15 Jul 2015

Hajj and Umra

The Ministry of Health of Saudi Arabia has issued their requirements and recommendations for Hajj (1437H) and Umra 2016
Hajj and Umra

 

Key Messages

Hajj, the annual pilgrimage to Makkah (Mecca), in the Kingdom of Saudi Arabia (KSA) is one of the largest gatherings of its kind in the world.
Performing the rituals of the Hajj and Umra is demanding and often involves walking long distances in hot weather. Pilgrims must ensure that they are as physically fit as possible.
All pilgrims who intend to undertake Hajj or Umra and seasonal workers, are required to provide proof of vaccination against meningococcal meningitis ACW135Y in order to obtain a visa for entry into KSA.
The KSA Ministry of Health (MOH) currently recommends that as a precautionary measure, elderly people, those suffering from chronic diseases, those with immune deficiency, pregnant women and children should postpone the performance of the Hajj and Umra [1,2].
 

Introduction

Each year, in early summer (UK), the Ministry of Health (MOH) of the Kingdom of Saudi Arabia (KSA) issues the requirements and recommendations for entry visas relevant to pilgrims and seasonal workers who intend to visit KSA during forthcoming Hajj and Umra season.

Requirements and recommendations may differ from year to year.

Hajj, the annual pilgrimage to Makkah (Mecca), in the Kingdom of Saudi Arabia (KSA) occurs between the 8th and 12th day of the twelfth month of the Islamic calendar and is one of the largest mass gatherings in the world. Every year, approximately three million Muslims from around the world gather in Makkah [3].

Umra is a shorter, non-compulsory pilgrimage for Muslims, which is performed as part of the Hajj ritual, but can also be undertaken at any time.

KSA is likely to be more crowded during the month of Ramadan, which takes place in the ninth month of the Islamic calendar starting with the sighting of the crescent moon [4].

Due to the large crowds, mass gatherings such as Hajj and Umra are associated with unique health risks [3].

Risk management advice should follow that of the general traveller and be tailored as described below.

Destination specific advice can be found on our Country Information pages.

Pre-travel preparation

Pilgrims should research their trip well in advance of travel by checking the information on pilgrimage to KSA at:

Pilgrims should also seek advice about the health risks for any travel that may be undertaken either before or following Hajj or Umra. Information on health risks for other destinations throughout the world can be found on the Country Information pages.

Pilgrims should ensure they are up to date with all routine immunisations, and ideally see their healthcare provider at least 4-6 weeks before travel for advice on vaccinations, malaria chemoprophylaxis (if appropriate), food and water precautions, risks from insect bites, and injury prevention.

Performing the rituals of Hajj is demanding and involves walking great distances usually in hot weather. Pilgrims should ensure that they are physically fit before travelling, and pilgrims with pre-existing medical conditions should discuss the suitability of travel with their doctor. If on prescribed medications, they should ensure they have a sufficient supply to cover their time abroad and carry a copy of their prescription.

In some situations deferment of travel should be considered when the risks to the pilgrim are assessed to be high.

In response to international outbreaks of disease, the Ministry of Health (MOH) KSA recommends that those aged over 65, pregnant women, children aged under 12 years, and those suffering from chronic diseases e.g. heart diseases, kidney diseases, respiratory diseases, diabetes, and immune deficiency (congenital and acquired), malignancy and terminal illness postpone the performance of the Hajj and Umra rituals for this year for their own safety [1].

Women who anticipate their periods occurring during the Hajj may wish to delay menstruation, which is possible to achieve using hormonal treatment. Women should discuss this with their GP or family planning clinic well before departure.

Pilgrims should identify in-country healthcare resources in advance of their trip, and ensure they have adequate travel insurance should they fall ill. Comprehensive travel insurance is essential for all aspects of the journey, and Sharia compliant travel insurance is available.

Vaccination

Pilgrims should be up-to-date with immunisations routinely administered in the UK, including measles, mumps and rubella (MMR). Information on specific health risks, including recommended vaccinations, for pilgrims to KSA can be found on our Country Information page.

