Hajj-associated infections

Diversity and antimicrobial susceptibility patterns of clinical and environmental Salmonella enterica serovars in Western Saudi Arabia

The diverse environmental distribution of Salmonella makes it a global source of human gastrointestinal infections. This study aimed to detect Salmonella spp. and explore their diversity and antimicrobial susceptibility patterns in clinical and environmental samples. Pre-enrichment, selective enrichment, and selective plating techniques were adopted for the Salmonella detection whereas the API 20E test and Vitek Compact 2 system were used to confirm the identity of isolates. Salmonella serovars were subjected to molecular confirmation by 16S rDNA gene sequencing. Disc diffusion method and Vitek 2 Compact system determined the antibiotic susceptibility of Salmonella serovars. Multiple antibiotic resistance index (MARI) was calculated to explore whether Salmonella serovars originate from areas with heavy antibiotic usage. Results depicted low Salmonella prevalence in clinical and environmental samples (3.5%). The main detected serovars included Salmonella Typhimurium, S. enteritidis, S. Infantis, S. Newlands, S. Heidelberg, S. Indian, S. Reading, and S. paratyphi C. All the detected Salmonella serovars (27) exhibited multidrug resistance to three or more antimicrobial classes. The study concludes that the overall Salmonella serovars prevalence was found to be low in environmental and clinical samples of Western Saudi Arabia (Makkah and Jeddah). However, antimicrobial susceptibility patterns of human and environmental Salmonella serovars revealed that all isolates exhibited multidrug-resistance (MDR) patterns to frequently used antibiotics, which might reflect antibiotic overuse in clinical and veterinary medicine. It would be suitable to apply and enforce rules and regulations from the One Health approach, which aim to prevent antibiotic resistance infections, enhance food safety, and improve human and animal health, given that all Salmonella spp. detected in this investigation were exhibiting MDR patterns.

A scoping review of Islamic pilgrimage to Mecca: Mapping the health concerns and proposed solutions

OBJECTIVES

To map the current evidence about the health concerns and the potential solutions related to the Islamic pilgrimage to Mecca.

DESIGN

A scoping review was applied. Papers published in English between 2012 and 2023 were included but non-human research and sources without any related data were excluded. Data charting and extraction were used to map the current evidence.

RESULTS

The total of 36 papers were included with the total number of pilgrims of 17,075,887. The majority of studies were published in the Asia Pacific region (36.11%) as original articles (88.89%). The health concerns were grouped into five main aspects. There were 7603 deaths recorded or about 44 incidences of deaths per 100,000 pilgrims during the pilgrimage. There were recorded 11,018; 6178; 3393; and 17,810 cases for communicable diseases; non-communicable diseases; injuries and trauma; and health services (i.e., cardiac catheterization) and vaccination, respectively.

CONCLUSION

Relating to the five health concerns, this study identified the top seven issues in each category (i.e., hypertension, influenza vaccination), except for the death record. Moreover, there were three solutions (for general health, non- and communicable-diseases) presented. Stakeholders could use this evidence to improve healthcare quality particularly related to the annual Islamic pilgrimage to Mecca.

Protection enhancement strategies of potential outbreaks during Hajj

OBJECTIVE

This study aimed to assist governments and organizers of mass gathering events in reviewing existing preventive measures for disease outbreaks to inform the adoption of enhanced strategies for risk reduction and impacts on public health.

DESIGN

A cross-sectional, quantitative, descriptive study.

SETTING

This study was conducted in a mass gathering of Hajj, an annual religious event in Mecca, Saudi Arabia.

PARTICIPANTS

A convenience sample of 70 personnel working in government ministries of Saudi Arabia (Ministry of Health, Ministry of Hajj, and Ministry of Interior) and the Saudi Red Crescent Authority involved in health management in Hajj, including policy formulation and implementation.

MAIN OUTCOME MEASURES

Perception and knowledge of health risks and outbreaks associated with Hajj.

RESULTS

The majority of the respondents (60 percent) expressed concern about the potential for infection transmission during Hajj. The respondents also reported having or knowing a colleague, a friend, or a family member with a history of infection during or after Hajj. However, the respondents' knowledge of the possible modes of infection of various diseases was limited.

CONCLUSIONS

Hajj is associated with various risks of outbreaks, and thus, better protection-enhancing measures are required. Training personnel involved in health management, including planners, coordinators, and healthcare providers, can help reduce the risks and prevent potential outbreaks.

Antimicrobial utilization in Hajj 2022: An evaluation of quality indicators

BACKGROUND

The mass gathering in Hajj (Islamic pilgrimage) makes the spread of infectious diseases inevitable. Antibiotics are frequently prescribed during this season. We aimed to measure antimicrobial utilization during the 2022 Hajj and evaluate the practice using quality indicators.

METHODS

Antimicrobial utilization by Hajj medical facilities (77 primary clinics and 7 hospitals) was measured using the anatomic therapeutic classification defined daily dose (DDD) and DDD/1,000-inhabitant/day (DID), where inhabitants were the Hajj 2022 pilgrims (n = 899,353). Quality indicators included percentages of consumption of different antibiotic classes of the total consumption of antibacterials for systemic use in DID.

