Acute rhinosinusitis during Hajj season 2014: Prevalence of bacterial infection and patterns of antimicrobial susceptibility

Risk factors for diarrheal diseases among pilgrims during Arba'een mass gathering: a case-control study

BACKGROUND

A significant portion of the Muslim community participates in the Arba'een pilgrimage, with participant numbers increasing each year. There have been relatively few studies on the health of Arba'een Mass gathering (MG). Researching the prevalence and distribution of diseases among Arba'een pilgrims is essential to recognize any outbreaks and take timely responses to contain them. The current study aimed to identify exposures and risk factors for diarrheal disease in pilgrims who referred to the clinics located in Iraq among the Arba'een MG in 2023.

METHODS

This case-control study randomly selected 200 outpatients (100 cases and 100 controls) who were referred to Iraq clinics. Cases were patients with gastrointestinal symptoms (diarrhea), while controls were randomly selected from unaffected pilgrims at the same time for the cases. The study groups matched for age, and sex. Face-to-face interviews using a reliable field based checklist of the Center for Disease Control and Prevention of Iran's Ministry of Health to collect potential exposures and risk factors for diarrheal disease. Multiple logistic regression was used to estimate the crude and adjusted odds ratio (AOR) for the risk of diarrhea with a 95% confidence interval (CI).

RESULTS

The average age of the participants was 38.6 years. Diarrhea in 100% and fever in 81% were the most common clinical symptoms in patients. Having underlying diseases was not associated with an increased risk of diarrhea disease (P > 0.05). Regarding risk factors for diarrheal, the final analysis after adjusting for potential confounders indicated that consumption of insanitary (unpackaged) drinking water (AOR = 1.95; 95% CI: 1.05-3.6; P = 0.024), inappropriate hand washing (AOR = 3.82; 95% CI: 1.7-8.6; P = 0.001), ritual foods (AOR = 2.56; 95% CI: 1.3-5.2; P = 0.004), and public toilets (AOR = 1.46; 95% CI: 1.04-4.3; P = 0.038) were significantly increased the likelihood of diarrheal disease.

CONCLUSIONS

Contamination of water sources, food, inadequate and poor hand washing were the most common sources of diarrheal diseases among Arba'een pilgrims. The results indicate that the potential occurrence of outbreaks, especially water- and foodborne diseases, threatens participants in the Arba'een MG. It is recommended to provide risk assessment, improve pilgrims' awareness, pre-and post-screening, vaccination, compliance with personal hygiene, improvement of the environment, provision of sanitary water and food sources and hygienic disposal of sewage, laboratory diagnosis to identify the common types of pathogens in Arba'een MG.

Nasal Microbiota and Sensitivity Pattern in Rhinosinusitis

Aims

To know the microorganism causing rhinosinusitis & to study the antibiotic sensitivity pattern for the isolated nasal microbiota in this region.

Background

Rhinosinusitis is inflammatory condition of nose and paranasal sinuses [1]. It is multifactorial condition, in which microorganisms play pathogenic role [2]. Interactions between microorganisms, mucosa and environmental changes influence on composition of bacterial ecosystem [2]. Though antibiotics are frequently used for medical management of rhinosinusitis, sensitivity directed antibiotics are rarely prescribed. So, this study is directed to know microbial isolate in rhinosinusitis and its antibiotic sensitivity pattern.

Methodology

in this 6 months prospective study during March to September 2022, done at Department of Otorhinolaryngology, Raichur Institute of Medical Sciences, Raichur; patients attending Otorhinolaryngology outpatient department and diagnosed to have rhinosinusitis were selected. Nasal swabs were collected from the middle meatus by diagnostic nasal endoscopy and were sent for culture and sensitivity. Statistical tests were applied for results(Size = 100).

Results

Out of 100 patients, 52 were males, 48 were females; 88 were adults & 12 were paediatric patients. 59 patients had acute, 32 chronic and 9 had recurrent rhinosinusitis. Most common organisms isolated in acute rhinosinusitis was Klebsiella 28%, Staphylococcus aureus 56% & 66% in chronic & recurrent rhinosinusitis respectively. Klebsiella was sensitive to beta lactams & quinolones, while Staphylococcus aureus was sensitive to beta lactams & cephalosporins.