Required vaccinations

Meningococcal disease

In order to obtain a visa for entry into KSA, all those arriving to perform Hajj or Umra, or undertake seasonal work, are required to have a valid certificate of vaccination against meningococcal disease.

Responsible authorities must check that the correct procedure of vaccination has been followed-

All adults and children aged over two years should be given a single dose the meningococcal A, C, W, Y vaccine either:

·         Polysaccharide ACWY vaccine – not more than three years and not less than ten days before arrival in KSA (this vaccine is no longer available in the UK).

·         Conjugate ACWY vaccine – given not more than eight years and not less than ten days before arrival in KSA [1, 2].

The vaccine is also recommended for personal protection against groups A, C, W and Y meningococcal disease (see also recommended vaccines).

Details of the vaccine given should be recorded in a patient-held vaccine record showing the traveller’s full name. If a traveller is in possession of an International Certificate of Vaccination or Prophylaxis (ICVP) booklet, meningococcal ACWY vaccination can be recorded in the ‘Other Vaccinations’ pages. Note that the conjugate meningococcal vaccine ‘certificate’ is valid for 8 years. However, the paper work must state clearly that a conjugate meningococcal vaccine was administered. If the vaccine type it not indicated, it will be assumed that it is not the conjugate vaccine and it the validity of the certificate will to be for 3 years [2].

In addition to being immunised in their own countries, travellers (excluding pregnant women and children under 12 years of age) arriving from the following countries in the African meningitis belt will be given chemoprophylaxis at the port of entry to lower the number of individuals undertaking pilgrimage who maybe carriers of meningococcal bacteria:

Benin, Burkina Faso, Cameroon, Chad, Central African Republic, Côte d’Ivoire, Eritrea, Ethiopia, Gambia, Guinea, Guinea-Bissau, Mali, Niger, Nigeria, Senegal, South Sudan and Sudan*

*note the KSA list may differ from that of the WHO

Additional information on specific meningococcal vaccination requirements for the current Hajj/Umra season are available in the KSA Ministry of Health website.

 

Polio

In order to obtain a visa for entry into KSA, proof of vaccination against polio, within the previous 12 months and at least 4 weeks prior to departure for Saudi Arabia, is a requirement for pilgrims and seasonal workers arriving from:

  • Countries where polio remains endemic [Afghanistan and Pakistan]
  • Countries reporting cases of circulating vaccine derived poliovirus during the past 12 months
  • Countries which remain vulnerable to polio

In addition, travellers from these countries will also receive a dose of OPV at border points on arrival in KSA regardless of their age or vaccination history.

Additional information on the countries and specific polio vaccination requirements for the current Hajj/Umra season are available on the KSA Ministry of Health website

Health professionals and travellers should refer to our Country Information pages for country-specific polio vaccine recommendations and requirements.

Yellow fever

All pilgrims to Hajj and Umra arriving from countries or areas at risk for transmission of yellow fever (YF) must present a valid International Certificate of Vaccination or Prophylaxis documenting YF vaccination [5].

Additional information on specific yellow fever vaccination requirements for the current Hajj/Umra season are available on the KSA Ministry of Health website. 

Recommended vaccinations

General vaccination advice for travellers to KSA can be found on our Country Information page.

All pilgrims should ensure that they are up-to-date with routine immunisations including measles, mumps and rubella (MMR) and diphtheria-tetanus-polio vaccine.

The following vaccine-preventable diseases have particular relevance to Hajj and Umra pilgrims.

Hepatitis B

Hepatitis B virus is found in body fluids and can be transmitted either percutaneously (through the skin) or by sexual contact. Percutaneous transmission can occur through the use of contaminated medical, dental, or other instruments; all pilgrims should consider receiving hepatitis B vaccine prior to travel.

One of the rites of Hajj is for men to have their head shaved. The KSA authorities provide licensed barbers with a new blade to use for each pilgrim. However, unlicensed barbers may not conform to this standard [6]. Pilgrims should avoid shaving with a blade previously used by another, as this could result in transmission of hepatitis B and other blood borne infections such as hepatitis C, for which there is no vaccine. Pilgrims can consider taking with them a disposable razor for personal use during this rite.