RESULTS

During Hajj, there was 87,173 outpatient visits and 740 hospitalizations (215 critically ill). Amoxicillin was the most prescribed antibiotic (DID=11.708) followed by azithromycin (DID=7.395). Penicillins fell in the second quartile (i.e., highly prescribed) with a quality indicator value (J01_CE%) of 48.149. The consumption of other antibacterials, including fluoroquinolones, fell in the first quartile (<25%). The overall ratio of broad- to narrow-spectrum antibiotic prescribing (J01_B/N) was 1.49.

CONCLUSION

Although the prescribing of β-lactams over fluoroquinolones indicates a good practice, clinicians should be reminded that most infections spreading in mass gatherings are viral; hence, do not require antibiotics. Implementation of antimicrobial stewardship is recommended to improve antimicrobial utilization.

Genetic diversity and molecular analysis of human influenza virus among pilgrims during Hajj

The risk of transmission of respiratory tract infections is considerably enhanced at mass gathering (MG) religious events. Hajj is an annual Islamic MG event with approximately 3 million Muslim pilgrims from over 180 countries concentrated in Makkah, Saudi Arabia. This study aimed to investigate the genetic diversity of influenza viruses circulating among pilgrims during the Hajj pilgrimage. We performed a cross-sectional analytical study where nasopharyngeal swabs (NPs) from pilgrims with respiratory tract illnesses presenting to healthcare facilities during the 2019 Hajj were screened for influenza viruses. Influenza A subtypes and influenza B lineages were determined by multiplex RT-PCR for positive influenza samples. The phylogenetic analysis was carried out for the hemagglutination (HA) gene. Out of 185 nasopharyngeal samples, 54 were positive for the human influenza virus. Of these, 27 were influenza A H1N1 and 19 H3N2, 4 were untypable influenza A, and 4 were influenza B. Phylogenetic analysis revealed that the H1N1 and H3N2 strains differentiated into different and independent genetic groups and formed close clusters with selected strains of influenza viruses from various locations. To conclude, this study demonstrates a high genetic diversity of circulating influenza A subtypes among pilgrims during the Hajj Season. There is a need for further larger studies to investigate in-depth the genetic characteristics of influenza viruses and other respiratory viruses during Hajj seasons.

Preparation for the next pandemic: challenges in strengthening surveillance

The devastating Coronavirus Disease 2019 (COVID-19) pandemic indicates that early detection of candidates with pandemic potential is vital. However, comprehensive metagenomic sequencing of the total microbiome is not practical due to the astronomical and rapidly evolving numbers and species of micro-organisms. Analysis of previous pandemics suggests that an increase in human-animal interactions, changes in animal and arthropod distribution due to climate change and deforestation, continuous mutations and interspecies jumping of RNA viruses, and frequent travels are important factors driving pandemic emergence. Besides measures mitigating these factors, surveillance at human-animal interfaces targeting animals with unusual tolerance to viral infections, sick heathcare workers, and workers at high biosafety level laboratories is crucial. Surveillance of sick travellers is important when alerted by an early warning system of a suspected outbreak due to unknown agents. These samples should be screened by multiplex nucleic acid amplification and subsequent unbiased next-generation sequencing. Novel viruses should be isolated in routine cell cultures, complemented by organoid cultures, and then tested in animal models for interspecies transmission potential. Potential agents are candidates for designing rapid diagnostics, therapeutics, and vaccines. For early detection of outbreaks, there are advantages in using event-based surveillance and artificial intelligence (AI), but high background noise and censorship are possible drawbacks. These systems are likely useful if they channel reliable information from frontline healthcare or veterinary workers and large international gatherings. Furthermore, sufficient regulation of high biosafety level laboratories, and stockpiling of broad spectrum antiviral drugs, vaccines, and personal protective equipment are indicated for pandemic preparedness.

Prevalence of emergency cases among pilgrims presenting at King Abdulaziz International Airport Health Care Center at Hajj Terminal, Jeddah, Saudi Arabia during Hajj Season, 1440 H - 2019

Introduction

About 2-3 million pilgrims come to Makkah, Saudi Arabia from all countries to perform Hajj. During the Hajj season of 2019 (1440 H), the total number of pilgrims was 2,489,406, of whom 1,855,027 came from foreign countries. This study aims to investigate the prevalence, pattern, and findings of emergency health problems among pilgrims travelling through King Abdul Aziz International Airport Health Care Center (KAIA-HC) at Hajj Terminal in Jeddah during hajj season of 1440-H.

Methodology

A cross-sectional study was conducted by reviewing the medical records of pilgrims coming for treatment at KAIA-HC, before and after Hajj between 1 Dhul Qi'dah to 29 Dhul Hijjah 1440 AH (Corresponding to 4 July to 31 August 2019 AD). The collected data included demographics, medical history, diagnoses of the emergency health problems, infections, and their findings. Data were analyzed using Epi Info 7 and SPSS 25.