Conclusion

Increase in antibiotic use has led to antibiotic resistance. Hence judicious, sensitivity directed antibiotic usage reduces the risk of antibiotic resistance and unnecessary use of antibiotics.

Epidemiological Differences in Hajj-Acquired Airborne Infections in Pilgrims Arriving from Low and Middle-Income versus High-Income Countries: A Systematised Review

This systematised review aims to compare the epidemiological patterns of Hajj-acquired airborne infections among pilgrims from low and middle-income countries (LMIC) versus those from high-income countries (HIC). A PubMed search was carried out for all published articles before February 2023, using a combination of MeSH terms and text words. The Newcastle-Ottawa Scale (NOS) was used to assess data quality. From a total of 453 titles identified, 58 studies were included in the review (LMIC = 32, and HIC = 26). In the pooled sample, there were 27,799 pilgrims aged 2 days to 105 years (male: female = 1.3:1) from LMIC and 70,865 pilgrims aged 2 months to 95 years (male: female = 1:1) from HIC. Pilgrims from both HIC and LMIC had viral and bacterial infections, but pilgrims from HIC tended to have higher attack rates of viral infections than their LMIC counterparts. However, the attack rates of bacterial infections were variable: for instance, pilgrims from LMIC seemed to have higher rates of meningococcal infections (0.015-82% in LMIC vs. 0.002-40% in HIC) based on the study population, but not Mycobacterium tuberculosis (0.7-20.3% in LMIC vs. 38% in HIC). Targeted measures are needed to prevent the spread of airborne infections at Hajj.

Threat of Antimicrobial Resistance among Pilgrims with Infectious Diseases during Hajj: Lessons Learnt from COVID-19 Pandemic

Hajj pilgrimage is a large mass gathering global event that may facilitate the spread and emergence of various infectious diseases as well as antimicrobial resistance (AMR) in a local and global scenario. Planning and preparing for these public health issues is a challenging and complex process for the Kingdom of Saudi Arabia (KSA) health authorities. Despite multiple efforts for the prevention and treatment of infectious diseases through longtime funding in education and medical care, the prevalence of infectious disease is still high among Hajj pilgrims. The commonly observed infectious diseases during Hajj include respiratory tract infections (influenza and pneumonia), urinary tract infections and skin infections that may necessitate the use of antimicrobials. Beta-lactams are used as a first-line treatment for hospital acquired infections as well as community acquired infections due to their broad-spectrum activity. However, most of the bacterial isolates such as Staphylococcus spp., Pseudomonas spp. and E. coli are resistant to beta-lactams. Irrational use of antimicrobials, lack of infection prevention practices and suboptimal healthcare access further exacerbate the risk of spreading AMR among Hajj pilgrims. Enhanced collaboration between countries, sharing of best practices and international cooperation are crucial in addressing AMR threats among pilgrims. Consequently, robust surveillance systems for early detection and monitoring of AMR, collaboration with national as well as international healthcare agencies, effective infection prevention and control measures, public awareness and rational use of antimicrobials via antimicrobial stewardship programs are required to mitigate the risk of AMR and ensure the health and well-being of pilgrims during Hajj.

Bacterium detected by gram stain and drug sensitivity in Chinese children with acute sinusitis

BACKGROUND

Acute rhinosinusitis (ARS) is one of the common diseases of upper respiratory tract infection in children. Bacterial infection is a significant aggravating factor in pediatric ARS. In this research, our goal was to detected the bacterial flora and antibiotic sensitivity of ARS in Chinese children.

METHODS

We recruited 133 children with ARS between January 2020 and January 2022 from our hospital. Sinus secretion were collected and cultured for Gram stain as well as antimicrobial susceptibility tests.

RESULTS

Moraxella catarrhalis, Staphylococcus aureus, Haemophilus influenzae, Streptococcus pneumoniae and Pseudomonas aeruginosa were detected in order in children with ARS, of which 25% were negative for bacterial culture and 10% were positive for two strains. Amoxicillin and clavulanate potassium were useful for Haemophilus influenzae, Streptococcus pneumoniae and Moraxella catarrhalis. Quinolones are useful for Staphylococcus aureus, Haemophilus influenzae, Streptococcus pneumoniae and Pseudomonas aeruginosa.