Meningococcal disease

Meningococcal disease may result in meningitis (infection of the lining of the brain) septicaemia (blood poisoning) and pneumonia (chest infection). Large outbreaks of meningococcal disease, including meningitis and septicaemia, have occurred during previous Hajj pilgrimages and spread to other countries by returning pilgrims [6]. A conjugated meningococcal ACWY vaccine is the preferred vaccine for all travellers because it not only protects against serious infection but also prevents vaccinated individuals from carrying the meningococcal bacteria and bringing it back with them.

Public Health England (PHE) recommends conjugated meningococcal ACWY vaccine as the preferred vaccine in all instances. The vaccines currently available in the UK are Menveo® and Nimenrix®. Full details of meningococcal vaccines and schedules can be found in Immunisation against infectious disease (the ‘Green Book’) [8] and the manufacturer’s Summary of Product Characteristics [9].

KSA considers the period of protection for polysaccharide vaccine to be three years and for conjugate vaccine, eight years [1].

These vaccines do not protect against all causes of meningitis and septicaemia; any pilgrim who becomes unwell after returning from the Hajj or Umra should contact their GP, NHS 111 or local hospital.

Rabies

There is a risk of rabies in KSA. Pilgrims should be advised of the importance of avoiding contact with wild or domestic animals and to seek urgent emergency medical treatment if any potential exposure (animal bite, lick or scratch) occurs.

Pre-exposure vaccination can be considered. However, rabies vaccination prior to travel does not eliminate the need for post-exposure medical evaluation and additional doses of rabies vaccine. A three dose course of rabies vaccine given pre-exposure simplifies post exposure rabies treatment and removes the need for post exposure rabies immunoglobulin, which is in short supply worldwide.

Seasonal influenza

Influenza is transmitted via the respiratory route and through contact (direct or indirect) with surfaces on which the virus has been deposited by sneezing or coughing. It is easily transmitted in crowded conditions.

The MOH KSA recommends that international pilgrims be vaccinated against seasonal influenza before arrival in the Kingdom, especially those at increased risk of influenza disease including pregnant women, children under 5 years the elderly and those with pre-existing health conditions such as HIV/AIDS, asthma, chronic heart or lung disease [1]. Such individuals may also be at risk of other respiratory illnesses and should consider postponing their travel to Hajj [1,2].

Certain groups are considered at particular risk of complications from influenza.

Pilgrims in clinical risk groups should receive influenza vaccine annually from their usual healthcare provider [10]. Those who do not fall into any of these risk categories can still pay and be vaccinated at some high street pharmacies, other retailers, or private travel clinics, but availability may be limited.

Viral respiratory infection (known as Hajj cough) experienced by many pilgrims at the Hajj, can range from a mild inconvenience to a severe illness, and can interfere with performing the rites. Advice about influenza prevention can be found in the factsheet on seasonal influenza.

Other health risks

Middle East respiratory syndrome coronavirus (MERS-CoV)

Middle East respiratory syndrome coronavirus (MERS-CoV), which can cause severe illness and death, was first identified in KSA in 2012; the majority of cases to date have occurred in the Arabian Peninsula and in particular in KSA [11, 12]. Cases have also been reported from countries outside the Middle East. A small number of cases associated with travel to the Middle East have been reported from European countries. During 2015 the largest outbreak outside the Middle East has occurred in the Republic of Korea. This outbreak was associated with one traveller who had returned from countries in the Middle East [12].

The annual Muslim pilgrimage to Mecca in Saudi Arabia last year, took place in September 2015 with no reported increase in travel-related cases of MERS-CoV. Intensive surveillance during the 2013 Hajj did not identify any cases of MERS-CoV among an estimated two million pilgrims. However, several cases of MERS-CoV imported to countries outside of Saudi Arabia in 2014 had returned from Umra [13].

PHE remains vigilant and closely monitors developments in the Middle East and in the rest of the world where new cases have emerged, and continues to liaise with international colleagues to assess whether their recommendations (see below) need to change [13].