Results

About 296 (3.87%) of 7,643 pilgrims treated at KAIA-HC were emergency cases. Their average age was 43 years (Standard Deviation (SD) ±7.5); 51.3% were females; the highest (45.3%) was between 30 - 59 years age group, both males and females; the highest two nationalities were Indonesian (14.2%) and Egyptian (12.5%). Diagnoses included hypertension 59(19.9%), bronchial asthma 53 (17.9%), and 23 cases (10.5%) were suffering from hypotension. 16 (5.4%) of patients had a myocardial infarction and 10 (3.4%) had cerebrovascular accidents. In 13 cases (4.4%), a chest infection was reported. Diabetes complications (hyperglycemia, hypoglycemia, and diabetic ketoacidosis) were reported in 28 (9.4%) of the cases. There were 28 (9.5%) surgical diagnoses, 13 (4.4%) were cut wounds, 11 (3.7%) were bone fracture and dislocation, and 4 (1.4%) were head trauma. With regard to the findings, 82 (27.7%) were referred to hospitals; 10 (3.3%) cases required Cardio-Pulmonary Resuscitation, seven of whom survived. The most common referral causes were myocardial Infarction amounting 12(4.05%), followed by cerebrovascular accident 10(3.3%) and chest infection in 8 (2.7%). 13 (4.4%) of the total cases died. The most common causes of death were myocardial infarction, asthma, hypertension and hyperglycemia.

Conclusion

Our study emphasizes that emergency cases presented at KAIA-HC were few. Cardiovascular diseases represented the main reason for emergency cases, followed by respiratory diseases. 51% of patients were discharged without the need for a higher level of medical care.

Cellulitis in Hajj Pilgrims: Role of Environmental Temperature and Population Size of Pilgrims as a Contributory Factor

Background Cellulitis is a common infection of the skin and subcutaneous tissue. Meteorological and environmental temperatures were previously identified as potential risk factors for causation and the patient's odds of hospitalization. In this regard, we aim to study the pattern of cellulitis during 10 Hajj seasons and examine the impact of changing seasonal temperatures and overall pilgrim populations as potential risk factors. Methodology In-hospital cellulitis was studied within the context of the Hajj. A retrospective review of pilgrim patients coded for cellulitis was undertaken for the Hajj seasons between 2004 and 2012. Possible roles of environmental temperatures, pilgrim population sizes, and ethnicity were examined as potential risk factors. Results A total of 381 patients belonging to 42 nationalities were identified, with 285 (75%) males and 96 (25%) females with a mean age of 63 years. On average, cellulitis accounted for 23.5% of general surgical admissions with proportional increases from 2004 to 2012 (r= 0.73, p= 0.016), which significantly correlated with the rise in seasonal temperatures (r = 0.7, p= 0.023). Conclusions The findings of this study identified cellulitis as a significant health risk during the Hajj, which is likely to be prevalent in warmer seasons. Our results may assist clinicians in educating Hajj pilgrims of different nationalities about the increased risk of cellulitis during warm seasons and possible predisposing environmental factors of infection.

A Systematic Review of Water, Sanitation, and Hygiene for Urban Poor in Low- and Middle-Income Countries during the COVID-19 Pandemic through a Gendered Lens

Inadequate water, sanitation, and hygiene (WASH) among urban poor women is a major urban policy concern in low- and middle-income countries (LMICs). There was a paucity of systematic information on WASH among the urban poor during the pandemic. We reviewed the opportunities and challenges faced by the urban poor in LMICs during the COVID-19 pandemic. We used the PRISMA guidelines to conduct a comprehensive search of 11 databases, including MEDLINE, Embase, Web of Science, and CINAHL, between November 2019 and August 2021. We used thematic analysis to synthesize the qualitative data and meta-analyses to estimate the pooled prevalence. We screened 5008 records, conducted a full-text review of 153 studies, and included 38 studies. The pooled prevalence of shared water points was 0.71 (95% CI 0.37-0.97), non-adherence to hygiene practices was 0.15 (95% CI 0.08-0.24), non-adherence to face masks was 0.27 (95% CI 0.0-0.81), and access to shared community toilets was 0.59 (95% CI 0.11-1.00). Insufficient facilities caused crowding and long waiting times at shared facilities, making physical distancing challenging. Women reported difficulty in maintaining privacy for sanitation, as men were present due to the stay-at-home rule. Due to unaffordability, women reported using cloth instead of sanitary pads and scarves instead of masks.

Evaluation of the rate, pattern and appropriateness of antibiotic prescription in a cohort of pilgrims suffering from upper respiratory tract infection during the 2018 Hajj season

Hajj is associated with an increased risk of the transmission of infectious diseases including upper respiratory tract infections (URTIs). It can be a focal point for the emergence, persistence and dissemination of antimicrobial-resistant (AMR) bacteria. The overuse of antibiotics during Hajj can promote the development of antimicrobial resistance. Little information is known regarding the true appropriateness of prescribing antibiotics for treating URTIs during Hajj. Here we studied the rate, patterns and appropriateness of antibiotic prescription among a cohort of pilgrims who were treated for URTIs during the 2018 Hajj season. Adult pilgrims who sought medical services for URTIs [presenting with coryza, runny nose, nasal irritation, nasal congestion, cough, sore throat, headache or fever (even if subjective)] within the Holy sites were enrolled in this study and consented to provide swabs and medical information. A total of 121 pilgrims were enrolled, with the majority (60.3 %) originating from North African Arab countries. Most were male (89.3 %) with a median age of 45 years. Bacterial infections were detected in 7.3 % (n=9) of the URTI cases. The identified bacteria included Haemophilus influenzae (n=6, all resistant to ampicillin), Streptococcus pneumoniae (n=2), Staphylococcus aureus (n=1, resistant to oxacillin) and Moraxella catarrhalis (n=1, resistant to ampicillin and trimethoprim/sulfamethoxazole). The antibiotic prescription rate was 52.1%, most of which was amoxicillin (81 %). The data demonstrated that the proportion of appropriate practices in treating bacterial URTIs in this cohort was 45.5 %. This study highlights the need for implementing laboratory identification of the aetiological agents and related AMR profiles when treating URTIs in Hajj, rather than relying on clinical assessment alone.

