 Hijri (December sions, ER consultations, and deaths). imposing added burdens on civilian 2010). Figures were rounded to the nearest infrastructures [11]. whole number. On-way analysis of vari- ance (F-test),Tukey (HSD) test and In the Middle East, the Hajj is the Methods chi-squared test were used to identify best known and most closely studied significant differences in average daily mass gathering. Many studies have been A cross-sectional study was conducted figures and frequency data between the conducted on describing public health in the city of Karbala (population ap- 3 phases. Epi Info and SPSS were used consequences associated with Hajj, par- proximately 500 000; located 100 km for data entry and analysis. P < 0.05 was ticularly outbreaks of communicable south-east of the capital, Baghdad) on all considered statistically significant. diseases and injuries [12–14]. patients who were admitted to the hos- In Iraq, several religious mass gath- pital wards or attended the emergency erings are held throughout the year, room (ER) in all 3 public hospitals in Results mainly in Karbala, Najaf and Baghdad. Karbala (Al-Husainy General Hospital, Ashura is the third largest religious the Obstetrical/Gynaecological Hospi- Data were collected on a total of 18 415 mass gathering in Karbala. It is com- tal and the Paediatric Hospital) during health-care contacts; Table 1 describes memorated by Shi’a Muslims as a day of 1–26 December 2010. Morbidity data the basic characteristics of the study mourning for the martyrdom of Husayn were obtained from the registry books population. The majority (51%) of ibn Ali, the grandson of the Prophet of the hospital wards and emergency patients were in the 15–44 years age

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group; there was an almost equal male with pre- and post event phases, but during the event phase than pre- (P = to female ratio, and more than 97% of this was not statistically significant (P 0.016) or post-event (P = 0.025). Also, people seeking care at the study sites ≥ 0.05)(Table 2). In the Paediatric diagnosis of fever and febrile convul- were from Karbala province. The pro- Hospital there was an increase of more sions was 7 times greater during the portion of patients in the age group than 100% in average daily attendance event than pre-event, and 4 times great- < 15 years was significantly higher in during the event (257) compared with er than post-event phases (P < 0.001). the event phase (42.6%) compared to pre-event (109) (P< 0.001), and post- Regarding injuries, the average daily the pre- (24.2%) and post-event phases event (172) (P = 0.019). attendance was significantly higher dur- (28.9%) (P < 0.001).While the number The average daily ER consultation ing the event compared to pre-event of males exceeded that of females in rate was significantly higher during the phase (P = 0.041). Although in general, the pre-event (52.7%), and post-event event phase (772) compared with the the / attendance (54.4%) phases, females predominated pre-event (480) and post-event (607) was not significantly different between in the event phase (55.9%)(P < 0.001). phases (P < 0.001)(Table 2). The av- the phases, average attendance for cae- The proportion of attendees from other erage daily admissions to the hospital sarean section was significantly higher provinces in Iraq constituted 2.8% in wards was lower in the event phase during the post-event phase compared the pre-event, and 1.8% in the post- (127) compared with the pre-event with the event (P = 0.002) and pre-event event, and only 0.4% in the event phase (136) and post-event (169) phases, (P = 0.038) phases. “Other”, which (P < 0.001). but the difference was not statistically mainly included less urgent cases, were Across the study period, about significant(P = 0.907). significantly higher in the post event 79% of contacts were reported from According to provisional diagnosis, compared to event (P = 0.041) phases ERs; about 69.2% attended Al-Husainy the average daily attendance for com- (Table 3). General Hospital, 9.6% attended the plications of diabetes was 3 times higher In general, in the pre-event phase, Obstetrical/Gynaecologic Hospital, during the event phase compared with the ratio of noncommunicable diseases: and 21.2% attended the Paediatric Hos- pre- and post-event phases (P < 0.001) communicable diseases: injuries was pital. The average daily attendance to (Table 3). Similarly, the average daily 2.4:3.7:1 for the ER, and 12.9:6.1:1 for Al Husainy and the Gyn/Ob hospitals attendance for diagnoses of cardiovas- hospital admissions. The correspond- increased during the event compared cular disease was significantly higher ing ratio during the event phase was

Table 1 Demographic characteristics of people (n = 18 415) who attended 3 public hospitals before, during and after Ashura mass gathering, Karbala, 2010 Characteristic Phase Total P-value Pre-event Event Post-event No.%No.%No.%No.% Age (years) a < 1 643 7.5 247 6.9 505 8.2 1 395 7.6 1–4 832 9.7 663 18.4 763 12.4 2 258 12.3 5–14 600 7.0 623 17.3 510 8.3 1 733 9.5 < 0.001 15–44 4 687 54.5 1 476 41.1 3 188 51.8 9 351 51.0 45–64 1 380 16.1 423 11.8 911 14.8 2 714 14.8 65+ 451 5.2 163 4.5 273 4.4 887 4.8 Sex b Female 4 061 47.3 2 009 55.9 2 820 45.6 8 890 48.4 Male 4 527 52.7 1 586 44.1 3 366 54.4 9 479 51.6 < 0.001 Residence c Karbala 8 342 96.9 3 565 99.2 6 065 97.9 17 972 97.7 Other provinces 241 2.8 15 0.4 112 1.8 368 2.0 < 0.001 Other countries 23 0.3 15 0.4 15 0.2 53 0.3 Total 8 612 46.8 3 597 19.5 6 206 33.7 18 415 100.0

aAge missing on 77 records. bSex missing on 46 records. cResidence missing on 22 records.

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Table 2 Average daily attendance of patients (n = 18 415) who attended 3 hospital departments, and average daily deaths according to event phase, Ashura mass gathering, Karbala, 2010 Variable Daily average (no.) P-valuea P-valueb Pre-event Event Post-event Pre- vs event Pre- vs post- Event vs post- Hospital Husainy 447 564 541 0.05 0.118 0.107 0.923 Gynaecology-Obstetrics 59 79 63 0.362 0.329 0.908 0.556 Paediatric 109 257 172 < 0.001 < 0.001 0.017 0.019 Hospital department Emergency 480 772 607 < 0.001 < 0.001 0.025 0.037 Admission 136 127 169 0.075 0.907 0.101 0.148 Deaths 7.4 9.8 10.9 0.786 0.993 0.774 0.911 Total 615 899 776 < 0.001 0.001 0.011 0.202

aF-test. bTukey (HSD).

1.5:2.7:1 in the ER, and 13.8:9.4:1 for hospital admissions during mass gath- demonstrated an increase in consulta- hospital admissions. For the post-event erings in some neighbouring coun- tions for chronic diseases, particularly phase, the ratio was 2.4:4.2:1 for the ER tries [12–14]. This is likely due to the diabetes mellitus and cardiovascular dis- and 10.7:4.8:1 for hospital admissions. modification of the health-care delivery eases. The observed a 3-fold increase in Across the study period there were system during Ashura and similar mass attendance for complications of diabetes 230 deaths; 37 (16%) of these were re- gatherings: hospitals postponed all ser- mellitus may be due to poor adherence ported from the provincial coroner’s of- vices for non-emergency conditions. to diet or medications during the event. fice, reflecting deaths occurring outside Although new, simpler, mobile and In mass gatherings, noncommunicable hospital. The proportion of deaths in the fixed health-care delivery outlets are diseases and injuries have caused more pre-event, event and post-event phases located very close to the scene of the deaths and greater morbidity than have were: 45%, 17%, and 38%, respectively. mass gathering, still they provide only communicable diseases [21]. Corresponding average daily deaths the basic ambulatory services and first A 2-fold increase in injuries was not- were: 7.4, 9.8, and 10.9, respectively but aid; more serious cases that required ed; many were related to cultural habits the differences were not statistically sig- more professional intervention are such as intentional scalp lacerations nificant (P > 0.05) (Table 2).The most still referred to the hospitals. The new practised by some attendees. Human frequent causes of death throughout outlets help absorb the health burden stampedes are the most feared disaster the study were cardiovascular disease attributed to less-serious conditions during mass gatherings because they are (44.3%), respiratory disease (12.2%) during the mass gathering, particularly frequent and are associated with a high and injuries (10.0%). Mortality analysis for visitors who are not familiar with fatality rate [22]. In Iraq in 2005 a stam- for cause, age, sex and residence across how to access the hospitals. This is sup- pede resulting in about 1000 deaths the 3 phases did not show any specific ported by the finding the majority of was triggered by the false rumour of trends or statistical significance. attendees to the 3 public hospitals in a suicide bomber [23]. The increase this study were local residents. in injuries recorded is consistent with Despite an overall reduction in previous studies conducted for other Discussion hospital admissions during the event, mass gatherings [24–26]. there was still an increase in hospital Conversely, the average daily admis- Although many religious mass gather- consultations for a number of key condi- sion for caesarean section, and other ings are held in Iraq, to our knowledge tions. There was an increase in morbid- conditions (mostly non-urgent cases) this is the first study that describes pub- ity attributed to acute febrile conditions, greatly declined during the event, but lic health issues related to such events in likely reflecting acute and markedly increased after the event. Al- this country. respiratory illnesses. This is consistent though this could be due to the planned We found a reduction in hospital with other studies on mass gatherings postponement of admission for less- admissions during the period of the that documented excess admissions urgent conditions to after the event, event. This contrasts with the findings for infectious diseases associated with hindered access to the hospitals or poor of other studies that showed excess overcrowding [20]. Similarly, our study triage of more severe conditions should

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Table 3 Average daily attendance at 3 hospitals according to provisional diagnosis and event phase, Ashura mass gathering, Karbala, 2010 Provisional diagnosis Daily average (no.) P-valuea P-valueb Pre-event Event Post-event Pre- vs event Pre- vs post- Event vs post- Complication of chronic disease 78.5 135.0 78.1 < 0.001 < 0.001 0.999 < 0.001 Cardiovascular disease 61.6 89.5 61.3 0.016 0.016 0.999 0.025 Diabetes mellitus 16.8 45.5 16.7 < 0.001 < 0.001 1.000 < 0.001 Fever/febrile convulsion 13.0 92.0 22.4 < 0.001 < 0.001 0.105 < 0.001 Gastrointestinal tract disease 173.0 199.7 210.4 0.475 0.785 0.496 0.967 Neuropsychiatric illness 23.0 41.5 39.4 0.039 0.123 0.073 0.974 Pregnancy-related disorder 57.5 68.3 60 0.719 0.696 0.968 0.832 Caesarean section 6.0 3.0 10.7 0.002 0.124 0.038 0.002 Normal vaginal delivery 27.0 34.0 28.7 0.69 0.939 0.794 0.705 Other gynaecological/ obstetric disorders 24.3 31.2 20.5 0.396 0.602 0.78 0.364 Respiratory illness 102.2 154.7 152.7 0.034 0.137 0.056 0.997 Injury 74.4 153.7 90.1 0.053 0.042 0.792 0.156 Other (general) 93.3 54.2 122.7 0.018 0.163 0.185 0.014

aF-test. bTukey (HSD).

be still considered as a contributing the overall burden during the event, better planning and response, we rec- factor. especially the less-severe illnesses and ommend implementing public health There was a slight non-significant injuries. There may have been some surveillance during mass gatherings increase in mortality in the post-event degree of misclassification of illnesses which covers all the health-care de- phase that could be attributed to an both due to the lack of the use of stand- livery outlets and which is capable of accumulation of excess morbidities in ardized disease classification as well as identifying the burden and trend of the event phase, particularly complica- the use of provisional instead of final various health disorders. Finally, it is tions of chronic diseases, infections and diagnoses. recommended to implement use of the injuries. To sum up, the mass gathering we International Classification of Diseases There were a number of limitations studied was associated with an increase 10 (ICD-10) in health facilities as this to this study. Because the temporary in ER attendance and consultations will help in better understanding the health outlets did not keep any health for febrile conditions, complications of pattern and trend of morbidity and contact information, and data from chronic diseases, and injuries, besides mortality and facilitate implementation other health outlets were not included, a reduction in hospital admissions and and evaluation of control and preven- we were unable to accurately measure no change in mortality. To facilitate tive measures.

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Preparedness and health risks associated with Moulay Abdellah Amghar moussem, Morocco, 2009–2010 M. Youbi,1 N. Dghoughi,1 M. Akrim,1 A. Essolbi,1 A. Barkia,2 A.I. Azami,3 A.T. Fleischauer,4 D. Schneider 5 and A. Maaroufi 1

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ABSTRACT The objective of this study was to describe the risks and human health outcomes associated with attendance at the Moulay Abdellah Amghar moussem (a pre-planned mass gathering attracting more than 360 000 participants) for the purposes of public health prevention, planning, preparedness and response. We performed an environmental health risk assessment and retrospectively reviewed local health centre records before, during and after the event. In addition, standardized interviews with key stakeholders were performed to qualitatively evaluate local public health preparedness and response capacities. During the event, average daily health centre visits increased 5-fold. The sex ratio of health-care visits changed significantly from an average of 1.8:1 female:male visits per day to 1.2:1. The proportion of injuries varied from an average of 3.7% pre- and post- event to 14.8% (P < 0.01) during the event. A significant increase in digestive diseases was also observed during the event. Recommendations include increasing accessibility to free sanitation and hygiene facilities and improving health communications concerning hand washing and food and water safety.

