Hajj: infectious disease surveillance and control

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.

Strengthening global health security through health early warning systems: A literature review and case study

Disease transmission is dependent on a variety of factors, including the characteristics of an event, such as crowding and shared accommodations, the potential of participants having prolonged exposure and close contact with infectious individuals, the type of activities, and the characteristics of the participants, such as their age and immunity to infectious agents [1-3]. Effective control of outbreaks of infectious diseases requires rapid diagnosis and intervention in high-risk settings. As a result, syndromic and event-based surveillance may be used to enhance the responsiveness of the surveillance system [1]. In public health, surveillance is collecting, analyzing, and interpreting data across time to inform decision-making and aid policy implementation [1]. In this review article we aimed to provide an overview of the principles, types, uses, advantages, and limitations of surveillance systems and to highlight the importance of early warning systems in response to the information received by disease surveillance. The study conducted a comprehensive literature search using several databases, selecting, and reviewing 78 articles that covered different types of surveillance systems, their applications, and their impact on controlling infectious diseases. The article also presents a case study from the Hajj gathering, which highlighted the development, evaluation, and impact of early warning systems on response to the information received by disease surveillance. The study concludes that ongoing disease surveillance should be accompanied by well-designed early warning and response systems, and continuous efforts should be invested in evaluating and validating these systems to minimize the risk of reporting delays and reducing the risk of 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.

Understanding the pattern of musculoskeletal pain and its contributing factors among Hajj pilgrims

BACKGROUND

Hajj is a series of rituals that are done in specific areas and periods in Mecca. Performing Hajj requires a great amount of physical demand which may result in musculoskeletal pain (MSP) in different age groups.

OBJECTIVE

To estimate the prevalence of MSP and understand its pattern via exploring the factors that could be associated with muscular pain among pilgrims in the 2022 Hajj.

METHODS

A web-based survey was distributed during the annual Hajj mass gathering. Pilgrims were recruited from Hajj ritual sites. The collected data included demographics, musculoskeletal pain at ten anatomical body sites, and physical activity (PA) level. Descriptive and inferential statistics were used to analyze the data at a 0.05 significance level.

RESULTS

A total of 248 pilgrims participated in the study. The mean age of the sample was 43.49±12.70 years. Of all pilgrims, 78.6% had reported MSP in at least one anatomical body site during performing Hajj. Results revealed that Pilgrims were more likely to have MSP in the lower limb while performing Hajj rituals where the most prevalent reported pain was in the legs (46% ), followed by the lower back (45% ), knees (37% ), and ankles/feet (30% ). Age, sex, and PA were not significantly associated with MSP except the BMI was found to be a significant factor related to MSP among pilgrims (p <0.05).

CONCLUSION

Many pilgrims exhibited pain in at least one body part. Although physical fitness recommendations are published in the Saudi Ministry of Health, MSP preventative measures need to be disseminated by organizations and interested parties worldwide.

Public holidays increased the transmission of COVID-19 in Japan, 2020-2021: a mathematical modelling study

OBJECTIVES

Although the role of specific holidays in modifying transmission dynamics of infectious diseases has received some research attention, the epidemiological impact of public holidays on the transmission of coronavirus disease 2019 (COVID-19) remains unclear.

METHODS

To assess the extent of increased transmission frequency during public holidays, we collected COVID-19 incidence and mobility data in Hokkaido, Tokyo, Aichi, and Osaka from February 15, 2020 to September 30, 2021. Models linking the estimated effective reproduction number (Rt) with raw or adjusted mobility, public holidays, and the state of emergency declaration were developed. The best-fit model included public holidays as an essential input variable, and was used to calculate counterfactuals of Rt in the absence of holidays.

RESULTS

During public holidays, on average, Rt increased by 5.71%, 3.19%, 4.84%, and 24.82% in Hokkaido, Tokyo, Aichi, and Osaka, respectively, resulting in a total increase of 580 (95% confidence interval [CI], 213 to 954), 2,209 (95% CI, 1,230 to 3,201), 1,086 (95% CI, 478 to 1,686), and 5,211 (95% CI, 4,554 to 5,867) cases that were attributable to the impact of public holidays.