Hajj health examination for pilgrims with asthma in Malaysia: An ethnographic study

Background

Methods

Results

Conclusions

Status of infectious disease content in the professional pharmacy curriculum in Saudi Arabia: Results of a national survey

Objectives

Antimicrobial resistance is one of the main global problems faced by healthcare institutions. Healthcare professionals as service providers must have a basic understanding of this emerging threat; additionally, considering the evolving role of pharmacists in both the community and hospital setting, it is crucial that pharmacists are part of the fight against this threat. Therefore, this study aimed to assess infectious disease subjects covered in the pharmacy curriculum in Saudi Arabia, to evaluate teaching and knowledge assessment strategies concerning infectious diseases, and to explore challenges faced by faculty members in teaching infectious disease courses.

Methods

We constructed a questionnaire with 26 items and sent it to infectious disease faculty members at 26 Saudi Arabian pharmacy colleges. It included questions regarding the faculty and institution, infectious disease topics, hours dedicated to each topic, and tools and strategies used in the courses for better understanding and assessment of students. In addition, we enquired about the faculty members' current satisfaction of, and future plans for, the curriculum.

Results

The questionnaire was completed by infectious disease faculty members, department chairs, or college deans. Among the respondent schools, 85.5% were governmental and 14.5% were private institutions. The majority of colleges (98.2%) followed a semester format schedule, with 67.3% offering solely the Doctor of Pharmacy (PharmD) program. More than 78% of respondents covered all tier 1 infectious disease topics from the American College of Clinical Pharmacy Pharmacotherapy Didactic Curriculum Toolkit. The main tool used for teaching was lectures (94.5%), while patient case application was the main teaching strategy (54.5%). Approximately 63% of respondents thought that the curricula were adequate when they were asked about their opinion of the curricula coverage, and 63.64% thought that the curriculum provided adequate baseline knowledge on infectious diseases for the following 5 years.

Conclusions

The study revealed variations in infectious disease topics covered and the time dedicated to them among pharmacy colleges in Saudi Arabia. The faculty members who responded to our questionnaire were generally satisfied with their infectious disease curriculum. To the best of our knowledge, this is the first study to assess infectious disease curricula among Saudi pharmacy colleges. Thus, the findings of this study may encourage faculty members to advocate for the standardization of infectious disease courses offered at Saudi Arabian pharmacy colleges.

Paving the way for human vaccination against Rift Valley fever virus: A systematic literature review of RVFV epidemiology from 1999 to 2021

BACKGROUND

Rift Valley fever virus (RVFV) is a lethal threat to humans and livestock in many parts of Africa, the Arabian Peninsula, and the Indian Ocean. This systematic review's objective was to consolidate understanding of RVFV epidemiology during 1999-2021 and highlight knowledge gaps relevant to plans for human vaccine trials.

METHODOLOGY/PRINCIPAL FINDINGS

The review is registered with PROSPERO (CRD42020221622). Reports of RVFV infection or exposure among humans, animals, and/or vectors in Africa, the Arabian Peninsula, and the Indian Ocean during the period January 1999 to June 2021 were eligible for inclusion. Online databases were searched for publications, and supplemental materials were recovered from official reports and research colleagues. Exposures were classified into five groups: 1) acute human RVF cases, 2) acute animal cases, 3) human RVFV sero-surveys, 4) animal sero-surveys, and 5) arthropod infections. Human risk factors, circulating RVFV lineages, and surveillance methods were also tabulated. In meta-analysis of risks, summary odds ratios were computed using random-effects modeling. 1104 unique human or animal RVFV transmission events were reported in 39 countries during 1999-2021. Outbreaks among humans or animals occurred at rates of 5.8/year and 12.4/year, respectively, with Mauritania, Madagascar, Kenya, South Africa, and Sudan having the most human outbreak years. Men had greater odds of RVFV infection than women, and animal contact, butchering, milking, and handling aborted material were significantly associated with greater odds of exposure. Animal infection risk was linked to location, proximity to water, and exposure to other herds or wildlife. RVFV was detected in a variety of mosquito vectors during interepidemic periods, confirming ongoing transmission.

CONCLUSIONS/SIGNIFICANCE

With broad variability in surveillance, case finding, survey design, and RVFV case confirmation, combined with uncertainty about populations-at-risk, there were inconsistent results from location to location. However, it was evident that RVFV transmission is expanding its range and frequency. Gaps assessment indicated the need to harmonize human and animal surveillance and improve diagnostics and genotyping. Given the frequency of RVFV outbreaks, human vaccination has strong potential to mitigate the impact of this now widely endemic disease.