Préparation et risques sanitaires associés au moussem de Moulay Abdellah Amghar (Maroc), 2009-2010

RÉSUMÉ La présente étude avait pour objectif d’identifier les risques et les résultats sanitaires pour l'homme associés à la participation au moussem de Moulay Abdellah Amghar (un rassemblement de masse prévu à l'avance qui attire plus de 360 000 personnes) à des fins de prévention, de planification, de préparation et d'action dans le domaine de la santé publique. Nous avons évalué les risques environnementaux pour la santé et avons procédé à un examen rétrospectif des registres des centres de santé locaux avant, pendant et après l’événement. Nous avons également réalisé des entretiens standardisés avec les principales parties prenantes afin d’évaluer, en termes de qualité, les capacités locales pour la préparation et la riposte en matière de santé publique. Pendant le rassemblement, le nombre moyen de consultations journalières dans les centres de santé a été multiplié par cinq. Le rapport de masculinité pour les consultations médicales a évolué de manière significative, passant d’une moyenne journalière de 1,8 femme pour 1 homme à 1,2 femme pour 1 homme. Le pourcentage des traumatismes est passé d’une moyenne de 3,7 %, avant et après l’événement, à 14,8 % pendant le rassemblement (P < 0,01). On a aussi constaté une forte augmentation des maladies digestives pendant l’événement. Il est recommandé, entre autres, d'augmenter l’accessibilité des installations gratuites d’assainissement et d’hygiène et d'améliorer la communication en ce qui concerne l’hygiène des mains et la sécurité sanitaire de l’eau et des aliments.

1National Institute of Health Administration; 2Directorate of Epidemiology and Diseases Control, Ministry of Health, Rabat, Morocco (Correspondence to M. Youbi: [email protected]). 3Regional Observatory of Health, Casablanca, Morocco. 4North Carolina Division of Public Health, Raleigh, North Carolina, United States of America. 5Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.

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Introduction and hygiene facilities [1,2]. Addition- rash, conjunctivitis, fever of unknown ally, healthcare facilities may not have origin), heat-related illness (e.g. heat Moussems are an integral part of Mo- appropriate surge capacity to manage exhaustion, sunburns, sun stoke, and roccan culture. They are pre-planned, these events. Information on human dehydration), scorpion bites, accidents public, mass gathering events held for health outcomes would help to inform attributable to the fantasia (e.g. falls from religious, social and cultural, and/or event-based preparedness and re- horses, injuries from the explosives), commercial purposes in urban and rural sponse efforts; however, no systematic violence, road traffic injuries, burns, jel- sites throughout the country. The term evaluation of health risks and outcomes lyfish stings, and drowning. All other “moussem” comes from the Moroccan associated with moussems has been per- visits such as chronic conditions were Arabic dialect and is related to the word formed in Morocco [3]. classified as “other.” “mawssim”, which, in classical Arabic, The objectives of this study were to A semi-structured questionnaire means “season”. Moussems are typically describe the specific health risks and was administered to key stakeholders of short duration, held seasonally, and morbidity associated with the Moulay including health workers (provincial usually commemorate a saint. There are Abdellah Amghar moussem and to evalu- directorate, hygiene team health cen- more than 300 annually, and the timing ate the healthcare infrastructure and tre), an official from the Economic of many of these events corresponds to public health preparedness capacity for and Control unit of the Ministry of the agricultural seasons (e.g. ploughing or this event. Interior at the provincial level, repre- harvest), well-known social events (e.g. sentatives of the moussem organizers the annual return of Moroccans who and the captain of the provincial civil work abroad, holidays), and celebration Methods protection unit. Questions included of culture and art (e.g. festivals of roses, characteristics of the moussem, social festival of engagements, spiritual music We conducted a retrospective study and behavioural risks (e.g. animal sac- events). to describe the human health risks and rifice, ritual dancing in a state of trance, The Moulay Abdellah Amghar outcomes associated with attendance at and other rituals specific to the Moulay moussem, one of the largest events, the Moulay Abdellah Amghar moussem. Abdallah Amghar moussem), oganiza- annually attracts more than 360 000 To accomplish the study objectives, we tional attributes, and the health system people from across Morocco and in- compared healthcare encounters be- structure in place. ternationally for a period of 8 days. It fore, during, and after the mass gather- is held in the summer in El Jaddida ing from health centre medical records. Data analysis province, Doukkala-Abda region, in Additionally, we conducted standard- Medical records and questionnaire data the western part of the country on the ized interviews with key stakeholders were collected and entered into a Micro- Atlantic coast. Thismoussem is held in to characterize the organizational and soft Excel spreadsheet. Statistical testing honour of a religious saint, Moulay health preparedness aspects of this using the chi-squared test to compare Abdellah, and includes music, sport, moussem. proportions was performed using Epi cultural and religious activities, and fan- We reviewed medical records of Info, version 6. tasia, traditional horse shows in which all patients seen at the health centre in riders perform military re-enactments Moulay Abdellah Amghar during the Ethical considerations with firearms that use powder (gun- pre-event period (–14 days to –7 days), All aspects of this study, including ac- powder) explosive. the 8 days of the event and the post- cess to medical records, were approved Although there have been anecdo- event period (+7 days to +14 days) for by the Ministry of Health of Morocco. tal reports of acute illnesses, outbreaks, the past 2 annual moussems (2009 and Interviews were conducted after having and injuries associated with attendance 2010). periods were selected because obtained informed consent. Informa- at a moussem, the reports are typically they are outside the period when at- tion obtained from medical records not validated or surveyed by health tendees congregate at the event site and other health service providers officials. Environmental health risks (visitors begin to arrive several days was kept strictly confidential and no and human health outcomes associ- before the event and stay several days names or other identifying informa- ated with mass gatherings have been after). Health centre visits were cat- tion on patients was collected. The well documented, and include haz- egorized as digestive disorders (acute key stakeholders and their supervisors ards resulting from crowding, traffic, gastrointestinal symptoms and/or were contacted in advance to explain violence and terrorism, adverse weather gastroenteritis), acute respiratory disor- the objectives of the study and official exposure, unlicensed food and water ders, other infectious diseases (e.g. phar- permissions were obtained prior to the vendors, and poor access to sanitation yngitis, sexually transmitted diseases, interviews.

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Results the event time period, a significant in- houses. Themoussem is hosted in a small crease was observed during the event rural village of 9000 residents, located Health outcomes associated for digestive disorders (10.9% pre- and on the coast near a small fishing port. with the Moulay Abdellah post-event vs 14.2% during the event, The site is only accessible by a single Amghar moussem P < 0.05) and accidents and injuries 10 km secondary road (1 lane in either The average number of health centre (3.7% vs 14.8%, P < 0.01). In contrast, a direction) from a main highway. visits during the moussem period in 2009 significant decrease was recorded for the Potable well water is provided by and 2010 was 1577 per year. While the number of acute respiratory disorders water fountains equipped with many average daily number of visits was 36 (9.4% vs 6.0%, P < 0.001) (Figure 1). faucets; the well water is treated and outside the moussem period, it increased During the moussem, men were monitored by a hygiene team from the to 197 during the event. nearly twice as likely to be injured or Ministry of Health. However, private The average daily ratio of female involved in an accident compared with unregulated vendors selling well water to male health centre visits during the women [331 (70.9%) visits vs 136 can be found throughout the site. Bath- moussem was 1.2. This ratio in the pre- (29.1%) visits, P < 0.01], while women room and shower facilities are avail- and post-event time periods was 1.8, were more likely to be seen for digestive able for a fee, but few people use them indicating an increase in health centre disorders [286 (63.8%) visits vs 162 because of the cost. Many attendees visits by males during the moussem. (36.2%) visits, P < 0.01] and infections relieve themselves outdoors without the Among the 3153 health centre vis- other than acute gastrointestinal or res- use of hand washing stations. Food is its during the event in 2009 and 2010, piratory infections [402 (57.1%) vs 302 prepared by the attendees themselves in 704 (22%) were potentially due to an (42.9%), P < 0.01]. their tents and rented rooms. However, infection other than a respiratory or many small restaurants are available gastrointestinal illness, 467 were classi- Risk assessment and event on site, often without the minimum planning analysis fied as accidents and injuries, 448 were requirements for food storage and con- for digestive disorders, 188 were likely The Moulay Abdellah Amghar moussem servation, including refrigerators. an acute respiratory illness (Figure 1). typically attracts approximately 360 000 Solid waste is handled by the city’s Other chronic and acute conditions national and international attendees waste management service and garbage accounted for the unclassified (“other”) each year for 8 days in July or August. collection is carried out twice a day. A health centre visits (42%). Approximately 40 000 (11%) of these private company is contracted to pro- Comparing the average for the stay in the area for the duration of the vide insect and rodent control. The hy- pre- and post-event time periods with moussem either, in tents or in rented giene team from the Ministry of Health, in collaboration with the Ministry of the Interior and the Ministry of Agriculture, inspect and manage the animal slaugh- ter facilities and ensure food safety. The local health centre is trans- formed into an emergency care facil- ity during the moussem and operates 24 hours a day during the event. This health centre has 4 beds for short-term observation. Three clinical teams, each consisting of 2 general practitioners and 4 nurses, work 8-hour shifts. During the moussem, the health centre is equipped with surge capacity of common phar- maceuticals and medical equipment. In addition, 2 ambulances and staff are co-located with the health centre. Figure 1 Reasons for health centre visits pre-event, post-event and during the Moulay Abdellah Amghar moussem, 2009 and 2010 (Dig = digestive disorders; Planning for the moussem begins Resp = acute respiratory disorders; Infect = other infectious diseases; Heat = heat- each year in January and is managed and related illness; Scorp = scorpion bites; visits for reasons classified as “other”, e.g. coordinated by a provincial committee chronic conditions, are not shown on this chart) led by the governor of El Jadida province.

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The provincial committee designates drowning and intentional injuries, are used to validate illnesses and injuries 7 specific commissions (Equipment much more attributed to males and categories for classing patients during and Site Management, Fantasia and could be explained by the use of drugs data compilation for our study; there- Folklore, Safety and Security, Surveil- and alcohol reported by all interviewed fore, selection bias could have been lance and Consumer Protection, Heath stakeholders in our study. introduced. Thirdly, we were unable to and Hygiene, Communication and Co- We also found that during the epidemiologically link the reasons for ordination, and Religious Activities). moussem, digestive disorders increased the visits to the health centres absolutely These commissions are charged with overall, particularly among females. This to the event, and specifically we were all organizational and planning aspects. was likely a result of poor sanitation or unable to confirm etiologies for most The Health and Hygiene Commission water and food contamination, despite acute illnesses. is supervised by the Ministry of Health. the sanitation and hygiene measures Additionally, and owing to the lack Coordination is done through meetings implemented by the organizers. In fact, of reliable data on the population distri- and periodic reports sent to the gover- the supply sources of private water ven- bution of the attendees, we were unable nor. During the moussem, the event site dors, as well as storage and distribution to calculate specific incidence rates of is divided into 6 areas, each of which conditions, may be very suspect. Other different health problem categories, is overseen by the head of the local au- aspects of hygiene may also be a source especially by age and sex, in order to thority (caïd). A coordinating centre is of suspicion, especially preparation of compare them with outside the event. established and daily meetings are held food in the many small restaurants on Despite these limitations, the results to discuss and assess the activities and the site and their storage conditions. of our study allow us to make some problems. The most important source of suspicion recommendations for the attention of could be, however, the limited access decision-makers, moussem organizers to sanitation facilities because they are and officials of the health system for Discussion only available for a fee; this would have better preparedness and management lead to deficiencies in personal hygiene, Moussems are culturally important and including a lack of hand washing. of the event with a view to minimizing widely popular mass gatherings held health risks. In this study, we expected greater throughout Morocco. This was the first proportion of digestive disorders during study to conduct a risk assessment and the moussem compared with accidents Recommendations identify human health outcomes associ- and injuries, but surprisingly, this was ated with a moussem, specifically Moulay not the case. This finding is concordant To minimize the risk of acute gastro- Abdellah Amghar, the most popular with a descriptive study of all moussems in one in Morocco. intestinal illness during moussems, we Morocco that was conducted in parallel recommend that the health and hygiene The finding that there was an in- to this one [Akrim M et al., unpublished crease in the average number of daily committee enhance their public health report]. Otherwise, it is possible that the interventions targeting hygiene and visits to the health centre confirms the number of cases reported during the large increase in workload during the sanitation, especially through increasing event was a significant underestimate accessibility to sanitation and hygiene event and amply justifies the implemen- since the incubation period of many tation of a continuous, 24-hour, service. facilities and making such facilities free acute illnesses is longer than the dura- to the public. The sex ratio of persons seeking tion of time spent at the moussem. healthcare has changed significantly Unregulated water sellers should be in favour of males during the moussem, Limitations prohibited. If this proves to be impos- suggesting a high male predominance The quality of our results may have sible, their sources must be identified among the attendees. This finding been affected by certain limitations, and treated and containers should be could explain the increase in the pro- especially in relation to the informa- checked and treated if necessary. portion of health centre visits for ac- tion abstracted from medical records. Small restaurants and food vendors cidents and injuries during the event. Firstly, the reasons for health centre should also be controlled and particular In fact, a large proportion of these ac- visits (e.g. complaints and diagnoses) attention should be paid to the condi- cidents were related to falls from horses were recorded by the clinical teams tions of preparation as well as storage. and from exploding firearms during using different medical notations and Connection of their facilities to electric- the fantasia performances, which are abbreviations that do not refer to any ity should be provided by the organ- exclusively male activities. Several specific criteria or uniform standards. izers and the availability of refrigerators other accidents and injuries, such as Secondly, no international standard was should be mandatory.