CONCLUSIONS

Public holidays intensified the transmission of COVID-19, highlighting the importance of considering public holidays in designing appropriate public health and social measures in the future.

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.

Spatiotemporal Distribution of Malaria in the Kingdom of Saudi Arabia

BACKGROUND

Malaria is a significant public health concern in the Kingdom of Saudi Arabia (KSA). This study aimed to investigate the spatiotemporal distribution of malaria in the KSA between 2017 and 2021.

METHODS

A spatial analysis was conducted using data for malaria cases stratified by Plasmodium species reported by the Ministry of Health for the period 2017-2021. Covariate data such as environmental, socioeconomic, and demographic factors were assembled from different publicly available sources.

RESULTS

A total of 13,852 cases were reported from 20 regions in the KSA during the study period. The study indicated a decline in the overall number of reported cases from 2715 in 2017 to 2616 in 2021, primarily driven by a decrease in Plasmodium falciparum infections. However, the number of Plasmodium vivax cases increased in 2021. Southern regions of the KSA remained at higher risk due to imported cases from neighboring Yemen. Socioeconomic and demographic factors, such as access to healthcare and education, were found to affect malaria transmission. Environmental factors, such as temperature and rainfall, were also identified as determinants of malaria risk.

CONCLUSIONS

This study showed significant spatial variation in malaria cases in the KSA that was related to underlying socioeconomic status and environmental factors. The findings of this study highlight the need for continued efforts to control and eliminate malaria in the KSA, particularly in regions with higher risk of malaria.

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.

Knowledge and Attitude of Human Monkeypox Viral Infection Among Healthcare Practitioners and Students in Saudi Arabia: A Cross-Sectional Study

BACKGROUND

Human monkeypox (Mpox) is a viral zoonotic infectious disease occurs mostly in central and western Africa that can be transmitted to humans and animal. On July 2022, the World Health Organization declared the global Mpox outbreak, which considered as a huge health issue. The prevalence of Mpox in Saudi Arabia has been very low until now.

AIM

This research aims to assess knowledge and attitudes of healthcare practitioners and students toward human Mpox in Saudi Arabia.

METHODS

 A cross-sectional study conducted among healthcare practitioners and students in Saudi Arabia assessing knowledge, practice and attitudes towards Mpox infection. We conducted descriptive statistics for all variables.

RESULTS

A total of 212 participants were included in the study. The majority of participants provided correct responses about the type of microorganisms that cause human Mpox infection and were aware about the low prevalence of the Mpox in Saudi Arabia, but they were not able to identify the correct number of cases in Saudi Arabia. About the symptoms of Mpox, participants showed good knowledge about the common symptoms like skin rash but poor knowledge about less common symptoms like lymph-node swelling. About 70% of participants were aware of the effectiveness of antiviral drugs to treat Mpox.

CONCLUSION

Gaps in knowledge were detected among participants. Therefore, increasing knowledge of Mpox by providing educational courses for healthcare practitioners and healthcare students is crucial.

Viral aetiology of severe acute respiratory illness among patients admitted during the 2022 peri-Hajj period

Introduction

Severe acute respiratory illness (SARI) among pilgrims continues to be an important healthcare issue. The aim of this study was to describe the viral aetiology of patients admitted to hospitals in the holy cities of Makkah and Madinah during the 2022 peri-Hajj period.

Methods

This is a retrospective analysis of patients admitted to hospitals with SARI. Patients were tested with multiplex polymerase chain reaction for the most common viral aetiologies.