Waterpipe Tobacco Smoking and Other Multiple Sclerosis Environmental Risk Factors

Introduction There are a number of well-established risk factors for multiple sclerosis (MS). Other factors however, showed conflicting or non-consistent results. Here we examine some factors that are unique to or more practiced in Saudi Arabia (SA) and the Arab region such as waterpipe tobacco smoking (WTS), face veiling, raw milk (RM), and camel milk (CM) consumption, tuberculosis (TB) infection in addition to other traditional factors. Methods This is a sex and age matched case-control study in which we used a structured questionnaire to examine the relation between a number of factors and exposures and the risk of MS. Three hundred MS patients and 601 controls were included. Data was analyzed across different statistical models using logistic regression adjusting for age, sex, marital status, duration of breastfeeding, age first joining school, coffee consumption, and face exposure. Results Cigarette smoking [OR = 1.79, (95% CI 1.01-3.17), P =0.047)], WTS [OR = 2.25, (95% CI 1.21-4.15), P =0.010)], and CM consumption [OR = 2.50, (95% CI 1.20-5.21), P =0.014)] increased the risk of MS. While performing hajj [OR = 0.47, (95% CI 0.34-0.67), P =0.001)], TB infection [OR = 0.29, (95% CI 0.11-0.78), P =0.015)], face veiling [OR = 0.32, (95% CI 0.23-0.47), P =0.001)] and coffee consumption [OR =0.67, (95% CI 0.49-0.89), P =0.008)], appeared to be associated with decreased risk. No association was found between fast food, processed meat, soft drinks, animal milk (other than camel) or RM consumption and the risk of MS. Conclusion The results of this case-control study confirm that different means of tobacco smoking are associated with increased risk of MS. It also sheds more light on the complex association between infections and MS.

A Saudi Arabian Public Health Perspective of Tuberculosis

Tuberculosis is a global health challenge due to its spreading potential. The Kingdom of Saudi Arabia (KSA) faces a challenge in the spread of tuberculosis from migrant workers, but the foremost threat is the huge number of pilgrims who travel to visit sacred sites of the Islamic world located in the holy cities of Makkah and Al Madina. Pilgrims visit throughout the year but especially in the months of Ramadan and Zul-Hijah. The rise of resistance in Mycobacterium tuberculosis is an established global phenomenon that makes such large congregations likely hotspots in the dissemination and spread of disease at a global level. Although very stringent and effective measures exist, the threat remains due to the ever-changing dynamics of this highly pathogenic disease. This overview primarily highlights the current public health challenges posed by this disease to the Saudi health system, which needs to be highlighted not only to the concerned authorities of KSA, but also to the concerned global quarters since the pilgrims and migrants come from all parts of the world with a majority coming from high tuberculosis-burdened countries.

Public health risks threatening health of people participating in mass gatherings: A qualitative study

Background

Mass gatherings (MGs) have made many problems for the health system and potentially threaten the health of those participated in these gatherings. MGs account for a range of public health risks including communicable diseases, waterborne diseases, water treatment, and outbreaks.

Objectives

The present study aimed to identify public health risks threatening the health of people participating in MGs in Iran.

Methods

A qualitative study was designed using a conventional qualitative content analysis approach. Participants were selected using a purposive sampling method among the managers and staff who have experiences in the field of health in MGs in Iran. Subjects were interviewed through individual in-depth interviews after obtaining informed consent. Semi-structured interviews were used to collect the data from December 2018 to February 2019. To analyze the data, the content of recorded interviews was written verbatim. Preliminary data were repeatedly and simultaneously retrieved to give a general understanding of them.

Results

The main theme emerged from data analysis on 16 interviews was related to public health risks involving the following categories: food hygiene deficiencies, communicable diseases risks, defects in health supervision, and the risk of environmental contamination.

Conclusion

It is of paramount importance to identify the risks threatening the health of people participating in MGs. In the present study, the main public health risks were detected.

Amplicon and Metagenomic Analysis of Middle East Respiratory Syndrome (MERS) Coronavirus and the Microbiome in Patients with Severe MERS

Middle East respiratory syndrome coronavirus (MERS-CoV) is a zoonotic infection that emerged in the Middle East in 2012. Symptoms range from mild to severe and include both respiratory and gastrointestinal illnesses. The virus is mainly present in camel populations with occasional zoonotic spill over into humans. The severity of infection in humans is influenced by numerous factors, and similar to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), underlying health complications can play a major role. Currently, MERS-CoV and SARS-CoV-2 are coincident in the Middle East and thus a rapid way of sequencing MERS-CoV to derive genotype information for molecular epidemiology is needed. Additionally, complicating factors in MERS-CoV infections are coinfections that require clinical management. The ability to rapidly characterize these infections would be advantageous. To rapidly sequence MERS-CoV, an amplicon-based approach was developed and coupled to Oxford Nanopore long read length sequencing. This and a metagenomic approach were evaluated with clinical samples from patients with MERS. The data illustrated that whole-genome or near-whole-genome information on MERS-CoV could be rapidly obtained. This approach provided data on both consensus genomes and the presence of minor variants, including deletion mutants. The metagenomic analysis provided information of the background microbiome. The advantage of this approach is that insertions and deletions can be identified, which are the major drivers of genotype change in coronaviruses. IMPORTANCE Middle East respiratory syndrome coronavirus (MERS-CoV) emerged in late 2012 in Saudi Arabia. The virus is a serious threat to people not only in the Middle East but also in the world and has been detected in over 27 countries. MERS-CoV is spreading in the Middle East and neighboring countries, and approximately 35% of reported patients with this virus have died. This is the most severe coronavirus infection so far described. Saudi Arabia is a destination for many millions of people in the world who visit for religious purposes (Umrah and Hajj), and so it is a very vulnerable area, which imposes unique challenges for effective control of this epidemic. The significance of our study is that clinical samples from patients with MERS were used for rapid in-depth sequencing and metagenomic analysis using long read length sequencing.