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These measures should be comple- while providing simulations to test and to adverse health outcomes during this mented by appropriate health education make the necessary improvements, ac- moussem [6]. on hygiene of water and food, particu- cording to World Health Organization larly on hand washing. A variety of com- recommendations [5]. munication channels should be used, Additionally, an annual risk assess- Acknowledgements such as interpersonal communication, ment prior to and during the mous- audio messages and pamphlets. The sem should be conducted in order to This study would not have been pos- installation of a dedicated moussem radio identify potential health hazards and to sible without the support and help of station could be useful for the dissemi- implement specific public health inter- Dr N. Ben Chama, Chief of Medicine, nation of health education messages. ventions. Provincial Service of Infrastructure and To reduce the number and severity In this context, and having regard Ambulatory Activities, and Interim of accidents and injuries, safety and secu- to the intensity of the workload at the Chief of Medicine, Ministry of Health rity measures need to be strengthened. health centre during the event, it is Delegation of El Jadida province. We They should focus on the regulation of recommended that health authorities also wish to thank Mr Allal Mechbouh access to the site and the management of strengthen the systems in place, includ- and Mme Soumya Belhamdounia the public, traffic control and maintain- ing both human and material resources. from SIAAP, Mr Tahar Halam, Chief ing permanent access for emergency ve- Particular attention should be given to of service “Action Economique et hicles, prevention of risks related to the drugs and equipment needed to care for de Contrôle”, El Jadida province, Le use of gas and electric equipment and trauma and injury. Capitaine Kamal, Commander of facilities [4]. Special attention should be Because of the difficulties we expe- “Campanie provinciale de la Protection paid to improving safety related to the rienced understanding the information Civile”, Dr Mohammed Kanar, Chief of organization of fantasia shows, in par- contained in the health centre regis- Medicine, My Abdellah Health Centre, ticular storage conditions of explosive ters, we recommend implementing a Mr Mohammed Erramch, Major, My powder and loading guns. surveillance system using appropriate Abdellah Health Centre and Mr Abder- All these measures should be surveillance forms and specific case defi- rahmane Moustaïd, SIAAP driver, El planned during the preparation phase nitions to rapidly identify and respond Jadida.

References

1. Ahmed QA, Arabi YM, Memish ZA. Health Risks at the Hajj. 6. Rassemblements mondiaux de masse : répercussions et opportu- Lancet, 2006, 367:1008–1015. nitéspour la sécurité sanitaire mondiale, Rapport du Secrétariat 2. Lucas N. Surveillance épidémiologique de l’Armada de Rouen [Global mass gatherings: implications and opportunities for [Epidemiological surveillance of Rouen Armada]. Saint- global health security, Report by the Secretariat]. Geneva, World Health Organization, 2012 (A65/18) (http://apps.who. 3. Maurice, France, Institut de Veille Sanitaire, 2004 (http:// int/gb/ebwha/pdf_files/WHA65/A65_18-fr.pdf, accessed 20 www.invs.sante.fr/publications/2004/armada_rouen/ar- September 2013). mada.pdf, accessed 20 September 2013). 7. Surveillance for early detection of disease outbreaks at an out- 4. Kadiri N et al. Morocco. In: Francoer RT, Noonan RJ, eds. The door mass gathering - Virginia, 2005. Morbidity and Mortality Continuum Complete International Encyclopedia of Sexuality. Weekly Report, 2006, 55(3):71–74. New York, Continuum International Publishing Group, 2004. 5. Memento manifestations publiques [Memento public events]. Puy-de-Dôme, France, Sapeurs Pompiers,2010 (GSMOO/ GSPR Version N°3).

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Public health surveillance at a mass gathering: urs of Baba Farid, Pakpattan district, Punjab, Pakistan, December 2010 S. Hassan,1 R. Imtiaz,1 N. Ikram,1 M.A. Baig,1 R. Safdar,1 M. Salman 1 and R.J. Asghar 1

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ABSTRACT The objective of this study was to identify health related problems encountered during an annual mass gathering in Pakpattan, Pakistan, the anniversary of the death (urs) of Baba Farid, and to make recommendations for planning and prevention activities. A surveillance system was established to capture health related data for the event. A list of reportable diseases was developed. Data were collected pre-, during, and post-event by health care workers trained for the purpose. A total of 5918 people reported to the 15 health care facilities providing services during the event; 58% of consultations were because of communicable diseases, 21% of which were respiratory tract infections and 26% gastrointestinal illness. Injuries accounted for 31% of cases and noncommunicable diseases for 11%. Prevalence of reportable disease during the event showed sizeable increases. No major disease outbreak was observed.

Surveillance de santé publique lors d’un rassemblement de masse : l’anniversaire de la mort de Baba Farid, dans le district de Pakpattan, au Pendjab (Pakistan), décembre 2010

RÉSUMÉ L’objectif de la présente étude était d’identifier les problèmes de santé rencontrés lors d'un rassemblement de masse annuel à Pakpattan (Pakistan), en l'occurrence l’anniversaire de la mort (urs) de Baba Farid Ganj Shakar, et de formuler des recommandations pour les activités de planification et de prévention. Un système de surveillance a été mis en place afin de relever les données sanitaires pour l’événement. La liste des maladies à déclaration obligatoire a été établie. Les données ont été recueillies en trois phases (avant, pendant et après l'événement) par des agents de santé formés dans ce but. Au total, 5918 personnes se sont rendues dans l’un des quinze établissements de santé qui fournissaient des services pendant l'événement. Les maladies transmissibles étaient à l’origine de 58 % des consultations, dont 21 % pour des infections des voies respiratoires et 26 % pour des maladies gastro-intestinales. Les traumatismes et les maladies non transmissibles représentaient respectivement 31 % et 11 % des cas. L'évolution de la prévalence des maladies à déclaration obligatoire pendant l’événement a enregistré une hausse significative. Toutefois, aucune flambée épidémique majeure n’a été constatée.

1Field Epidemiology and Laboratory Training Programme, Ministry of Health, Islamabad, Pakistan (Correspondence to S. Hassan: dr_shoaib@ hotmail.co.uk).

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Introduction automobile traffic. Narrow passages Aim are constructed using metallic bars The aim of this study was to determine Event history leading to Bahishti Dawaza so peo- the prevalence of communicable and Pakpattan is located 180 km from ple can safely walk through the door. noncommunicable diseases and injuries Punjab’s provincial headquarters, These gates and walls are removed important to public health at this annual Lahore. According to district health after the event. event. This information could be used department data, the population is On 25 October 2010 (around 6 to prevent both diseases and injuries 150 000. The anniversary of the death weeks before this event), about 6 peo- and therefore may lead to healthier and (urs) of Baba Farid (Hazrat Faridud- ple died and more than a dozen were safer mass gatherings in future. Specifi- din Mas'ud Ganjshakar) is observed injured in a bomb blast at the shrine [2]. cally, we aimed to: in this city during the first 10 days of Due to the intensity of religious senti- r identify stakeholders and include the Islamic calendar month Muhar- ments attached to events such as these, them in surveillance implementation there is always a threat of terrorism, and ram. Bahishti Dawaza (the Gate of and response; Paradise) at the shrine of the saint this can pose serious issues in regard to is the centre of the event. This gate public health response. r prioritize diseases under surveillance is open from sunset to sunrise dur- and collect data from selected sites; ing 5–9 Muharram. Thousands of Public health importance r analyse the collated data and dissemi- devotees form long queues that may Mass gatherings over extended periods nate information for timely action; extend up to 5 km. The 768th urs was of time pose unique challenges to the r make recommendations for future celebrated from 12 to 16 December existent systems [2]. The urs of Baba events. 2010. The actual celebrations started Farid attracts people from all walks of on 8 December 2010 (1 Muharram). life; the local health administration es- Devotees from across the world timates about 500 000 people attended Methods started arriving in the city as early as 3 the event in 2010. Large gatherings December. TheBahishti Dawaza was such as this one held in small towns After gaining approval from the local opened at sunset 12 December and or cities strains the local administra- administration to carry out surveil- closed each morning before sunrise. tion, which has to allocate additional lance at this mass gathering event, a This practice continued till 16 De- resources to manage the event [3]. A list of stakeholders was prepared. The cember 2010. large number of security personnel local administration and the health and from adjacent districts are deputed rescue departments were involved in Previous experiences to ensure the security and safety of at- implementing this surveillance system. The event is celebrated every year but tendees. Representatives of the security agencies there is no record of disease frequen- The numbers and diversity of the were also an integral part of the system. cies or injuries for previous years. There population attending the event poses Stakeholders agreed to a high prior- have been reports, however, from local many challenges. Such large numbers ity risk assessment exercise and daily health clinicians of increased numbers gathered in close quarters for variable evening coordination and debriefing for a range of diseases, particularly periods of time pose a risk of spreading meetings. The local health department gastrointestinal conditions, respira- communicable diseases, particularly ran a campaign on disease prevention tory illnesses, and injuries. In previous respiratory and gastrointestinal ail- and hygiene. years there has been no established ments. There is a high risk of outbreaks A pre-event risk assessment exer- surveillance system for such events in such gatherings. Overcrowding of cise was undertaken a few weeks prior in Pakistan, so most health events the streets with people and vehicles to the urs; this included reviewing any went unrecognized and uninvesti- leads to road traffic accidents. Many data available at local health depart- gated. In 2001, 27 people lost their hotels in the city are booked to capac- ment and local administration office lives in a stampede and another 125 ity forcing people to stay on the pave- from previous experience. The most were injured [1]; afterwards extensive ments on open streets. People with important considerations were dis- security arrangements were made to various diseases visit the shrine in the eases prevalent in the area, especially prevent any such occurrence in the belief that they will be cured. People those with an outbreak potential, and future. Temporary gates and walls are obliged to eat on the roadside, buy- environmental factors, which included are installed before the urs to control ing food from mobile vendors. Such both weather conditions and the na- all roads leading to the shrine. This practices make them susceptible to ture/characteristics of the crowd, e.g. is done to manage human as well as gastrointestinal problems. enormous crowds performing rituals

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and activities both indoors and out- r chronic disease on tasks like case definitions and pa- doors, extended exposure, and mobil- r ischaemic heart disease tient data recording and sharing. ity in large open spaces and in small r hypertension After initial medical care, patients closed areas. Security and terrorism r diabetes could be referred to the main district threats during the event were also con- r injury resulting from: hospital if necessary. Patients were sidered. r road traffic crashes treated even if they were not willing to The initial assessment exercise r falls participate in the survey or share their resulted in a breakdown of priority dis- r riots. information. Almost all those treated eases into 3 main groups of reportable Based on the priority disease list, a agreed to participate and all were as- diseases/conditions: communicable hybrid syndromic and injury surveil- sured that their identity would remain diseases, noncommunicable diseases, lance procedure was established. All confidential and would not be shared and physical trauma and injuries. Re- 15 health facilities providing health without their consent. portable conditions were: care around the locations of this event Everyone attending the selected were selected for collection of data: health care facilities, irrespective of r respiratory tract-related illness 8 public, 6 private and 1 nongovern- their permanent place of residence, r chronic obstructive pulmonary nmental (NGO)-based. Public health was included in this study. disease sector facilities were established within r asthma and near the shrine area as usual for Case definitions r gastrointestinal tract-related illness this event and these were provided Case definitions were developed r diarrhoea with medicines and first aid kits by the based on history and clinical examina- r dyspepsia/gastro-oesophageal re- local health department. Health facil- tion, discussions with general physi- flux disease ity counters established the purposes cians, and consultation of standard r febrile illness of this survey were made prominent references [4,5]. Case definitions r malaria with banners and signboards. Staff at were pre-tested at the district health r fevers other than malaria these facilities had pre-event training facility as a part of the pre-event phase

Table 1 Case definitions used for patients presenting at participating health facilities during the mass gathering for the urs of Baba Farid, Pakpattan, December 2010 Condition Case definition Acute respiratory illness < 4-hour history of cyanosis or dyspnoea, plus Breathing rate (for age group): ō 40/min (< 1 year) ō 30/min (1–5 years) ō 20/min (> 5 years) Asthma At presentation history of at least 2 recurrent episodes of: ō cough ō dyspnoea ō wheeze Chronic obstructive pulmonary At presentation history of at least 2 recurrent episodes of: disease ō cough ō sputum ō history of smoking Dyspepsia At presentation having at least 2 recurrent episodes of: ō anorexia ō vomiting ō tender epigastrium Diarrhoea Presenting with complaint of > 2 loose stools in 1 day Hypertension Having a single record of blood pressure > 140/90 at the time of presentation Ischaemic heart disease History of ischaemic heart disease or complaining of chest pain on exertion at presentation Diabetes mellitus Presenting with history of diabetes or blood sugar levels recorded as: ō fasting blood sugar > 7 mmol/L ō or random blood sugar > 11.1 mmol/L Malaria History of episodes of fever with chills and malaria positive confirmed by rapid diagnostic tests at health facility counter Other febrile cases Fever recorded as > 100 °F due to any illness except malaria