The MOH KSA recommends those over 65 years of age, those with chronic diseases (heart, kidney or respiratory disease, diabetes or immune deficiency), malignancy and terminal illness, pregnant women and children aged under 12 years to postpone their pilgrimage for their own safety [1].

The MOH KSA advises all pilgrims to comply with the following health guidelines to prevent the spread of MERS-CoV and other respiratory diseases:

  • Always wash hands with soap and water or a disinfectant, especially after coughing and sneezing, after using the toilet, before handling and consuming food and after touching animals.
  • Use a disposable tissue when coughing or sneezing and dispose of it in the dustbin.
  • Try as much as possible to avoid touching the eyes, nose and mouth by hand.
  • Avoid direct contact with people who appear to be ill (i.e. who are coughing, sneezing, expectorating, vomiting or have diarrhoea) and do not share their personal belongings.
  • Wear a mask when in crowded places.
  • Maintain good personal hygiene.
  • To avoid close contact with animals, particularly camels.
  • Avoid contact with sick animals.
  • Avoid drinking raw camel milk, avoid camel urine or eating meat that has not been well cooked.

In addition to the advice of the local authorities, PHE also advises the following measures for all travellers to the Middle East:

  • Practise good hand and general hygiene at all times (such as regular hand washing with soap and water), especially before and after visiting farms, barns or market areas.
  • Avoid any contact with camels and sick animals.
  • Avoid the consumption of camel milk and/or camel products from the Middle East.
  • Avoid the consumption of any type of raw milk, raw milk products and any food that may be contaminated with animal secretions unless peeled/cleaned/thoroughly cooked [13].

Travellers returning from the Middle East with mild respiratory symptoms are most likely to have a common viral respiratory illness rather than MERS-CoV.

However, any pilgrims or travellers from the Middle East who develop severe respiratory symptoms (e.g. increasing breathlessness) within 14 days of their return to the UK should seek medical advice by calling their GP or NHS 111 and must mention their travel history so that appropriate measures and testing can be undertaken, including which countries of the Middle East they have visited [13].

There are currently no travel restrictions in place relating to MERS-CoV. The situation continues to be monitored and travel advice will be reviewed as information becomes available.

PHE provides guidance for travellers to, and returning from the Middle East, alongside further information for health professionals.

Travellers’ diarrhoea

Diarrhoeal illnesses are transmitted by the consumption of contaminated food or water. Dehydration can occur with diarrhoea and is of particular risk in hot weather. Babies, infants, the elderly and those with chronic medical conditions are more vulnerable to dehydration.

All pilgrims are advised to take personal, food and water hygiene precautions.

Travellers should also take with them oral rehydration therapy and self-treatment for diarrhoea. An anti-motility agent such as loperamide can be carried and an antibiotic considered, especially for those travellers who have an underlying medical condition. Ciprofloxacin (500mg twice daily for up to three days) in the absence of contraindications is generally the antibiotic of choice for adults.

Vector-borne diseases

Malaria is not present in Medina or Makkah [Mecca] (or in the cities of Jeddah, Riyadh and Ta’if or areas of Asir province above 2,000m), but malaria is a risk in the south-western provinces of Saudi Arabia (including Asir province below 2,000m). Pilgrims planning further travel before or after Hajj or Umra to malaria risk areas in KSA or Asia, Africa and Latin America, should seek advice about malaria prevention.

Pilgrims are advised to practise insect bite avoidance measures that will reduce the risk of other vector-borne diseases, such as dengue.

Zika virus has not been detected in KSA [14]. The vector mosquito (Aedes aegypti) has not been detected in the Hajj and Umrah areas for many years [2]. However, travellers are advised to monitor for updates and avoid insect bites.

Other health considerations

Accidents and injuries

Minor injuries are relatively common, particularly to the feet. More serious injuries can occur as a result of stampedes as pilgrims undertake the stoning rite or other mass activities.

Pilgrims are advised to avoid peak times; elderly and infirm people, who have decided to make their pilgrimage, may wish to consider appointing a proxy for the performance of this rite. All pilgrims to Hajj and Umra should have adequate travel health insurance.