Results

In total, 179 cases of SARI were identified during the study period. Of these, 101 (56.4%) were males, 78 (43.6%) were females, and 78 (43.6%) were Saudi. The mean age was 58.60 years (standard deviation 20.5) years. The most common age group was ≥65 years (n=68, 36%), followed by 55-59 years (n=37, 19%). The most common comorbidities were diabetes mellitus (n=67, 36%), hypertension (n=65, 35%) and chronic lung disease (n=34, 18%). Eighty-five (47.5%) patients tested negative and 94 (42.5%) tested positive for various viral aetiologies. The most frequently detected viruses were severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) (n=28, 15%) and influenza (n=22, 12%); of the influenza cases, 16 were influenza A (6 (43%) were H3N2), and six were influenza B. The only case of Middle East respiratory syndrome coronavirus (MERS-CoV) was in a citizen, and none of the visitors or residents had MERS-CoV. Of the total cases, 27 (14%) died during the follow-up period. In a binary regression analysis, only age was associated with mortality (P=0.002).

Conclusion

The most commonly detected viruses among patients admitted to hospital with SARI were SARS-CoV-2 and influenza. It is important to continue surveillance of admitted and non-admitted patients in different Hajj periods to identify any shift in the aetiologic agents.

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.

Molecular Characterization of Influenza A/H3N2 Virus Isolated from Indonesian Hajj and Umrah Pilgrims 2013 to 2014

The Hajj and Umrah are the annual mass gatherings of Muslims in Saudi Arabia and increase the transmission risk of acute respiratory infection. This study describes influenza infection among pilgrims upon arrival in Indonesia and the genetic characterization of imported influenza A/H3N2 virus. In total, 251 swab samples with influenza-like illness were tested using real-time RT-PCR for Middle East Respiratory Syndrome Coronavirus (MERS-CoV) and influenza viruses. Complete sequences of influenza A/H3N2 HA and NA genes were obtained using DNA sequencing and plotted to amino acid and antigenicity changes. Phylogenetic analysis was performed using a neighbour-joining method including the WHO vaccine strains and influenza A/H3N2 as references. The real-time RT-PCR test detected 100 (39.5%) samples positive with influenza with no positivity of MERS-CoV. Mutations in the HA gene were mainly located within the antigenic sites A, B, and D, while for the NA gene, no mutations related to oseltamivir resistance were observed. Phylogenetic analysis revealed that these viruses grouped together with clades 3C.2 and 3C.3; however, they were not closely grouped with the WHO-recommended vaccine (clades 3C.1). Sequences obtained from Hajj and Umrah pilgrims were also not grouped together with viruses from Middle East countries but clustered according to years of collection. This implies that the influenza A/H3N2 virus mutates continually across time.

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.

Evaluation of Health Care Professionals' Knowledge, Attitudes, and Practice to Prevent the Pandemic Spread of COVID-19: A Questionnaire-Based Cross-Sectional Study from Abha, Saudi Arabia

BACKGROUND

Pharmacists and other healthcare professionals (HCPs) are at risk of transmitting the lethal COVID-19 virus globally and increasing its prevalence.

AIM

The aim of this study was to assess knowledge, attitudes, and practices (KAP) about coronavirus disease 2019 (COVID-19) among HCPs in the Asir region for the first time.

METHODOLOGY

A cross-sectional analysis with 491 healthcare professionals was tested using a pre-tested questionnaire in a tertiary care facility. The association between research variables and questions was determined using Chi-square tests and Kruskal-Wallis tests.

RESULTS

Pharmacists and other HCPs exhibited good knowledge, a positive attitude, and a negative practice pattern regarding COVID-19. There was a strong association between knowledge and attitude (correlation coefficient: 0.17; p < 0.001). However, healthcare practitioners had a suboptimal practice score of 2.09 ± 0.62 regarding COVID-19.

CONCLUSION

This study discovered that despite relatively insufficient practices for adherence to recommended techniques regarding COVID-19 prevention during the outbreak, pharmacists and other healthcare professionals have a high level of awareness and a positive attitude towards COVID-19 as a medical condition. There is a need for more involved HCPs, improved COVID-19 management training, and approaches to make healthcare providers feel less anxious.