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and edited based on the diversity of majority (67%) of the reporting pa- Discussion symptoms encountered (Table 1). tients were male. For injury surveillance at this venue, Among the reportable diseases, ob- Communicable diseases accounted road traffic accidents, falls, riots or served frequency 58% of consultations for the greatest number of visits to stampedes during the event were were for communicable diseases dur- healthcare facilities in all 3 phases recorded. ing the event period. This was up from of the event. There were some small 51% during the week prior to the event clusters reporting identical health Data collection and analysis (Table 2). Among the communicable related complaints; district health On-site, temporary health facility coun- diseases, respiratory tract infections ac- departments and other response ters were established to provide health counted for 21% and gastrointestinal in- units were informed on a real-time care and surveillance. Staff at these fections for 26% during the event phase. basis, but no outbreaks or common facilities were trained to carry out the Although the majority of the pa- sources were found. There were mo- survey. A central data collection unit tients reported at the public sector bile vendors selling food in the city was established in the control room health facilities, the data from the private without any inspection of hygiene at the executive district health office and NGO sectors were also important practices or food quality. Failure of and all the public health surveillance (approximately 24% of the total record- various efforts to capture any com- activities were coordinated there. In ed encounters). There were participants mon source for the gastrointestinal- consideration of the outbreak potential, of all ages, but the majority (62.3%) related conditions may be because increased numbers (more than the were aged 15–49 years. The second these vendors changed location usual levels) of high impact events like largest group was those aged 50+ years frequently as well as the huge influx food- or waterborne illnesses and mass (23.3%). of people and overcrowding during injuries had to be reported by telephone Prevalence of acute respiratory the event. as early as possible. illness showed the most dramatic in- Before the event started, the city Daily data collation and the database crease, rising from 6.7 per 100 000 in experienced a great influx of vehicles. were managed using Microsoft Excel. the week before the event to 167.0 per This not only put a strain on the traf- 100 000 during the event (Table 3). fic system but also contributed to air Prevalence of diarrhoea and dyspep- pollution. The number of road traffic Results sia increased considerably, from 6.0 accidents and respiratory tract-related and 4.0 per 100 000 to 82.0 and 114.0 illnesses are also a result of the heavy A total of 5918 consultations were per 100 000 respectively. Among the traffic influx. recorded at the 15 selected health chronic diseases, the greatest increase in This study had certain limitations. facilities. Most of the patients (76.2%) prevalence was for hypertension, from As health facilities were scattered reported at the 8 public sector fa- 12.0 per 100 000 in the week prior to around the event centre over different cilities, 18.5% reported at the 6 private the event to 66.0 per 100 000 during parts of the city, this may have resulted facilities, while 5.3% reported at the 1 the event. Malaria prevalence showed in some cases reporting to more than 1 NGO facility. Case definitions were no appreciable change, however, during facility to seek support at various times agreed for 4896 of the patients. About the event period, prevalence of fever during the course of the same illness. 80% of the complaints were about other than malaria was reported as 72 Owing to resource limitations, we had reportable, high priority diseases. The per 100 000 (Table 3). a limited workforce available for case

Table 2 Distribution of medical conditions according to type recorded during the three phases of the mass gathering for the urs of Baba Farid, Pakpattan, December 2010 Type of disease/condition Pre-event During event Post-event Total (n = 74) (n = 4719) (n = 103) (n = 4896)a No.%No.%No.%No.% Communicable 38 51 2742 58 49 48 2829 58 Noncommunicable 23 31 504 11 33 32 560 11 Injury 13 18 1473 31 21 20 1507 31

Pre-event (phase 1) = the week before the event. During event (phase 2) = over the 10 days of the event. Post event (phase 3) = the week after the event. aOf the 5918 patients recorded and treated in total, case definitions were agreed for 4896.

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Table 3 Prevalence (per 100 000) of selected conditions treated at 15 healthcare facilities providing services for the mass gathering for the urs of Baba Farid, Pakpattan, December 2010 Condition Pre-event During event Post-event Acute respiratory illness 6.7 167.0 7.3 Asthma 4.7 3.5 6.0 Chronic obstructive pulmonary disease 2.0 13.5 3.0 Hypertension 12.0 66.0 14.0 Malaria 2.0 5.0 0.0 Other fever 0.0 72.0 0.0 Diarrhoea 6.0 82.0 8.7 Dyspepsia 4.0 114.0 7.0

Pre-event (phase 1) = the week before the event. During event (phase 2) = over the 10 days of the event. Post event (phase 3) = the week after the event.

follow-up, active case finding and con- responded to. The participation of Acknowledgements tact or source tracing. It is possible there a trained epidemiologist may prove were more cases who did not report to helpful in case investigations of report- We wish to thank the following people the health facilities or who sought over- able diseases during future events. for their support during this study: the-counter treatment. The source of Although we did not directly ex- r Provincial Secretary for Health, Gov- the significant rise in acute respiratory perience a terrorist attack during our ernment of Punjab, Lahore; infections during the event could not study, considering the current wave of be verified because of the limited labo- such attacks, local administrative and r Director General for Health, Govern- ratory resources available. health departments should be trained ment of Punjab, Lahore; An improved traffic control plan, for disaster management in order to r District Coordination officer, Pakpat- put in place prior to the event, may deal with any unforeseen event. tan District; serve to decrease traffic-related injuries. Lastly, surveillance should con- r Executive District Officer Health, Pa- Local health and other related depart- tinue, not only for this event, but for kpattan District; ments should collaborate to improve other mass gatherings in Pakistan and r Executive District Officer Health, sanitation and food quality for this a comparative study over the coming Muzafar Garh District; mass gathering. In future, during such years needs to be implemented so that events laboratory services should be common health problems at mass gath- r Medical Superintendent, District considered part of the surveillance erings are seen holistically. The data Headquarter Hospital, Pakpattan systems. collected would lead to the implemen- District; It is necessary to have surveil- tation of adequate preventive measures r Medical Superintendent, Tehsil lance mechanisms in place so that the that would improve community health Headquarters Hospital Ali Pur, Mu- health events are both recorded and and make such gatherings safer. zafar Garh District;

References

1. Fatal stampede at Pakistan festival. London, BBC News (web- experience of the Tamworth Country Music Festival, Australia. site), 2001 (http://news.bbc.co.uk/2/hi/south_asia/1254207. Public Health, 2013, 127(1):32–8. stm, accessed 13 October 2013). 4. 2010 National notifiable infectious conditions. Atlanta, Geor- 2. Khan OF. Bomb blast at Sufi shrine in Pakistan kills 6, injures gia, Centers for Disease Control and Prevention, 2010 16. Ahmedabad, Times of India (website), 2010 (http:// (http://wwwn.cdc.gov/NNDSS/script/ConditionList. articles.timesofindia.indiatimes.com/2010-10-25/paki- aspx?Type=0&Yr=2010, accessed 13 October 2013). stan/28254457_1_pakpattan-shrine-abdullah-shah-ghazi, ac- 5. Colledge NR, Walker BR, Ralston SH (eds). Davidson's prin- cessed 13 October 2013). ciples and practice of medicine, 20th ed. Edinburgh, Churchill 3. Polkinghorne BG et al. Prevention and surveillance of public Livingstone, 2010. health risks during extended mass gatherings in rural areas: the

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Mass gathering in Aqaba, Jordan, during Eid Al Adha, 2010 S. Abdullah,1 G. Sharkas2 N. Sabri,2 I. Iblan,2 M. Abdallat,1 S. Jriesat,3 B. Hijawi,3 R. Khanfar 4and M. Al-Nsour 4

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ABSTRACT During the 5-day Eid Al Adha holiday, Aqaba is the site of one of the largest mass gatherings in Jordan. Public health concerns during this holiday included: food- and waterborne diseases, drowning, injuries by marine creatures, road traffic crashes, and pressure on emergency departments at hospitals. This cross-sectional study was carried out in Aqaba during the period 16–20 November 2010 and aimed to identify and prioritize the major public health risks and to overview the preparedness plans of the Health Directorate during previous Eid events in Aqaba. All related stakeholders participated in the study. An exploratory visit to Aqaba was made and an introductory workshop was conducted for participants. Relevant data were collected and compared with the figures for the week prior to the event. No food poisoning outbreaks were reported during the event. There was a 23% increase in emergency department attendance, a 33% increase in hospital admissions, and road traffic crashes increased by more than 300%. More males were affected than females.

Rassemblement de masse à Aqaba pendant l’Aïd Al-Adha (Jordanie), 2010

RÉSUMÉ Pendant les cinq jours de l’Aïd Al-Adha, Aqaba est le théâtre d’un des plus grands rassemblements de masse en Jordanie. Durant ce congé, les problèmes de santé publique sont notamment les suivants : maladies d’origine alimentaire et hydrique, noyades, blessures causées par des animaux marins, accidents de la circulation routière et surcharge des services des urgences dans les hôpitaux. La présente étude transversale avait pour but d’identifier et de hiérarchiser les principaux risques pour la santé, et de présenter les grandes lignes des plans de préparation établis par la Direction de la Santé lors des précédentes fêtes de l’Aïd à Aqaba. Toutes les parties prenantes ont participé à cette étude. Une visite d'exploration a eu lieu à Aqaba et un séminaire-atelier préliminaire s’est tenu à l'intention des participants. Des données pertinentes ont été recueillies et comparées avec les chiffres de la semaine précédant l’événement. Pendant le rassemblement, aucune flambée épidémique due à une intoxication alimentaire n'a été signalée. La fréquentation au service des urgences a augmenté de 23 %, les hospitalisations de 33 % et les accidents de la route de plus de 300 %. Davantage d'hommes que de femmes ont été affectés.

1Communicable Disease Directorate; 2Jordan Field Epidemiology Training Programme;3Primary Health Care Administration,Ministry of Health, Amman, Jordan (Correspondence to A. Sultan: [email protected]). 4Eastern Mediterranean Public Health Network (EMPHNET), Amman, Jordan.

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Introduction strategies to reduce injury outcomes, Muslim religious occasion, and a na- including live surveillance of injury type tional holiday in Jordan. Mass gatherings are characterized by and cause, risk management and public Eid Al Adha (5 days) occurs during large crowds of spectators and partici- education. the Hajj. The timing depends on the pants, and are an increasingly common Many mass gatherings are held in Islamic (Hijri) calendar, which is 11–12 feature in many cultures. There is the Middle East and North Africa re- days shorter than the solar year. The growing recognition of public health gion, however only the Hajj has been majority of visitors come to Aqaba by concerns in mass gatherings. These addressed in the literature [8,9].This is car via the Dead Sea highway and the include water and sanitation manage- one of the largest mass gathering events Desert highway. Visitors participate in ment, emergency preparedness, trans- in the world: millions of pilgrims from a number of activities including swim- portation, crowd management and almost every country gather annually ming, cruising, and shopping. bioterrorism. All of these are challenges over several days. Throughout its long The aims of this study were to over- to control during mass gatherings [1]. history, Hajj has been witness to a series view the preparedness plans executed Enhanced surveillance is needed to of major health issues, with respiratory by Aqaba Health Directorate and other detect events in a timely manner and infections the most frequently reported stakeholders during previous Eid events to communicate information on public complaints [10].There is also the poten- in Aqaba and review the success, effec- health concerns. Other methods of tial for further spread infectious diseases tiveness, and limitations of these plans. surveillance during mass gatherings when participants return home from We also aimed to identify, prioritize, include additional community-based mass gatherings. This was demonstrated and analyse public health risks during systems and setting up event-specific after Hajj 2000 and 2001,when clusters the Eid mass gathering, and create tools surveillance [2]. Integration and coI- of meningococcal cases (serogroup for the surveillance of public health ordination of surveillance systems is W135) were reported [11]. These were concerns that are not included in the critical to ensuring comprehensive and linked to either a history of recent re- current Jordanian surveillance system, coherent results[3]. turnees from the Hajj or of household e.g. drowning. Extensive planning and prepared- contact with returned pilgrims. ness are required in the provision of The lack of information regarding public health services for mass gather- Methods other mass gatherings in the region has ings, and important to the planning highlighted the importance of concen- is a thorough knowledge of the inci- Eid Al Adha vacation lasted for 5 days trating on this ignored area, which is of dence and types of health problems (16–20 November) in 2010. The great consequence to public health. that may occur [4]. expected number of visitors to Aqaba Jordan has a population of 6 million Studies have been done at mass during this period ranges from 30 000 [12]. It has a stable political, social, and gathering events in many countries. to 70 000. economic situation that encourages In Virginia, United States of America, Our study was multisectoral; stake- hundreds of thousands of people to health authorities conducted a daily holders (partners in this project) in- syndromic surveillance to monitor visit the country. Annually, many mass cluded: the Communicable Diseases diseases symptoms and injuries at a gathering events are held, including re- Directorate; Aqaba Health Directorate; sport summer camp. Gastroenteritis ligious, cultural, and recreational events. the Islamic Hospital; the Modern Aqa- outbreaks and heat-related injuries To the best of our knowledge, no stud- ba Hospital; Princess Haya Hospital; were recorded [5]. A study conducted ies have been conducted to investigate Aqaba Governorate; the Police Direc- at a 9-day agricultural and horticultural public health concerns during such torate; the Civil Defence Directorate; show in Australia in 2002 demonstrated mass gatherings in Jordan. Aqaba Special Economic Zone Author- the high injury burden and the increased Aqaba, population 70 000, is the ity; and the Tourism Directorate. strain this placed on medical services only coastal city in Jordan. It is located The existing surveillance system in [6]. Another study in Australia during a on the Red Sea 350 km south of the Jordan is basically passive (notification World Youth Day celebration in 2008 capital, Amman. It is visited by large by health facilities), and is monitored showed that implementing continuous number of people, mainly young adults by the Ministry of Health Directorate re-evaluation of case definitions and and families, from Jordan, the region, of Communicable Disease. The list of ongoing laboratory testing helped in and other countries for tourism. Aqaba about 45 notifiable diseases and events the early identification of an influenza is also a duty free zone, and is visited is divided into 2 groups: Group A, outbreak among attendees [7]. All this for trading purposes. The number of diseases which must be notified to the suggests a definite role for planning visitors increases greatly during Eid, a public health authorities within 24