A Longitudinal Study Regarding the Health Profile of the 2017 South African Hajj Pilgrims

The Hajj mass gathering annually attracts over two million Muslim pilgrims worldwide to the Kingdom of Saudi Arabia (KSA). We aimed to establish demographics and health profiles for the South African pilgrims performing the 2017 Hajj. Methods: This is a longitudinal survey-based study conducted on 1138 adult South African pilgrims in two phases (during and post-Hajj). Data on demographics, vaccination status, underlying health conditions, pre-Hajj training, health promotion, travel history, and health issues during and post-Hajj were collected using pre-designed questionnaires. Results: Participants had a mean age of 49.2 years (SD = 13.3; range 18–81), with a male: female ratio of 1.2:1. The majority of pilgrims were married (88.2%), of Indian/Asian background (73%), and literate (>99%). Nearly all pilgrims were vaccinated against meningococcal disease and yellow fever, but only 23.7% were vaccinated against Influenza. Hypertension, diabetes, and elevated cholesterol levels were the most common underlying health conditions reported by 22.6%, 13.2%, and 11.5% of pilgrims, respectively. One month after return to South Africa, nearly 65% of pilgrims reported illness during Hajj, while 40% reported falling ill post event upon return to South Africa. Nevertheless, only a few were admitted to hospitals (12 during Hajj and 15 post-Hajj). Among ill pilgrims, respiratory symptoms were the most commonly experienced symptoms during (70.2%) and post-Hajj (82.2%). Other symptoms such as walking-related symptoms include symptoms directly related or mainly caused by walking (e.g., leg pain, sore feet, blisters on the feet), dehydration, and gastrointestinal tract symptoms reported during Hajj. Medication to treat respiratory symptoms and antibiotics were the most commonly used medications during and post-Hajj. Having an underlying health condition was an independent predictor of falling ill during or post Hajj. Conclusion: Our study indicates that a sizable proportion of South African pilgrims are elderly with underlying health conditions and most contract respiratory tract infections during and post Hajj. Our study highlights the need for systematic collection of prospective pilgrims’ demographics and health data and more attention to post-Hajj health follow-ups of pilgrims.

Place and health infrastructure in the Gulf Cooperation Council: A systematic scoping review of GIS applications in health

The rising burden of non-communicable diseases is taxing health systems globally. Using data science and information systems is necessary to support public health practices. Geographic Information Systems (GIS) are key to inform and help guide public health policies related to place (i.e. location or where one lives) and how it affects health. Despite the increasing use of GIS for public health globally, its applications to health in the Gulf Cooperation Council (GCC) states remains largely unknown. This systematic scoping review aimed to uncover how GIS has been used in the GCC states to understand "place" and "health". A comprehensive search of the literature was performed in PubMed, Scopus, Science Citation Index Expanded, ScienceDirect, Embase, IEEE Xplore, and ACM Digital Library during June 2020. All journal articles involving the use of GIS for human health applications in the GCC states published in English in peerreviewed scientific journals were considered. After removing duplicates and applying eligibility criteria, qualitative content analysis was performed for 24 of 630 studies. GIS uses in the GCC states were categorized as health access and planning (n=9), health risk analysis (n=8), disease surveillance (n=6) and community health profiling (n=1). The majority of the uncovered evidence in this study focused on the Kingdom of Saudi Arabia. The results of this study indicate a deficiency of published evidence regarding the use of GIS in support of public health in other GCC states. This stands to compromise planning and strategic decision making in health risk analysis, disease surveillance, community health profiling, health services provision and health interventions.

Use of face masks and other personal preventive measures by Hajj pilgrims and their impact on health problems during the Hajj

BACKGROUND

The Hajj is one of the world's largest pilgrimage and gathers millions of Muslims from different nationalities every year. Communicable diseases have been reported frequently, during and following the Hajj, and these have been linked to individual behavioural measures. This study aimed to measure the effect of personal preventive measures, such as face mask use, hand hygiene and others, adopted by pilgrims in reducing the acquisition of infectious diseases.

METHODS

We conducted a cross-sectional study at the Hajj terminal in King Abdulaziz International Airport in Jeddah, Saudi Arabia. Pilgrims were approached in the airport lounges after the 2017 Hajj season and prior to the departure of their flights from Jeddah to their home countries. An electronic data collection tool ('Open Data Kit') was used to gather survey data in regards to health problems and preventive measures during the Hajj.