CONCLUSIONS

This research updates the proportion of ARS bacterial infection in children in southern China and the antibiotic sensitivity.

Transmission of Antimicrobial Resistant Bacteria at the Hajj: A Scoping Review

BACKGROUND

The Hajj is an annual religious mass gathering event held in Makkah, Saudi Arabia. With millions of participants from across the globe attending the Hajj, the risk of importation, transmission, and global spread of infectious diseases is high. The emergence of antimicrobial resistant (AMR) bacteria is of worldwide concern and the Hajj poses a serious risk to its dissemination. This review aims to synthesize published literature on AMR bacteria acquisition and transmission associated with the Hajj.

METHODS

We searched electronic databases to identify literature published between January 1990 and December 2021. The search strategy included medical subject headings and keyword terms related to AMR bacteria and the Hajj.

RESULTS

After screening 2214 search results, 51 studies were included in the analysis. The review found 6455 AMR bacteria transmissions related to the Hajj. Thirty predominantly enteric or respiratory disease-causing AMR bacterial species were reported with isolates identified in cases on five continents. Most were male, aged above 50 years and were diagnosed in Makkah. Most cases were identified through hospital-based research; few cases were detected in community or primary health care settings.

CONCLUSIONS

This review provides a contemporary account of knowledge related to AMR transmission at the Hajj. It emphasizes the need for the enhancement of surveillance for AMR bacteria globally.

The Emergence, Persistence, and Dissemination of Antimicrobial-Resistant Bacteria in Environmental Hajj Settings and Implications for Public Health

The emergence of antimicrobial resistance is causing the loss of what was once considered the miracle cure. The transmission of antimicrobial resistance during mass gathering is a potential threat in addition to other infectious diseases. Here, we review the English language literature on the rate and the acquisition of antimicrobial resistance during the Hajj. There is a variable incidence of methicillin-resistant Staphylococcus aureus, Escherichia coli, and Enterobacteriaceae. There had been no report of multi-drug-resistant Mycobacterium tuberculosis. Continued surveillance of antimicrobial resistance coupled with public health measures are needed to decrease the rate of emergence of resistance.

Pilot Survey of Knowledge, Attitudes and Perceptions of Hajj Deployed Health Care Workers on Antibiotics and Antibiotic Prescriptions for Upper Respiratory Tract Infections: Results from Two Hajj Seasons

Antimicrobial resistance (AMR) is a global public health issue. Upper respiratory tract infections (URTIs) are common illnesses during Hajj, for which antibiotics are often inappropriately prescribed. Hajj healthcare workers' (HCW) knowledge, attitudes and perceptions (KAP) about AMR and antibiotic use for URTIs are not known. We conducted a survey among HCWs during Hajj to explore their KAP regarding antibiotic use for URTIs in pilgrims. Electronic or paper-based surveys were distributed to HCWs during the Hajj in 2016 and 2017. A total of 85 respondents aged 25 to 63 (median 40) years completed the surveys. Most participants were male (78.8%) and were physicians by profession (95.3%). Around 85% and 19% of respondents claimed to have heard about AMR and antimicrobial stewardship programs, respectively, among whom most had obtained their knowledge during their qualification. Implementation of URTI treatment guidelines was very low. In conclusion, HCWs at Hajj have significant knowledge gaps regarding AMR, often do not use standard clinical criteria to diagnose URTIs and display a tendency to prescribe antibiotics for URTIs.

Arbaeen public health concerns: A pilot cross-sectional survey

BACKGROUND

Arbaeen is an annual religious procession in Iraq with an estimated 17-20 million participants. Public health risks associated with such a mass gathering can be serious at both local and global levels. This is the first quantitative examination of risk factors for, and symptoms of, infectious disease among Arbaeen participants.

METHODS

A cross-sectional survey was conducted of a convenience sample of 191 Arbaeen participants in 2017. Interviewers administered a structured questionnaire. Questions included food sources, preventive measures used and symptoms of infectious diseases during the procession.