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hours (e.g. cholera, food poisoning) coming Eid holiday. Visits also targeted r enhancing awareness among clini- and Group B, diseases and events that hospitals to check their capacity to deal cians during visits of the FETP team must be notified via the weekly report with expected events. An introductory to hospitals; (e.g. chicken pox, hepatitis) [13]. For workshop was conducted on 20 Octo- r training clinicians on the new paper- surveillance purposes,health centres, ber 2010, where the study objectives, based surveillance system and case clinics, and hospitals report to one of the its importance to public health, and definitions of diseases; 21 reporting sites, which in turn report cooperation between stakeholders r strengthening ties with clinicians and to the Directorate of Communicable were addressed and discussed. other partners; Diseases. The available data from hospitals, r collecting data on a form specifical- Health facilities in Aqaba include 1 police administration, and Civil De- ly designed for the purposes of the military hospital (127 beds), 2 private fence administration for the Eid events study, covering age, sex, nature and hospitals (40 beds each), 4 Ministry during the previous 2 years were time of the concern, and outcome. of Health health centres and many analysed to assess public health con- During Eid Al Adha, the Jordan Field private clinics. All of these facilities cerns during the holiday. These data Epidemiology Training Programme report to Aqaba Health Directorate. included the number of patients who team as well as the Ministry of Health Aqaba Special Economic Zone Au- attended emergency departments, focal point were present in Aqaba. Daily thority is responsible for food safety, numbers admitted to hospital, and meetings to follow the situation with and during Eid the authority strength- numbers of road traffic crashes and relevant focal points, receiving and re- ens the measures on food safety in drownings. Preventive measures were viewing daily reports, and daily visits to the city to prevent food poisoning also identified. These were discussed health facilities were among the team outbreaks. In the event of an outbreak and agreed upon by stakeholders so activities during the event. food poisoning, the epidemiological they could be implemented during Eid investigation is done by the surveil- Al Adha 2010. Post event activities lance department in Aqaba Health A closeout workshop was held in Aqaba Directorate under the supervision of Surveillance system for the Eid on 3 December, 2010 to present the the Directorate of Communicable event, 2010 study. Diseases, while food and environ- This cross-sectional study was approved mental investigation is done by the by the Ministry of Health and Aqaba Previous data review Aqaba Special Economic Zone. The Governorate. No baseline data could be drawn Food and Environmental Depart- Surveillance activities began 14 days up owing to the poor quality of the ment in Aqaba Health Directorate is before the event and extended until 10 information in there porting forms. responsible for water safety in the city days afterwards. An enhanced surveil- The reports from hospitals, the police in collaboration with the Directorate lance system was conducted between administration and the Civil Defence of Environmental Health in Amman. 2 and 30 November 2010. The existing administration during 2008 and 2009 Sources for drinking water and the surveillance system was enhanced by: were in the main administrative rather water network are tested chemically r operating an additional paper-based than epidemiological. and biologically. Once contamina- reporting system from hospitals, po- tion is detected, provision of water lice administration, and Civil Defence Risk assessment is discontinued immediately till the administration; Through reviewing the reports as well contamination is removed. r increasing the frequency of reporting as from discussions with stakeholders, Preparedness from weekly to daily (case definitions the following public health issues were given priority since all are of high likeli- The main stakeholders in Aqaba, such were the same as in the surveillance hood and have urgent consequences: as hospitals, the Health Directorate guidebook); and the police administration, were r including drowning in the system; r food- and waterborne diseases, visited by the Field Epidemiology r enhancing laboratory capacity and r drowning, Training Programme study team on reporting by facilitating the immedi- r injuries by marine creatures which are 20 October, 2010. These visits aimed ate delivery of laboratory samples present in the Red Sea, to examine the experiences of all part- to Amman in cases (e.g. meningitis ners during previous Eid holidays, the and food poisoning) where the local r road traffic crashes, expected number of visitors, and the laboratory is not qualified to perform r pressure on emergency departments preparedness of each partner for the the tests; at hospitals.

S31 EMHJ r 7PM 4VQQMFNFOU  &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF

Table 1 Variation in public health concerns during Eid Al Adha, Aqaba, 2010 Incident No. of cases in week No. of cases during Eid Increasea before Eid Road traffic crash 11 39 345% Hospital admission 56 75 33% Emergency room attendance 1442 1766 23% Injurycaused by marine creatures 0 22 +22 Drowning 0 7 +7 Food poisoning 0 0 0

aExpressed as percentage or absolute number.

Preventive measures The number of drownings increased To ensure public health safety during The following preventive measures from 0 in the previous week to 7 during mass gatherings, the surveillance sys- were introduced: the event. There was a more than 3-fold tem must provide sufficient numerical increase in road traffic crashes. No food findings to plan, implement, and evalu- r strengthening of control measures on poisoning outbreaks were detected dur- ate public health actions related to the food and drinks street vendors to pre- ing the study period. The main public event. vent food- and waterborne diseases; health events are shown in Table 1. Our results showed a considerable r preparedness of health facilities includ- Males accounted for 92% of road increase in the occurrence of certain ing health personnel, equipment, etc.; traffic crash victims, 87% of injuries by public health risks during the Eid holiday r establishing a mobile health station marine creatures, and 71% of drownings in Aqaba even though many preventive on the beach to deal with emergency (Table 2). measures had been implemented. Large cases promptly and effectively; There were 39 road traffic crashes numbers of participants in mass gather- r advising people to swim in safe places during the Eid period. Collisions were ings usually lead to increased demand and only where lifeguards are avail- the most common type (69%) followed on food vendors;consequently, the in- able (health messages were delivered by being run over (18%) (Table 3). cidence of foodborne diseases often in- via signs/signals placed on beach); All the preventive measures that creases. A study in Saudi Arabia showed r banning driving in specific streets were introduced were implemented that diarrhoea was the third most com- identified (based on previous experi- except preventing camping in the mon cause of hospitalization during the ence) as being crowded with pedes- streets. Hajj [14]. Many factors may contribute trians; to this problem including inadequate standards of food hygiene, shortage of r banning visitors from camping in the water, the presence asymptomatic car- streets and other areas in the city. Discussion riers of pathogenic bacteria, and inap- For this study, the reviewed data and propriate storage of food. However,the Results reports from previous similar events in strict monitoring measures on food and Aqaba demonstrate the poor capacity water safety in force during the event During the 5 days of the event, the of the existing surveillance system to we studied may explain the absence of weather was moderate with tempera- identify cases of public health con- food poisoning outbreaks. The health tures ranging between 15 °C and 29 °C. cern during mass gathering events. authorities responded appropriately

Table 2 Distribution of public health concerns according to sex, Eid Al Adha, Aqaba, 2010 Incident Males Females No.%No.% Emergency room attendance 905 53 861 47 Hospital admission 39 52 36 48 Drowning 5 71 2 29 Injury caused by marine creatures 19 87 3 13 Road traffic crash 36 92 3 8

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Table 3 Distribution of road traffic crashes according to type, Eid Al Adha, Aqaba, Recommendations 2010 Type No. % There is a need to strengthen the pre- Collision 28 72 ventive measures during the Eid holiday Run over 7 18 period in Aqaba. The enhanced surveil- Overturning 4 10 lance system that was put into place was Total 39 100 effective in linking the related sectors with the public health situation on a daily basis. r A permanent committee should be to the increased population during the of course, be reflected in the increase in established headed by the health au- Eid event. hospital admissions. thorities to deal with public health The number of hospital admissions Most of the participants use their issues during Eid. and emergency cases increased notice- own cars to visit Aqaba. Thus, the vastly r This study should be shared with ably during the Eid period. The location increased number of vehicles within a decision-makers to highlight the im- of Aqaba so far from other cities may small confined area resulted in the huge portance studies on mass gatherings. also have increased the load on the city increase recorded in the number of traf- r Rigid control measures on food and health facilities. fic crashes, again having an effect on the water safety should be continued. Swimming is one of the main ac- hospital admission figures. r Educational pamphlets should be tivities enjoyed by visitors, since the There was a predominance of prepared for future Eid events target- Gulf of Aqaba is the foremost place in males in the public health conse- ing road traffic crashes, downing, and Jordan for outdoor swimming. Many quences during Eid in Aqaba, particu- injuries by marine creatures. These visitors, however,go swimming without larly for drownings, injuries caused pamphlets should be distributed to adequate training. These are the most by marine creatures and road traffic visitors before they arrive in Aqaba. likely reasons for the increase in drown- crashes. The greater numbers of males r Assess the safety of beaches and the ing cases and injuries by marine crea- taking part in these activities is likely to possibility and efficacy of employing tures during the Eid event. This would, be the reason for this. lifeguards.

References

1. ThackwayS et al.Should cities hosting mass gatherings invest 8. Shafi S et al. Hajj: health lessons for mass gatherings. Journal of in public health surveillance and planning? Reflections from Infection and Public Health, 2008, 1:27–32. a decade of mass gatherings in Sydney, Australia. BMC Public 9. Al-Azeri A et al. Meningococcal carriage among Hajjis in Makm- Health, 2009, 9:324. kah, 1421 H. Saudi Epidemiology Bulletin, 2002, 9(1). 2. Kaiser R, CoulombierD. Epidemic intelligence during mass 10. Shafi S et al. Hajj: health lessons for mass gatherings. Journal of gatherings. Eurosurveillance, 2006, 11(51):21. Infection and Public Health, 2008, 1:27–32. 3. Communicable disease alert and response for mass gather- 11. Aguilera JF et al.; W135 Working Group. Outbreak of sero- ings. Key considerations. Geneva, World Health Organization, group W135 meningococcal disease after the Hajj pilgrimage, 2008. Europe, 2000. Emerging Infectious Diseases, 2002, 8:761–767. 4. Tsouros AD,Efstathiou PA (eds). Mass gatherings and public 12. Department of Statistics [Jordan] and ICF Macro . Jordan Popu- health. The experience of the Athens 2004 Olympic games.Co- lation and Family Health Survey 2009. Calverton, Maryland, penhagen, World Health Organization Regional Office for USA: Department of Statistics and ICF Macro, 2010. Europe, 2007. 13. [Jordan Surveillance Guidebook]. Amman, Directorate of Com- 5. Surveillance for early detection of disease outbreaks at an municableDiseases, Ministry of Health, 2010 [in Arabic]. outdoor mass gathering – Virginia, 2005. MMWR, 2006 14. Al-Ghamdi SM et al. Pattern of admission to hospitals duri- 55(3):71–74. ing Muslim pilgrimage (Hajj). Saudi Medical Journal, 2003, 6. Zeitz K, Zeitz C, Kadow-Griffen C.Injuryoccurrences at a mass 24(10):1073–1076. gathering event. Journal of Emergency Primary Health Care (on- line), 2005, 3(1-2) (Article No. 990098). 7. Blyth CC et al. Influenza outbreaks during World Youth Day 2008 mass gathering.Emerging Infectious Diseases. 2010 May; 16(5):805–819.

S33 EMHJ • Vol. 19 Supplement 2 2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale

Patterns of diseases and preventive measures among domestic hajjis from Central, Saudi Arabia [complete republication] Fahad S. Al-Jasser, Ibrahim A. Kabbash, Mohammad A. AlMazroa, Ziad A. Memish

N=p_˜šCÐphýnSŽUÐÓÐÊÐ}@üÐís"ЋHŽYÊnf?ÌÓn=nÉüÐíéngHüÐíïŽd_UТafšUÐÛng!ÐßÐ}YÌÔí{Aé{_Y{x{ĻæÐzvúÐoåÉ°#Ð phUíúÐph[UÐpxnL}UÐ~TÐ}e=Ndœ—CÐÕnœ"ÐN=ê2009Fe—xØOÎFeRŽiŒYÒGaUÐéĆBph_]bCÐpHÐÚ{UÐì|wqx}@Ìô oaw|\TÐ Õnœ"Ð p=nÉüÐŒL‹4ÐkH‹>rhA‡>n4ÐéĆBŒYs"ÐŒY‹*؎LڎRÕnœ"ÐŒYÓninh˜UÐ +‹>{Sí ýn—UÐÑngšUøЋh_]>DLéŽ[dU ‹gfY%54.7p=nÉÎN˜>ÕnA1507N=ŒYrým™eTÐ s"ÐÊnf?Ìp_˜šCÐphýnSŽUÐÓnhTŽd—UÐOÎpRn”ün=ºéngHüÐíºïŽd_UТafšUÐÛng!ÐßÐ}Yj= p”}L}›TÌ‹wnYnLð 40ŒL‹wÚ5LÌŠb>Œx|UÐÕnœ"ÐënT{bU éngHÎÓønA%9.3íïŽd_UТafšUÐÛng!n=ngfY%97ënTíºph”}YßÐ}Lj= pSĆL؎@í„AĆx3í éngHüÐÔí{Aí}e_UÐN=p”Ðíphýn[AÎpSĆL‰UnfwŒcx3iÌEQºïŽd_UТafšUÐÛng!ÐßÐ}Yj=p=nɳU —YN=pxŽf_YpUøØíÙàn˜>ÚÐènfwënT5fh=ºÓn=nÉüÐíÌïŽd_UТafšUÐÛng!ÐßÐ}YÌÔí{Aí‹hd_šUÐ—YN=p”Ðíphýn[AÎ p”Ðíphýn[AÎpSĆLënT5fh=ºÓn=nÉüÐíéngHüÐÔí{Aíph—f!ÐN=p”Ðíphýn[AÎpSĆL؎@íN˜šx35T éngHüÐÔí{Aí‹hd_šUÐ p”Ðíphýn[AÎp@Ú{=ŠdbxÒ}eš—YÒڎ[=‡iúÐí‹aUÐânfSé5_šHÐëÌn\xÌN˜>5T ïŽd_UТafšUÐÛng!ÐßÐ}YÌÔí{Aíph—f!ÐN=ð Œx|UÐÕnœ"ÐN=p_ýnIípYnwpdcZYïŽd_UТafUÐÛng!ÐßÐ}YÌëj=pHÐÚ{UÐì|wÓ}gKÌo/mA ïŽd_UТafšUÐÛng!ÐßÐ}YÌÔí{AŒY ŒYŠhdbšUÐ:>ÊnaTŒY‹Q}UÐDLÐØí{7éÐÛnY‡iúÐí‹aUÐânfSêÐ{žšHÐëÌøÎphýnSŽUÐÓÐÊÐ}@ün={hð @ŠcZ=‹gYÐ~šUÐpYnLÒڎ[=y\>Ð  ïŽd_UТafšUÐÛng!ÐßÐ}Yj=p=nÉüÐÔí{A