Environmental hazards (cold, heat and sun)

During the winter months the weather can be very cold overnight. Pilgrims should ensure they take appropriate bedding with them such as blankets and sleeping bags.

Daytime temperatures in KSA, even during the winter months, can reach over 30°C. Associated risks include sunburn, dehydration, heat exhaustion, and heat stroke.

If possible, travel before the start of Hajj should be considered in order to allow a period of acclimatisation to the heat. Pilgrims should ensure that they drink plenty of clean water (preferably bottled or boiled and cooled) to avoid dehydration.

Sun protection (SPF) of at least 15 should be applied liberally to exposed skin every two to three hours. Male pilgrims are not allowed to cover their heads; however an umbrella will provide shade from the sun.

Desert sand can reach very high temperatures; good quality footwear should be worn to avoid burning the feet. Footwear must be removed during times of prayer, and to avoid losing them, pilgrims are advised to carry their footwear in a bag.

Food and water advice

Fresh food cannot be brought into KSA by travellers and strict regulations about food apply [1].

All pilgrims are advised to take personal, food and water hygiene precautions.

Menstruation

Women who anticipate their periods occurring during the Hajj may wish to delay menstruation, which is possible to achieve using hormonal treatment. Women should discuss this with their GP or family planning clinic well before departure.

Physical fitness

Performing the rituals of Hajj is demanding and involves walking great distances usually in hot weather. Pilgrims should ensure that they are physically fit before travelling.

Illness abroad

Pilgrims should pack a first aid kit that will also help them manage relevant, common issues. Pilgrims should identify in-country healthcare resources in advance of their trip, and carry the emergency contact numbers for their insurance company.

Further information on health risks for travellers to KSA can be found here on the Saudi Arabia Country Information page.

Additional practical advice and health tips for pilgrims undertaking Hajj or Umra is provided by the KSA MOH.

Pilgrims should also seek advice about the health risks for any travel that may be undertaken either before or following Hajj or Umra. Information on health risks for other destinations throughout the world can be found on our Country Information pages.

First Published :   15 Jul 2015
Last Updated :   10 Nov 2016

  1. World Health Organization. Wkly Epi Rec 1 July 2016; 26/27.91:329-340 [Accessed 5 July 2016]
  2. Ministry of Health, Kingdom of Saudi Arabia, Health Regulations, Health Requirements for Travellers to Saudi Arabia for Pilgrimage to Makkah (2016/1437H Hajj)  [Accessed 3November 2016].
  3. Bowron CS, Maalim SM. The Middle East and North Africa. Saudi Arabia: Hajj Pilgrimage. Ch4. Yellow Book. [Accessed 5 July 2016]
  4. Her Majesty’s Nautical Almanac Office. [Accessed 5 July 2016]
  5. World Health Organization. International Health Regulations (2005). [Accessed 5 July 2016]
  6. Memish ZA. The Hajj: Communicable and non-communicable health hazards and current guidance for pilgrims. Eurosurveillance. 15(39); 30 September 2010. [Accessed 5 July 2016]
  7. World Health Organization. 2001 – Meningococcal disease, serogroup W135 – update. 16 May 2001 [Accessed 5 July 2016]
  8. Public Health England. Meningococcal, Ch. 22. Immunisation against infectious disease. Updated 22 September 2015. [Accessed 5 July 2016]
  9. Electronic Medicines Compendium
  10. Public Health England. Influenza, Ch. 19. Immunisation against infectious disease. Updated 28 August 2016. [Accessed 5 July 2016]
  11. Kingdom of Saudi Arabia. Ministry of Health. Command and Control Centre: Statistics. [Accessed 5 July 2016]
  12. World Health Organization. Middle East respiratory syndrome coronovirus. [Accessed 4 July 2016]
  13. Public Health England, Risk Assessment of Middle East Respiratory Syndrome Coronavirus (MERS-CoV). Updated March 2016. [Accessed 5 July 2016]
  14. Public Health England, Zika virus: country specific risk, 20 October 2016.https://www.gov.uk/guidance/zika-virus-country-specific-risk [Accessed 4 November 2016]

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