RESULTS

A total of 2973 Hajj pilgrims were surveyed. In all, 38.7% reported symptoms of upper respiratory tract infections (URTIs) and 5.4% reported symptoms of travel diarrhoea. Compliance with face mask use was 50.2%. Changing a face mask every 4 h was found to be significantly associated with lower prevalence of URTIs [adjusted odds ratio 0.56 (95% confidence interval 0.34-0.92), P = 0.02]. There was no statistical difference between overall face mask use and URTI acquisition. The main sources of food, eating raw vegetables/food, frequency of hand washing or use of hand sanitizers were not found to be significantly associated with reported travellers' diarrhoea. Unlicensed barbers were used by 12% of pilgrims and 9.2% of pilgrims reported using blades that were reused by other pilgrims.

CONCLUSION

Preventive measures are the most effective way to prevent infections. Pilgrims can benefit from face masks by changing them frequently. There is still limited information on the effect of the use of face mask in decreasing the risk of URTI in mass gatherings.

Fractional exhaled nitric oxide and respiratory complaints in Hajj pilgrims wearing a cotton towel or plain cotton ihram

Objective

Hajj is an important component of Islam. This study aimed to determine the effect of wearing a cotton towel or plain cotton ihram on the onset of respiratory symptoms and fractional exhaled nitric oxide (FeNO) levels in Hajj pilgrims.

Methods

One hundred male nonsmoking subjects (age: 20–60 years) without a previous clinical history of respiratory illnesses were included. Fifty subjects were dressed in a cotton towel ihram and 50 wore a plain cotton ihram (control group). Respiratory symptoms and FeNO levels were recorded on the day before leaving for Hajj, when ihrams were removed, and when the pilgrims had returned home.

Results

Pilgrims who wore cotton towel ihrams showed significantly higher rates of respiratory symptoms, including being generally ill, coughing, a sore throat, and a runny nose, than those who wore plain ihrams. FeNO levels also tended to be higher in pilgrims who wore a cotton towel ihram compared with those with a plain cotton ihram during and after Hajj.

Conclusions

Hajj pilgrims who wear cotton towel ihrams may have a risk of respiratory symptoms, including a cough, sore throat, and runny nose. Therefore, a plain cotton ihram is advisable while performing Hajj to minimize respiratory illness.

Risks threatening the health of people participating in mass gatherings: A systematic review

CONTEXT

Mass gatherings (MGs) are established for different religious, social, political, cultural, and sport motivations. Many risks threaten the participants' health in MGs for different reasons. One duty of health-care system is to identify the risks and manage them to reduce the participants' injuries in MGs. This study aimed to identify and classify the risks threatening the health of participants in MGs and review related articles systematically.

SUBJECTS AND METHODS

In this study, we investigated electronic databases including Science Direct, PubMed, Ovid, ProQuest, Web of Science, Scopus, and Google Scholar. This systematic review investigated those health articles which studied MGs published after 2000. Keywords that were searched included (Mass gathering OR Crowd) AND (Assessment OR Evaluation) AND (Disaster OR Emergencies) AND (Injuries OR Stamped). The final full text articles were assessed qualitatively by STROBE article assessment checklist, and then the data extracted from the results of the articles were analyzed and reported.

RESULTS

Initially, a total of 1874 articles were found, qualitative exclusion and inclusion criteria were applied, and finally 29 full-text articles were selected for the analysis. More than forty health-related risks were recognized. In order to better understand the risks and use of the results more efficiently, the risks were classified and reported into the following five domains: environmental risks, individual risks, psychological risks, public health risks, and management risks.

CONCLUSION

Many risks threaten the health of participants in MGs. Recognizing and managing the risks are considered the primary and basic essentials of health sector for the better management of MGs.

Patterns of emergency department visits during Hajj period: Towards healthcare optimization in view of Saudi Arabia's vision 2030

Objective:

This study aimed to examine the pattern of emergency department (ED) visits by Hajj patients and determine the urgency of emergency visits at an advanced healthcare center.

Methods:

A retrospective review of medical records of Hajj patients visiting the ED at King Abdullah Medical City Makkah from September 1 to October 5, 2015 was conducted.

Results:

We considered 233 visits by 199 Hajj patients. Most diseases were cardiovascular related. Approximately half of the ED visits led to hospital admission, which were largely during the evening and nighttime. Potentially avoidable visits were significantly encountered during the daytime. Average bed occupation time in the ED was similar for both cases: those admitted to inpatient care and discharged from ED. Results from the Canadian Triage and Acuity Scale revealed that most patients were triaged with a score of III (48.4%) followed by a clinically better score of IV (32%); however, scores did not change significantly throughout the Hajj day.

Conclusions:

During Hajj, a significant proportion of patients who visited the ED at the ultimate healthcare facility were discharged within 24 hours, with a higher rate in the morning-afternoon period. Both admitted and discharged cases required equal levels of care. Therefore, an extension in working days at primary care centers and optimization of advanced healthcare facilities during Hajj is currently warranted.

Proportion of adult community-acquired pneumonia cases attributable to Streptococcus pneumoniae among Hajj pilgrims in 2016

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The study evaluated the burden of pneumococcal community-acquired pneumonia (CAP) during Hajj 2016.

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The majority of CAP cases (70.6%) were admitted to hospitals in Mecca, and 53% were admitted after Hajj.