RESULTS

Data were collected for 191 participants (143 males, 58 females). The most prevalent symptoms were respiratory (runny nose: 22.6%, cough: 22.5%). Diarrhoea was reported by 12.6% of participants, with a strong association with high-income country origin and eating (commercial) street food (odds ratios 6.1 and 4.1, respectively, p < 0.05). All symptoms investigated, except breathlessness, were more prevalent in high-income country participants (p < 0.05).

CONCLUSION

Street food and high-income country origin were independent risk factors for respiratory or gastrointestinal infection symptoms in this sample of Arbaeen participants. However, these results cannot be generalised due to possible selection bias. Further studies are required to inform policy development and health system preparedness to reduce Arbaeen-associated health risks.

Respiratory tract infections among French Hajj pilgrims from 2014 to 2017

Respiratory tract infections (RTIs) are common among Hajj pilgrims, but risk factors for RTIs and respiratory pathogen acquisition during the Hajj are not clearly identified. Based on previous studies, most frequent pathogens acquired by Hajj pilgrims were investigated: rhinovirus, human coronaviruses, influenza viruses, Streptococcus pneumoniae, Staphylococcus aureus, Klebsiella pneumoniae and Haemophilus influenzae. 485 pilgrims were included. 82.1% presented with RTIs. Respiratory chronic diseases were associated with cough, Influenza-like illness (ILI) and the acquisition of H. influenzae. Vaccination against invasive pneumococcal diseases (IPD) and influenza was associated with a decrease in the acquisition of S. pneumoniae and prevalence of ILI (aRR = 0.53, 95%CI [0.39-0.73] and aRR = 0.69, 95%CI [0.52-0.92] respectively). Individuals carrying rhinovirus and H. influenzae-S. pneumoniae together were respectively twice and five times more likely to have respiratory symptoms. Individual with H. influenzae-K. pneumoniae carriage were twice (p = 0.04) as likely to develop a cough. The use of disposable handkerchiefs was associated with a decrease in the acquisition of S. aureus (aRR = 0.75, 95%CI [0.57-0.97]). Results could be used to identify pilgrims at increased risk of RTIs and acquisition of respiratory pathogens. Results also confirm the effectiveness of influenza and IPD vaccinations in reducing ILI symptoms and acquisition of S. pneumoniae carriage respectively.

Bacterial respiratory carriage in French Hajj pilgrims and the effect of pneumococcal vaccine and other individual preventive measures: A prospective cohort survey

Background

Viral respiratory tract infections are known to be common in Hajj pilgrims while the role of bacteria is less studied.

Methods

Clinical follow-up, adherence to preventive measures and PCR-based pharyngeal bacterial carriage pre- and post-Hajj, were assessed in a cohort of 119 French Hajj pilgrims.

Results

55% had an indication for pneumococcal vaccination. Occurrence of respiratory symptoms was 76.5%, with cough (70.6%) and sore throat (44.5%) being the most frequent; fever was reported by 38.7% pilgrims and 42.0% took antibiotics. Respiratory symptoms, fever and antibiotic intake were significantly more frequent in pilgrims with indication for vaccination against pneumococcal infection. The prevalence of S. pneumoniae carriage (1.8% pre-, 9.8% post-Hajj), H. influenzae carriage (0.9%, 45.4%) and K. pneumoniae (2.8%, 9.8%) significantly increased post-Hajj. Pilgrims vaccinated with conjugate pneumococcal vaccine were seven time less likely to present S. pneumoniae carriage post-Hajj compared to those not vaccinated (3.2% vs. 18.0%, OR = 0.15; 95% CI [0.03–0.74], p = 0.02).

Conclusions

Pilgrims at risk for pneumococcal disease are more likely to suffer from febrile respiratory symptoms at the Hajj despite being immunized against pneumococcal disease and despite lowered S. pneumoniae carriage and should be targeted for reinforced prevention against respiratory infections.

Infectious Diseases and Mass Gatherings

Purpose of Review

Mass gatherings (MGs) are characterized by a high concentration of people at a specific time and location. Infectious diseases are of particular concern at MGs. The aim of this review was to summarize findings in the field of infectious diseases with a variety of pathogens associated with international MGs in the last 5 years.