ABSTRACT Objectives: To identify the occurrence of upper respiratory tract infections (URTI), diarrheal diseases and trauma during the Hajj season, and the practice of some preventive measures by pilgrims. Methods: A cohort study during November and December 2009 among hajjis registered while visiting Primary Health Care Centers of Riyadh, Kingdom of Saudi Arabia to get mandatory meningococcal meningitis vaccination. On return from hajj, hajjis were contacted on telephone to collect information on occurrence of URTI and diarrhea along with other associated activities in Hajj. Results: Out of 1507 hajjis, 54.7% developed symptoms; 97% reported upper respiratory tract symptoms, and 9.3% reported diarrheal symptoms. Those <40 years of age were more likely to develop an URTI. The incidence of diarrheal diseases or trauma was not statistically associated with age. No statistical difference for educational level was found for URTI or trauma, but there was a statistically significant difference for diarrheal diseases. There was no statistical difference for nationality in relation to diarrheal diseases and trauma, but there was a statistically significant difference for URTI. There was a statistically significant difference of URTI between those pilgrims who used the face mask most of the time and those who used it sometimes. Conclusion: Upper respiratory tract infections is a common health problem among studied domestic hajjis. Generally, there is room for improvement in the adoption of preventive measures by hajjis; and there is still limited information on the use of facemasks in spite of the fact that using it significantly decreases the risk for URTI.

From the Field Epidemiology Training Program (Al-Jasser, AlMazroa, Memish), Ministry of Health, Riyadh, Kingdom of Saudi Arabia and the Public Health and Community Medicine Department (Kabbash), Faculty of Medicine, Tanta University, Tanta, Egypt ([email protected]).

This paper was first published in the Saudi Medical Journal, 2012, 33(8):879–886 and is reproduced here with kind permission of the Saudi Medical Journal. It is included in this supplement because the paper arose from one of the studies undertaken by the “Surveillance in Mass Gathering Workshops” for Field Epidemiology Training Program Residents and graduates under the mentorship of Centers for Disease Control and Prevention (CDC)/Eastern Mediterranean Public Health Network (EMPHNET) experts.

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Introduction slaughter, as part of Hajj rituals the risk Riyadh City has 87 primary health care of exposure to zoonotic diseases is in- centres (PHCC) that give meningococ- Hajj (pilgrimage) is a yearly event in creased [7]. Another Hajj ritual which cal vaccination as an obligatory require- which more than 2 million Muslims poses a health risk is head shaving for ment for those who will perform the from around the world gather in men. Head shaving is performed with Hajj. These PHCC are distributed in 7 Mecca, Saudi Arabia. It is the largest razors or blades which if used without health sectors. The number of PHCCs annual gathering of its kind in the changing for several hajjis can transmit in each health sector ranges from 7-20 world bringing millions of people in blood borne infections ( HIV, hepatitis centres. Therefore, the study population a small and geographically confined B and hepatitis C) [8]. Many Hajj stud- consisted of all adults older than 20 area. All adult Muslims who are physi- ies showed a change in the pattern of years of age living in Riyadh City with cally and financially able to do so have diseases detected among hajjis from the intention to perform the Hajj in a religious obligation to make the infectious diseases to chronic diseases 2010, who sought their required menin- pilgrimage once in their lifetime. The [9–11]. Mina is a key place in the Hajj gococcal immunization at a PHCC. limited time and space in which this area. It is where the hajji spends the Vaccinations started on 16th October mass gathering takes place exposes most of the time in the Hajj season (at 2010 and continued on daily basis until these hajjis to several risk factors [1]. least 4 days). This relatively long dura- 7 November 2010, which was the first Overcrowding increases the chances tion account for the burden on health day in the Hajj season. of trauma and transmission of com- services in this area. Many researchers municable diseases. Transportation studied pattern of diseases among haj- Case definition to the Hajj area is mainly through air jis visiting Mina hospitals. Those cases For the purpose of this study, URTI was for international hajjis. Domestic hajjis that reach hospitals are usually the tip defined as any person who reported can reach the Hajj area either by air or of the iceberg and they are mostly having developed at least one of the con- surface transport, which is a cheaper advanced stages of the disease, which stitutional symptoms (fever, headache, mode of transport. Hajjis can use buses can be less representative to the real myalgia) and one of the local symptoms for transport within the Hajj area or Hajj population [5,12–14]. Currently (running nose, sneezing, throat pain, can move around on foot. In this Hajj there is no surveillance system for some cough with /or without sputum) after season, the services of train transporta- hajj-related and post hajj illnesses. The reaching Makkah for the Hajj or within tion between key locations in the Hajj primary objectives of this study were 2 weeks from return to Riyadh [15]. area were made available. A hamla is a to assess the incidence of selected dis- Diarrhoea was defined as the passage company that is specialized in Hajj ser- eases and injuries among hajjis and to of 3 or more loose or liquid stools per vices. These hamlas are responsible for use this information by the Ministry of day after reaching Makkah for the Hajj travel arrangements, accommodation Health (MOH) for future surveillance or within 2 days from return to Riyadh and food arrangements for every hajji of specified conditions at the Hajj, and to ensure that diarrhoea infection was who paid for their services [2–5]. The to assess preventive measures practiced acquired during hajj period not after changing of Hajj season from sum- by hajjis. Specific conditions of inter- return home. mer to winter changes the pattern of est included upper respiratory tract diseases that are detected among hajjis. illnesses (URTI), diarrhoeal illnesses, Sampling Since Hajj season has changed in the and injuries. A 2 stage sampling technique was last few years from summer to winter, used. In the first stage, Riyadh City diseases that were seen in summer was stratified into 7 strata according to season (such as heat stroke, food poi- Methods the number of health sectors. Simple soning and exhaustion) are not seen random sampling of 1-2 PHCC from anymore [6]. In Hajj season diseases Study setting each stratum was carried out according are expected to be more common This cohort study was conducted dur- to the number of PHCC in each health such as influenza, asthma and chronic ing November and December 2009 in sector. From health sectors with 10 or obstructive pulmonary disease. Dur- Riyadh City, the capital of Saudi Arabia fewer PHCC, one PHCC was selected. ing Hajj rituals, hajjis are exposed to with a population of nearly 5 million. Two PHCC were randomly selected several health risks. Physical exertion is Since there is no common station to from health sectors with more than 10 a health risk itself and it can aggravate identify and recruit hajjis returning to PHCC, resulting in a total of 11 centres. pre-existing health conditions (such as Riyadh from Hajj, subjects were re- In the second stage, study subjects were diabetes mellitus, cardiovascular and cruited as they sought their required systematically selected from each of renal disease) [2,4]. During animal pre-Hajj meningococcal vaccination. the 11 centres by selecting every third

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person seeking meningococcal vaccina- (84.5%). Hajjis from South Asia com- length of stay at the Hajj (Makkah and tion for their Hajj requirement. prised 7.4%, South East Asia 4.9%, and Mina) was 7.04 ± 1.78 days and all A sample size of 1499 was calculated Africa 3.2% of the study population. but 2 pilgrims were able to complete using Epi-Info version 3.5.1 to estimate Half of the study population (49.5%) the Hajj. diseases with proportion of 1% or more had a university education, includ- Illness symptoms were reported by in the study sample with a precision of ing Master’s and Doctorate degrees. 825 (54.7%) of the returning Hajjis. 0.5% at 95% confidence level; and was The occupational status of study These symptoms were used to catego- then increased to 1804 to account for participants was reported as 31.4% rize participants into disease groups. the anticipated non-responders. unemployed, 13.7% manual workers, Of the 825 reporting symptoms, 97% Recruits were asked to give their 21.4% employee, 21.3% professional, reported upper respiratory tract symp- contact information and consent at 3.8% retired, 4.9% were students, and toms (53% of total studied group), and the time of recruitment so that they 3.5% self employed. All participants 9.3% reported diarrhoeal symptoms could be contacted 48 hours upon re- were vaccinated for meningococcal (5.1% of total studied group) (not turn from the Hajj up to a period of meningitis. Some hajjis received vac- mutually exclusive). Of the 825 with 4 weeks after return. A standardized cines upon their request other than symptoms, 51% reported contact with phone-based questionnaire regarding meningococcal meningitis (n = 218); a person having similar symptoms and selected illnesses (which include diabe- 5.9% were vaccinated against Hepa- 43.2% sought medical care at a health tes, hypertension, cardiac diseases, renal titis A, 6.4% against Hepatitis B, and care facility whether during hajj or upon diseases and bronchial asthma), injuries, 94.4% were vaccinated for seasonal flu return home. Traumatic injuries were and preventive measures was developed (categories not mutually exclusive). reported by 2.9% (Table 1). and pilot-tested prior to administering it Different modes of travel to Mak- Face masks were used by 851 to returning hajjis. Three trained inter- kah were available; 50.6% of hajjis (56.5%) of participants. Of those, 216 viewers contacted participants during travelled by bus, 20.2% by plane and (25.4%) reported using it most of the working hours, with follow-up calls at 29.2% by car. The travel coordination time and 635 (74.6%) reported using other times to improve the response. services of a Hamla were utilized by it sometimes. Of the 577 females in the Those who were not contacted after 4 nearly all Hajjis (95.7%). The average study population, 333 (57.7%) reported days of attempts were classified as non- responders and were excluded. Table 1 Distribution of domestic hajjis in relation to health problems in Hajj Statistical analysis Health problems in Hajj n % The collected data were organized, Having symptoms: n = 1507 tabulated, and statistically analysed us- Yes 825 54.7 ing SPSS software statistical package No 682 45.3 version 19. The number and percent- Diseasesa n = 825 age distribution for each variable was URTI 800 97.0 calculated. Observed differences were Diarrheal diseases 77 9.3 statistically analysed using Chi square b test and risk estimation was carried out Others 16 1.9 using relative risk and 95% confidence Contact with similar case: n = 825 intervals. The level of significance was Yes 421 51.0 adopted at P<0.05. No 259 31.4 Do not know 145 17.6 Visited any health care facility: n = 825 356 43.2 Results Trauma: n = 1507 44 2.9 Type of trauma: n = 44 Out of 1804 initial enrolled, 1507 Hajj Fractures 1 2.3 pilgrims responded and were included Cut wounds 16 36.4 into the study. Males predominated Contusions 13 29.5 the study population (61.7%). The Strain 14 31.8 mean age was 37.9 ± 12.1 years with a aMore than one disease were sometimes reported. range of 21–83 years of age. The main bAllergy, chest pain, hemorrhoids, joint pain, blocked nose, neck pain,sinusitis, sputum, URTI - upper nationalities were Saudi and Arabs respiratory tract illnesses.