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A large proportion of cases were older adult males and 45.4% of cases were treated in the intensive care unit (ICU).

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The overall case-fatality rate was 10.1%, but was higher among those treated in the ICU and in those with invasive disease.

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The proportion of CAP cases positive for Streptococcus pneumoniae was 18.0%.

Background

The Hajj mass gathering is a risk for pneumococcal disease. This study was performed to evaluate the proportion of adult community-acquired pneumonia (CAP) cases attributable to Streptococcus pneumoniae among Hajj pilgrims in 2016. To add sensitivity to etiological attribution, a urine antigen test was used in addition to culture-based methods.

Methods

Adult subjects hospitalized with X-ray-confirmed CAP were enrolled prospectively from all general hospitals designated to treat Hajj pilgrims in the holy cities of Mecca and Medina. Patients were treated according to local standard of care and administered the BinaxNow S. pneumoniae urine antigen test.

Results

From August 23 to September 23, 2016, a total of 266 patients with CAP were enrolled in the study, 70.6% of whom were admitted to hospitals in Mecca; 53% of the cases were admitted after the peak of Hajj. Patients originated from 43 countries. Their mean age was 65.3 years and the male to female ratio was 2:1. Just over 36% of the cases had diabetes, 10% declared that they were smokers, and 45.4% of cases were treated in the intensive care unit (ICU). The overall case-fatality rate was 10.1%, but was higher among those treated in the ICU and in those with invasive disease. The proportion of CAP cases positive for S. pneumoniae, based on culture or urine antigen test, was 18.0% (95% confidence interval 13.9–23.1%).

Conclusions

CAP during Hajj has an important clinical impact. A proportion of CAP cases among Hajj pilgrims were attributable to S. pneumoniae, a pathogen for which vaccines are available. Additional studies to determine the serotypes causing pneumococcal disease could further inform vaccine policy for Hajj pilgrims.

Documentation of Measles Elimination in Iran: Evidences from 2012 to 2014

Background: Documentation of achieving the goal of measles elimination to justify to international organizations including the WHO is a priority for public health authorities. This study aimed to address the status of Iran in the achievement of the measles elimination goal from 2012-2014.

Study Design: A descriptive study.

Methods: Data on the measles outbreaks were extracted from the national notifiable measles surveillance system in Iran from 2012 to 2014. The required documents regarding the achievement of measles elimination, including Effective Reproduction Number (R) and the distribution of outbreak size, was addressed. The R was calculated using the proportion of imported cases as 1 − P, where P is equal to the proportion of cases that were imported. The distribution of the measles outbreaks size was described using descriptive statistics to show their magnitudes. The proportion of large outbreaks with more than 10 cases was considered as a proxy of the R value.

Results: The total number of measles cases was 232 cases (including 186 outbreak related cases) in 2012 and 142 cases in 2014, including108 outbreak related cases. The distribution of the measles outbreak size of occurred outbreaks from that period indicated that there were 37 outbreaks with three or more than three cases. The R value in 2012 was 0.87 and the corresponding value for 2014 was 0.76.

Conclusions: According to the magnitude of effective reproduction number and distribution of outbreaks' size, measles has been eliminated in Iran. However, it is necessary to consider the potential endemic activity of measles because of no authorized immigration.

Multiple Sources of Genetic Diversity of Influenza A Viruses during the Hajj

Outbreaks of respiratory virus infection at mass gatherings pose significant health risks to attendees, host communities, and ultimately the global population if they help facilitate viral emergence. However, little is known about the genetic diversity, evolution, and patterns of viral transmission during mass gatherings, particularly how much diversity is generated by in situ transmission compared to that imported from other locations. Here, we describe the genome-scale evolution of influenza A viruses sampled from the Hajj pilgrimages at Makkah during 2013 to 2015. Phylogenetic analysis revealed that the diversity of influenza viruses at the Hajj pilgrimages was shaped by multiple introduction events, comprising multiple cocirculating lineages in each year, including those that have circulated in the Middle East and those whose origins likely lie on different continents. At the scale of individual hosts, the majority of minor variants resulted from de novo mutation, with only limited evidence of minor variant transmission or minor variants circulating at subconsensus level despite the likely identification of multiple transmission clusters. Together, these data highlight the complexity of influenza virus infection at the Hajj pilgrimages, reflecting a mix of global genetic diversity drawn from multiple sources combined with local transmission, and reemphasize the need for vigilant surveillance at mass gatherings.IMPORTANCE Large population sizes and densities at mass gatherings such as the Hajj (Makkah, Saudi Arabia) can contribute to outbreaks of respiratory virus infection by providing local hot spots for transmission followed by spread to other localities. Using a genome-scale analysis, we show that the genetic diversity of influenza A viruses at the Hajj gatherings during 2013 to 2015 was largely shaped by the introduction of multiple viruses from diverse geographic regions, including the Middle East, with only little evidence of interhost virus transmission at the Hajj and seemingly limited spread of subconsensus mutational variants. The diversity of viruses at the Hajj pilgrimages highlights the potential for lineage cocirculation during mass gatherings, in turn fuelling segment reassortment and the emergence of novel variants, such that the continued surveillance of respiratory pathogens at mass gatherings should be a public health priority.