Recent Findings

In the context of Hajj, one of the largest religious MGs at Mecca, Saudi Arabia, respiratory tract infections are the leading cause of infectious diseases in pilgrims with a prevalence of 50–93%. The most commonly acquired respiratory viruses were human rhinovirus, followed by human coronaviruses and influenza A virus, in decreasing order. Haemophilus influenzae, Staphylococcus aureus, and Streptococcus pneumoniae were the predominant bacteria. The prevalence of Hajj-related diarrhea ranged from 1.1 to 23.3% and etiologies included Salmonella spp., and Escherichia coli, with evidence of acquisition of antimicrobial-resistant bacteria. In other MGs such as Muslim, Christian, and Hindu religious events, sports events, and large-scale open-air festivals, outbreaks have been reported less frequently. The most common outbreaks at these events involved diseases preventable by vaccination, notably measles and influenza. Gastrointestinal infections caused by a variety of pathogens were also recorded.

Summary

Because social distancing and contact avoidance are difficult measures to implement in the context of many MGs, individual preventive measures including vaccination, use of face mask, disposable handkerchief and hand hygiene may be recommended. Nevertheless, the effectiveness of these measures has been poorly investigated in the context of MGs.

Knowledge, attitude and practice (KAP) survey regarding antibiotic use among pilgrims attending the 2015 Hajj mass gathering

BACKGROUND

Overuse and misuse of antibiotics have been reported in Hajj. However, little is known about Knowledge, Attitude and Practice (KAP) of pilgrims themselves in relation to these agents.

METHODS

Adult pilgrims from seven countries attending the 2015 Hajj were interviewed using a structured KAP questionnaire.

RESULTS

KAP information was collected from 1476 pilgrims. Misconceptions regarding antibiotics included that they: cure all diseases (24.6%); cure common cold and flu (63.0%); are used to stop fever (47.3%); have no side effects (43.2%). Negative attitudes included prophylactic use (50%), self-medication (43.2%), non-compliance with therapy (63.5%) and storage of left-overs for future use (54.1%). In practice, 87.3% of pilgrims admitted to using non-prescribed antibiotics, only 19.3% use antibiotic as directed by their doctor and 54% do not usually check the expiry date of antibiotics before use. Over 60% brought antibiotics from their home country to KSA and 39.2% acquired non-prescribed antibiotics in Saudi Arabia. KAP scores were higher among the younger age group (≤43 years old) and among those with healthcare-related work or education and increased with increasing levels of education.

CONCLUSIONS

Multifaceted and multidisciplinary approaches, both in KSA and in pilgrims' countries of origin, are needed to address antibiotic misuse during Hajj.

Emergence of drug resistant bacteria at the Hajj: A systematic review

BACKGROUND

Hajj is the annual mass gathering of Muslims, and is a reservoir and potential source of bacterial transmission. The emergence of bacterial transmission, including multi-drug resistance (MDR) bacteria, during Hajj has not been systematically assessed.

METHODS

Articles in Pubmed, Scopus, and Google scholar were identified using controlled words relating to antibiotic resistance (AR) at the Hajj from January 2002 to January 2017. Eligible studies were identified by two researchers. AR patterns of bacteria were obtained for each study.

RESULTS

We included 31 publications involving pilgrims, Hajj workers or local patients attending hospitals in Mecca, Mina, and the Medina area. Most of these publications provided antibiotic susceptibility results. Ten of them used the PCR approach to identify AR genes. MRSA carriage was reported in pilgrims and food handlers at a rate of 20%. Low rates of vancomycin-resistant gram-positive bacteria were reported in pilgrims and patients. The prevalence of third-generation cephalosporin-resistant bacteria was common in the Hajj region. Across all studies, carbapenem-resistant bacteria were detected in fewer than 10% of E.coli isolates tested but up to 100% in K. pneumoniae and A. baumannii. Colistin-resistant Salmonella enterica, including mcr-1 colistin-resistant E.coli and K.pneumoniae were only detected in the pilgrim cohorts.

CONCLUSION

This study provides an overview of the prevalence of MDR bacteria at the Hajj. Pilgrims are at high risk of AR bacterial transmission and may carry and transfer these bacteria when returning to their home countries. Thus, pilgrims should be instructed by health care practitioners about hygiene practices aiming at reducing traveler's diarrhea and limited use of antibiotics during travel in order to reduce the risk of MDR bacterial transmission.