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Table 2 Use of preventive measures among domestic hajjis from Riyadh Nearly half of the hajjis used hand sani- Preventive measures n % tizer during Hajj (45.5%). None of the Face mask (n = 1507) females reported smoking, and among Most of the time 216 14.3 males, 307 (33.3%) were smokers Sometimes 368 24.4 (Table 2). Occasionally 267 17.7 Selected chronic diseases were re- Never 656 43.5 ported by 278 (18.4%) of study partici- Face cover (n = 577) pants. Of those, diabetes was reported in 55.7%, hypertension in 60.7%, other Most of the time 300 52.0 cardiac disease (7.5%), and bronchial Sometimes 25 4.3 asthma (11.5%) (not mutually exclu- Occasionally 8 1.4 sive). Hajjis who had a chronic disease Never 244 42.3 were using their medications regularly Eat usually (n = 1507) (82.0%); of those with a chronic disease, Street vendor 272 18.0 89.2% reported that they had enough Hamla 1109 73.6 supply of their medications (Table 3). Self cooked food 126 8.4 Gender was found to be significantly Eat raw food/vegetables: (n = 1507) 1265 83.9 associated with the occurrence of diar- Shaved head (n = 930) rhoea were males reported an incidence Did not shave 375 40.3 of 6.3% compared to 3.1% for females Shaved: 555 59.7 (RR=2.03, P=0.006). On the other By licensed barber 392 70.6 hand, nationality (whether Saudi or By unlicensed barber 56 10.1 non-Saudi) did not affect the risk of By another hajji 107 19.3 diarrhoea. The incidence of diarrhoea Ask for new blade 532 95.9 was highest among hajjis who stayed 4 Scalp wounds 126 13.5 days or less (11.5%). Longer durations Animal slaughter: (n = 930) 11 1.2 of stay were found to have lower risk for Hand washing (n = 1507) diarrhoea, which was lowest for those 7 days of stay where the incidence was re- Less than 5 times/day 146 9.7 P More than 5 times/day 1361 90.3 ported to be 2.9% (RR= 0.25, =0.021). Source of food, eating raw vegetables, Using hand sanitizer: (n = 1507) 686 45.5 frequency of hand washing and use of Source of drinking water (n = 1507) hand sanitizers did not significantly af- Bottled water 1340 88.9 fect the incidence of diarrhoea among Shared water 41 2.7 studied hajjis (Table 4). Gender, na- Public water 334 22.2 tionality whether Saudi or non-Saudi Smoking (n = 1507) 307 20.4 did not show significant effect on risk More than one source of drinking water were reported. of occurrence of URTI. The incidence of UTRIs significantly increased with increased level of education where it wearing a face cover and 90.1% reported The services of a licensed barber were was highest among those with primary wearing it most of the time while 33 utilized by 392 (70.7%) of the 555 male education (RR= 1.65, P=0.002). Con- (9.9%) wore it sometimes. Food service participants who shaved their heads. cerning duration of stay in hajj areas, was provided by a Hamla for 73.6%; Unlicensed barbers (10.1%) and other those who stayed 8 days or more were the remainder reported consuming self hajjis (19.3%) were also utilized; 40.3% significantly suffering from lower risk cooked meals (8.4%) and food from did not shave. Requests for a new shav- of infection (RR=0.78, P=0.006) com- street vendors (18.0%). Consumption ing blade were made by 95.9%. Scalp pared to other hajjis spending shorter of raw food or vegetables from any wounds from shaving were reported by periods. Never or sometimes using source was reported by 83.9% and most 13.5%. Few of the hajjis reported being face mask was found to significantly in- used bottled water for drinking dur- involved in animal slaughter (1.2%). A crease the risk for URTI (RR= 1.17 and ing participation in the Hajj (88.9%). majority of hajjis washed their hands RR=1.21) compared to those who used (Table 2). more than 5 times per day (90.3%). it most of times. On the other hand,

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Table 3 Distribution of chronic diseases among domestic hajjis from Riyadh from inhalation of aerosols containing Chronic diseases n % organic and inorganic particulates [17]. Any chronic disease (n = 1507) 278 18.4 Therefore, as a preventive measure,the Type of chronic diseases (n = 278) recommendations for the prevention Diabetes 155 55.7 of influenza include wearing face mask [18].Although wearing mask may not Hypertension 169 60.7 provide complete protection from Cardiac diseases 21 7.5 infection; it may reduce exposure to Bronchial asthma 32 11.5 droplet nuclei, considered one of the Renal diseases 1 0.3 main modes of transmission of most Having exacerbations of current disease (n = 278) 79 28.4 URTIs [18] Diabetics (n = 155) 50 32.2 The use of face cover (Hijab/Niqab) Hypertensive’s (n = 169) 57 33.7 by women can also be treated as use of Using medications regularly during Hajj (n = 278) 228 82.0 face mask. As most of the female hajjis Have enough supply of medications during Hajj were Saudis, who practices face cover (n = 278) 248 89.2 more often during Hajj as compared Types of chronic diseases were not mutually exclusive. to other nationalities,the usage of face mask was quite frequent. But there was the use of face cover was not found to to URTI cases [11]. The present study no evidence of significant decrease in significantly decrease the risk of infec- showed that those who stayed more the incidence of URTI, among women in the present study related to using face tion (Table 5). than 8 days suffered less URTIs. This mask or face cover. This difference from could be explained by the fact that hajjis males can be explained on the basis who tend to spend shorter periods were of other customary practices. Women Discussion in hurry to perform all rituals during the when alone in their tents with other rush time, which increases the physi- females do not cover their face (as the Acute respiratory tract infections, cal burden and possibility of getting use is meant mainly for Hijab and not diarrhoeal diseases and injuries occur infected. On the other hand those for personal hygiene) thus having the worldwide throughout the year and are spending a relatively longer duration same high risk of disease transmission not limited to any specific age, gender, or had more opportunity to avoid periods in a closed environment with exposure nationality. For example, several factors of overcrowdings and perform rituals to droplet infection. Thus, the use of face contribute to the wide spread of URTIs relatively more comfortably. including direct contact with affected cover as proxy of face mask in status. As in many mass gatherings, it is person, change in climate, and crowded This change of practice within tents places; all of these contributing factors important to understand how to may not be so prominent in men, who are present in the Hajj environment prevent the occurrence of a heavy are using face mask as personal hygiene [16]. Significant proportion (53%) of burden of URTI. Given the circum- measure, independent of the place hajjis from Riyadh reported experienc- stances of Hajj,it is almost impossible where they were. ing an URTI during or immediately to adequately control the spread of In this study, 9.3% of hajjis from after the Hajj. This high incidence of an illnesses, facilitated by crowding. The Riyadh who reported symptoms had illness reveals a high burden of disease. use of personal protective measures an attack of diarrhoeal disease during While outside the scope of this study, such as vaccination,chemoprophylaxis, or immediately after the Hajj. The high potential secondary spread among the frequent hand washing/sanitizing,and risk of diarrhoea among males could be susceptible population in the home- the use of a face mask provide some explained by the liability of males to get town of returning hajjis can occur. protection [15]. food from different sources due to their The disease is uniformly distributed Use of a face mask in our study wide range of movement compared between both genders both old age and population, was the most important to females who are usually in the tents diabetes mellitus is known to reduce practical protective factor against de- most of the time. The Hajj season this the immunity and increase the risk for velopment of an URTI, although the year was in the month of November, URTIs and other viral infections. The research evidence regarding the effec- which means that the weather was cool reduced risk between these 2 groups tiveness of face masks does not include and that was not in favour of food born can be due to the reduced mobility of consensus agreement. The use of face diseases. Also, most of the study par- these groups making them less exposed masks has been advocated to protect ticipants ate food prepared by a Hamla

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Table 4 Factors affecting incidence of diarrhoea among Hajjis from Riyadh (1431 Hijra [2009 Gregorian]) Source of food Total hajjis Cases of Incidence (%) Relative risk 95% confidence P-value (n = 1507) diarrhoea interval (n = 77) Gender Male 930 59 6.3 2.03 1.21-3.41 0.006 Female 577 18 3.1 1 Nationality Saudi 610 31 5.1 1 Non-Saudi 897 46 5.1 1.01 0.65-1.57 0.968 Educational level Illiterate 53 2 3.8 1 Primary school 159 4 2.5 0.67 0.13-3.54 0.632 Intermediate school 188 8 4.3 1.13 0.25-5.15 0.876 High school 362 12 3.3 0.88 0.20-3.82 0.863 University 745 51 6.8 1.81 0.45-7325 0.385 Duration of stay in Hajj area in days <4 26 3 11.5 1 5 144 8 5.6 0.48 0.14-1.70 0.254 6 520 28 5.4 0.47 0.15-1.44 0.186 7 344 10 2.9 0.25 0.07-0.86 0.021 >8 473 28 5.9 0.51 0.17-1.58 0.248 Source of food Street vendor 272 13 4.8 1 Hamla 1109 58 5.2 1.09 0.61-1.97 0.763 Self cooked food 126 6 4.8 1.00 0.39-2.56 0.994 Eat raw vegetable 0.59-1.90 0.840 Yes 1265 64 5.1 1 No 242 13 5.4 1.06 Hand washing <5 times/day 146 8 5.5 1 >5 times/day 1361 69 5.1 0.93 0.45-1.89 0.831 Use of hand sanitizer Yes 686 42 6.1 1 No 821 35 4.3 0.70 0.45-1.08 0.103

The reference group is the one with relative risk = 1.

and drank bottled water. Nearly half better by the low educated who may be crowdedness, hajjis were forced to rely of the studied hajjis were using hand exposed to similar conditions at their on other hajjis for head shaving or hair sanitizers and mostly was washing their homes while the highly educated can- cutting, which gave a good chance for hands more than 5 times per day. The not leading to their more suffering from the unlicensed mobile barbers to be high percentage of diarrhoea among diarrhoea active or hajjis learning head shaving on those with high educational level may In the present study, more than half their fellow hajjis with increased risks be contributed to their chance to live of the hajjis had used the razor blades of cuts. Less than 15% of hajjis who get in better housing conditions and neigh- to shave their head during hajj. Head their head shaved were aware of having bourhood compared to those with low shaving exposes hajjis to scalp wounds at least one cut wound in their scalps. educational level and low income. At especially in case of unexperienced Excessive scalp wounds with the added hajj, and due to overcrowdings, the barbers, hastiness due to rush or the risk of poor personal hygiene create environment suffers much from pollu- hajjis shaving for each other. Due to ideal environment for skin infections tion which can be relatively tolerated inability to find barber shops and their and wound contaminations. It is good

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Table 5 Factors affecting incidence of upper respiratory tract illnesses (URTI) among Hajjis from Riyadh (431 Hijra [2009 Gregorian]) Source of food Total hajjis Cases of URTI Incidence (%) Relative risk 95% confidence P-value (n = 1507) (n = 800) interval

Gender Male 930 483 51.9 1 Female 577 317 54.9 1.06 0.96-1.16 0.256 Nationality Saudi 610 326 53.44 1 Non-Saudi 897 474 52.84 0.99 0.90-1.09 0.819 Educational level Illiterate 53 20 37.73 1 Primary school 159 99 62.26 1.65 1.14-2.38 0.002 Intermediate school 188 99 52.65 1.40 0.96-2.02 0.055 High school 362 190 52.48 1.39 0.97-1.99 0.045 University 745 392 52.61 1.39 0.98-1.98 0.036 Duration of stay in Hajj area in days <4 26 14 53.84 1 5 144 84 58.33 1.08 0.74-1.59 0.670 6 520 296 56.92 0.98 0.83-1.14 0.762 7 344 192 55.81 0.96 0.81-1.13 0.609 >8 473 214 45.24 0.78 0.65-0.92 0.006 Used face mask Most of the time 216 98 45.37 1 Sometimes 635 341 53.70 1.17 1.00-1.38 0.045 Never 656 361 55.03 1.21 1.03-1.43 0.014 Used face cover (Hijab/Niqab)* Most of the time 300 164 54.66 1 Sometimes 33 22 66.66 1.22 0.94-1.59 0.188 Never 244 131 53.68 0.98 0.84-1.15 0.820

The reference group is the one with relative risk = 1. *total number was 577 as the question was for females only.

to find that 95.5% of hajjis asked for a collection, and possibly recall bias since study with previous behavioural risk fac- new blade before shaving which was some of our recruits were contacted tors studies conducted in 1998, 2002, similarly found by other studies where a week post Hajj while others were and 2066 [19,20] improvements were the hajjis who got their head shaved with contacted 4 weeks post Hajj. Also noticed in some of the variables, such the used razor were only 6% (Choudhry demographic data of nonrespondents as increase in proportion of hajjis for et al. Behavioural risk factors for diseases were not available to determine if they whom Hamla was the main source of during the pilgrimage to Makkah, [un- differed from respondent or not. The cooked food, for whom sealed plastic published]). This reflects an increase strengths of this study included the use bottles/ bags were the main source of in awareness about the danger of us- of trained interviewers, use of standard- drinking water, who get their hair cut by ing used blades for head shaving and ized questionnaire and collecting infor- professional barber, who used face mask reduces transmission of blood-borne mation regarding symptoms rather than during hajj, who had both influenza and disease such as HIV, Hepatitis B and C. disease names, which should reduce Hepatitis A vaccination coverage; and variation in participant description. A decrease in proportion of hajjis who Study limitations substantial study size (n=1507) pro- suffered from injuries. Limitations of this study included the vided for ample statistical power. While In conclusion, URTI is a com- self-reported nature of information comparing the results of the present mon health problem among studied

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domestic hajjis. Generally, there is im- In recommendations, the surveil- Health education programs should be provement in the adoption of preven- lance system for URTI need to be en- organized to all those who intended tive measures by hajjis, however still face hanced by the Ministry of Health due to perform hajj to increase the aware- mask use is limited in spite of the fact to its high incidence and the burden it ness about protective measures against that using it significantly decreases the has on health system both in Hajj area URTI, diarrhoeal diseases, injuries and risk for URTI. and the city of residence of the hajjis exacerbations of chronic diseases.

References

1. Gatrad AR, Sheikh A. Hajj: journey of a lifetime. BMJ 2005; 12. Yousuf M, Al-Saudi DA, Sheikh RA, Lone MS. Pattern of medi- 330: 133-137. cal problems among Haj pilgrims admitted to King Abdul Aziz 2. Ahmed QA, Arabi YM, Memish ZA. Health risks at the Hajj. Hospital, Madinah Al-Munawarah. Ann Saudi Med 1995; Lancet 2006; 367:1008-1015. 15:619-621. 3. Shafi S, Memish ZA, Gatrad AR, Sheikh A. Hajj 2006: com- 13. Madani TA, Ghabrah TM, Al-Hedaithy MA, Alhazmi MA, municable disease and other health risks and current official Alazraqi TA, Albarrak AM, et al. Causes of hospitalization of guidance for pilgrims. Euro Surveill2005; 10: E051215. pilgrims in the Hajj season of the Islamic year 1423 (2003). Ann Saudi Med 2006; 26:346-351. 4. Al-Harthi AS, Al-Harbi M. Accidental injuries during Muslim pilgrimage. Saudi Med J 2001; 22:523-525. 14. Al-Ghamdi SM, Akbar HO, Qari YA, Fathaldin OA, Al-Rashed RS. Pattern of admission to hospitals during Muslim pilgrimage 5. Madani TA, Ghabrah TM, Albarrak AM, Alhazmi MA, Alazraqi (Hajj). Saudi Med J 2003; 24:1073-1076. TA, Althaqafi AO, et al. Causes of admission to intensive care units in the Hajj period of the Islamic year 1424 (2004). Ann 15. Choudhry AJ, Al-Mudaimegh KS, TurkistaniAM, Al-Hamdan Saudi Med 2007; 27:101-105. NA. Hajj-associated acute respiratory infection among hajjis from Riyadh. East Mediterr Health J 2006; 12:300-309. 6. Khan NA, Ishag AM, Ahmad MS, El-Sayed FM, Bachal ZA, Ab- bas TG. Pattern of medical diseases and determinants of prog- 16. Chin J. Control of communicable diseases manual. 17th ed. nosis of hospitalization during 2005 Muslim pilgrimage Hajj in Washington (DC): American Public Health Association; a tertiary care hospital. A prospective cohort study. Saudi Med 2000.p. 425-425. J 2006; 27:1373-1380. 17. Pippin DJ, Verderame RA, Weber KK. Efficacy of face masksin 7. Rahman MM, Al-Zahrani S, Al-Qattan MM. Outbreak of preventing inhalation of airborne contaminants. J OralMaxil- hand injuries during Hajj festivities in Saudi Arabia. Ann Plast- lofacSurg1987; 45:319-323. Surg1999; 43: 154-155. 18. CDC. Recommendations for the Prevention of Influenza. 8. Gatrad AR, Sheikh A. Hajj and risk of blood borne infections. MMWR 2008; 57:1-60. Arch Dis Child 2001; 84:375. 19. Al-Fefy S, EI-Bushra H, Al-Wehebi S, Al-Salman S, Ba Omer 9. Yousuf M, Nadeem A. Meningococcal infection among pil- A,Khawaja A, et al. Behavioral risk factors for pilgrims to Mak- grims visiting Madinah Al-Munawarah despite prior A-C vac- kah,1997. Saudi Epidemiology Bulletin 1998; 5:1-4. cination. J Pak Med Assoc 2000; 50: 184-186. 20. Al-Maghderi Y, Al-Joudi A, Chaudhry A, Al-Rabeah A, Ibra- 10. Khan MA. Outbreaks of meningococcal meningitis during himM, Turkistani AM. Behavioral Risk Factors for Diseases Hajj: changing face of an old enemy. J Pak Med Assoc 2003; duringHajj 1422 H, (2002 G). Saudi Epidemiology Bulletin 2001; 53:1-3. 9:19-20. 11. Ahmed AM. Care of diabetic patients on the Haj. Diabetes International 2002; 12: 8-9.

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Review Public health considerations for mass gatherings in the Middle East and North Africa (MENA) region M. AlNsour 1 and A. Fleischauer 2

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ABSTRACT This review describes major mass gatherings in the MENA region and the public health implications of these events, and provides recommendations for public health officials of the host country. Through our search of the literature for peer-reviewed publications, we identified relevant 77 papers; all were related to the annual Hajj. Using the information obtained from the literature review, the Eastern Mediterranean Public Health Network (EMPHNET) and the Centers for Disease Control and Prevention (CDC) developed and conducted 2 workshops on Public Health Surveillance during Mass Gatherings for field epidemiology training programmes and ministry of health focal points from 10 countries. The main potential public health concerns associated with mass gatherings include: infectious diseases (e.g. respiratory disease, gastro-intestinal tract disease, foodborne disease), injuries, traffic accidents, heat-related illnesses, insect stings, non-communicable diseases and terrorism.

Considérations de santé publique pour les rassemblements de masse dans la région du Moyen-Orient et de l'Afrique du Nord

RÉSUMÉ Le présent article porte sur les principaux rassemblements de masse dans la région du Moyen-Orient et de l'Afrique du Nord ainsi que sur leurs conséquences pour la santé publique. Il fournit des recommandations à l’intention des responsables de la santé publique dans le pays d’accueil. À l’issue d’une recherche de publications parues dans des revues à comité de lecture, nous avons identifié 77 articles pertinents, relatifs au pèlerinage annuel de la Mecque (Hajj). À partir des informations tirées de cet examen de la documentation, le Réseau de la Méditerranée orientale pour la santé publique (EMPHNET) et les Centers for Disease Control and Prevention (CDC) ont préparé et organisé deux séminaires-ateliers sur la surveillance de la santé publique lors des rassemblements de masse, à l’intention des programmes de formation à l’épidémiologie de terrain et des points focaux au ministère de la Santé de dix pays. Les principaux problèmes de santé publique lors de tels rassemblements sont notamment : les maladies infectieuses (maladies respiratoires, de l'appareil gastro- intestinal, d'origine alimentaire, etc.), les traumatismes, les accidents de la circulation, les maladies liées à la chaleur, les piqûres d’insectes, les maladies non transmissibles et les actes terroristes

1Eastern Mediterranean Public Health Network, Amman, Jordan (Correspondence to M. AlNsour: [email protected]). 2Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.

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Introduction health officials of the host country. It or public health focus on planned also includes a description of the mass mass gatherings in the MENA region Mass gatherings, defined as planned gathering training workshop that took [3–79]: place as a part of this project or spontaneous events for a specific All 77 were related to the Hajj. purpose, in a specific location, and for Specifically, 71 were research papers a specific period of time and typically Methods and 6 were reviews. Most (50, 65%) with attendance exceeding 25 000 focused on communicable diseases persons, may increase the likelihood We conducted a literature search for such as an investigation of an outbreak; of acute public health threats and 7 assessed all potential risks associ- strain the response resources of the peer-reviewed publications regarding ated with attendance at a planned mass hosting site [1]. Due to potential mass gatherings in the MENA region gathering; 5 examined noncommu- risk factors such as overcrowding, by using the following search terms nicable diseases and 10 investigated exposure to unsafe food and water, in PubMed: “Hajj”, “mass gatherings”, heat stroke-related issues; 5 focused improper sanitation, and adverse “sporting events”, “social events”, on other issues specific to Hajj such weather, these threats may manifest “festival” and “pilgrimage”. Our search as skin-related disease and vaccination in an increased risk for communicable focused only on planned mass gather- requirements. disease transmission, acute injuries, ings. Manuscripts were excluded if the and opportunities for terrorism. In- focus of the mass gathering event was Although our research addressed creasingly, international mass gather- outside the MENA region. only the Hajj as a major mass gathering ings, such as the 2010 FIFA World We consulted with ministries of event, there are many other planned Cup in South Africa, are being held in health across the MENA region and mass gatherings in the MENA region developing countries and provide an used internet search engines to de- still not addressed in the literature. economic boon to the host country. scribe the purpose, scale and frequency Table 1 shows various examples of Public health preparedness is nec- of major mass gatherings in the region. planned mass gatherings in the region. Some of these events attract only a few essary to support public safety and Using the information obtained thousand participants, but many attract minimize potential health risks to resi- from the literature review, The Eastern millions. The main potential public dents and travellers. Although many Mediterranean Public Health Net- areas of public health preparedness are work (EMPHNET) and the Centers health concerns associated with such needed, efforts for international and for Disease Control and Prevention gatherings include: infectious diseases high profile mass gatherings should (CDC) designed, developed and con- (e.g. respiratory disease, gastrointesti- include, at a minimum, a thorough ducted the first workshop on Public nal tract disease, foodborne disease), risk assessment coupled with some Health Surveillance During Mass injuries, traffic accidents, heat-related form of enhanced epidemiologic sur- Gatherings for field epidemiology illnesses, insect stings, noncommuni- veillance and response [1]. training programmes and ministries cable diseases and terrorism. While there have been publica- of health focal points in the MENA re- Residents on field epidemiology tions that have addressed the public gion in Amman, Jordan during 25–29 training programmes and Ministry health threats associated with mass September 2010. The workshop was of Health focal points from 9 coun- gatherings in the Middle East and aimed at enhancing preparedness, sur- tries (Afghanistan, Egypt, Iraq, Jordan, North Africa (MENA) region, those veillance and response during mass Morocco, Pakistan, Saudi Arabia, available have described acute out- gathering events in the MENA region. Syria, and Yemen) attended the Pub- comes associated with The Hajj. Dur- The workshop was supported by lic Health Surveillance during Mass ing The Hajj, communicable disease Training Programs in Epidemiology Gatherings workshop. Attendees dis- outbreaks have been reported repeat- and Public Health Interventions Net- cussed the existing strategies and ex- edly [2].However, no publication work (TEPHINET), and the Council periences of their countries with mass to date has addressed the scope and of State and Territorial Epidemiolo- gatherings. They worked with external scale of mass gatherings in the MENA gists (CSTE). CDC and EMPHNET experts to region and the public health implica- identify ways in which those strategies tions of these events for countries in might be strengthened. The workshop the region. Results provided the participants with com- This review describes major mass prehensive training on dealing with gatherings in the MENA region and Our search identified 77 peer- public health risks pre-, during, and provides recommendations for public reviewed manuscripts with a research post-event. Training focused on risk

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Table 1 Attendance at major mass gatherings in the Middle East and North Africa region Event Type Estimated attendance Afghanistan Nawroz Cultural 150 000–300 000 Egypt International Egyptian marathon Sport >1500 Mohammed’s (BPUH) birthday (Nile Delta) Religious 3 million Iraq Anniversary ofdeath of Imam Alhussain Religious 3–4 million 40th day of Imam Alhussain Religious 5–6 million Anniversary of birth of Imam Almahdi Religious 5–6 million Jordan Dead Sea Ultra Marathon Sport >4000 Jerash Festival of Culture and Arts Cultural 100 000 Eid event in Aqaba city Religious 70 000–100 000 Morocco Moussems Religious 30 000–100 000 Marrakech international marathon Sport >5000 Pakistan Basant Festival Cultural 100 000 Tablighi Ijtema Religious >500 000 Dawat-e-Islamie Religious 200 000 Urs events of famous saints Religious 300 000–400 000 Saudi Arabia Hajj Religious 3 million Riyadh Motor Show Trade 96 000 during 5 days Saudi International Motor Show Trade >100 000 during 5 days Al Janadriyah Heritage and Cultural Festival Cultural > 1 million during 2 weeks Syrian Arab Republic Bosra festival Cultural 1.2–2.5 million over 10 days Anniversary of death of Imam Alkadhem Religious 5–6 million Yemen Al-Hamdi mass gathering Religious 12 000–45 000 20th Gulf Cup (football) sport 60 000

assessment, surveillance, training, risk gathering workshop which gave Discussion communication, response, and post them the opportunity to present their event activities. country’s mass gathering plan and the In working closely with the workshop By the end of the workshop, findings of their surveillance evalua- participants and Ministry of Health residents had developed the mass tion. They also received training on focal points from 9 countries in the gathering plan for their countries. scientific communication skills, es- MENA region, it was clear that many Participants then implemented their routine and sporadic mass gatherings pecially manuscript writing, and then country projects within the follow- events are held in the MENA Region, worked closely with CDC, CSTE, ing 6 months under the guidance of including cultural, religious and experts from CDC, CSTE, and EM- and EMPHNET experts to translate sporting events. While the literature PHNET. their surveillance evaluation results review shows that prior research in In February 2011, the field into scientific manuscripts for publi- the region has concentrated solely on epidemiology training programme cation in peer- reviewed public health the Hajj, one of the largest mass gath- residents attended a second mass journals. erings in the world, it is evident there

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is a gap in research focusing on other region. These challenges are can vary lance and utilizing experience of significant mass gatherings that occur between different countries. others. in the region. Public health practice The World Health Organization r Develop a system for sharing health and research must address other mass developed guidance for “communica- information of travellers to track the gathering events to determine risks ble disease alert and response for mass health situation of the attendees. and identify adverse health outcomes gatherings” [1]. This guidance assesses r Enhance the involvement of field to improve the safety of these events the operations and methods required epidemiology training programmes for the region. to strengthen health systems for alerts in the region in conducting mass Absence or weak surveillance sys- and response to communicable dis- gatherings surveillance projects by tems at mass gathering events, lack eases. It is recommended to develop providing technical assistance for the of information for decision-makers, mass gathering guidance specific to the participants on these training pro- poor advocacy supporting the estab- MENA region. grammes to analyse the data collected during gatherings. lishment and/or strengthening of Further recommendations for surveillance systems at mass gather- strengthening public health surveillance r Organize and support related pro- ings, a shortage of skilled public health in the MENA region were: jects and activities. personnel, lack of specific training r Enhance the exchange of field epide- r programmes, and the absence of, or Assign mass gatherings focal points of miology training programme partici- poor, comprehensive plans for mass contact at EMPHNET. pants in the region so they are able to gathering events, are major challenges r Develop policies for sharing the participate in different mass gathering that face the countries in the MENA results of mass gatherings surveil- events.

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