Microbial surveillance of Hajj tents: Bioaerosol sampling coupled with real-time multiplex PCR

BACKGROUND

Respiratory tract infections are common among pilgrims attending annual Hajj in Mecca, Saudi Arabia. Pilgrims typically spend most of the Hajj period inside ventilated tents, where microorganisms may be transmitted through bioaerosols and droplets.

OBJECTIVE

To perform microorganism surveillance inside Hajj tents and assess the similarities between microorganisms isolated from tent bioaerosol samples and nasopharyngeal swabs (NP) of tent occupants.

METHODS

Respiratory microorganisms in bioaerosols collected from Hajj tents over a 4-day period were compared with NP of tent occupants using real-time multiplex polymerase chain reaction analysis.

RESULTS

A total of 152 samples were collected: 120 tent bioaerosol samples collected on days 9, 10, 11, and 12 of Dhu al-Hijjah, and 32 NP collected on day 12 of Dhu al-Hijjah (corresponding to 23/08/2018). Eighty-three (69.2%) bioaerosol samples tested positive for at least 1 microorganism, with the number of pathogens increasing over the 4 days of sampling. Twenty-seven (84.38%) NP swabs from tent occupants also tested positive. Microorganisms identified in pilgrim nasal carriage and tent bioaerosol samples were similar, and included K. pneumonia, S. aureus, S. pneumonia, human adenovirus, Moraxella, influenza A, and H. influenza.

CONCLUSIONS

The data suggest that the Hajj tent environment may contribute to the spread of airborne infections during Hajj. This can have important ramifications for novel pathogens with pandemic potential.

Proceedings of the Expert Consensus Group meeting on meningococcal serogroup B disease burden and prevention in India

Meningococcal disease is highly transmissible, life-threatening and leaves significant sequelae in survivors. Every year, India, which has a plethora of risk factors for meningococcal disease, reports around 3000 endemic cases. However, the overall disease burden and serogroup distribution are unknown, creating a setting of general disease negligence and unawareness. Vaccination with quadrivalent meningococcal conjugate vaccine A, C, W, and Y is only recommended for high-risk children, and there is no overall guidance for meningococcal serogroup B (MenB) vaccination. MenB vaccines, which recently have been licensed in many countries but not in India, have significantly aided the fight against meningococcal disease. However, these MenB vaccines are not available in India. An Expert Consensus Group meeting was held with leading meningococcal disease experts to better understand the current disease epidemiology, particularly serogroup B, the prevalence gaps, and feasible ways to bridge them. The proceedings are presented in this paper.

Assessment of drugs administered in the Middle East as part of the COVID-19 management protocols

The pandemic spread of coronavirus (COVID-19) has been reported first at the end of 2019. It continues disturbing various human aspects with multiple pandemic waves showing more fatal novel variants. Now Egypt faces the sixth wave of the pandemic with controlled governmental measures. COVID-19 is an infectious respiratory disease-causing mild to moderate illness that can be progressed into life-threatening complications based on patients- and variant type-related factors. The symptoms vary from dry cough, fever to difficulty in breathing that required urgent hospitalization. Most countries have authorized their national protocols for managing manifested symptoms and thus lowering the rate of patients' hospitalization and boosting the healthcare systems. These protocols are still in use even with the development and approval of several vaccines. These protocols were instructed to aid home isolation, bed rest, dietary supplements, and additionally the administration of antipyretic, steroids, and antiviral drugs. The current review aimed to highlight the administered protocols in the Middle East, namely in Egypt and the Kingdom of Saudi Arabia demonstrating how these protocols have shown potential effectiveness in treating patients and saving many soles.

Hajj 2021: Role of mitigation measures for health security

PURPOSE

After the impressive results of the 2020 Hajj management, Saudi authorities decided to expand the quota to 60,000 pilgrims in 2021, which resulted in a convenient and successful experience.

PATIENTS AND METHODS

This was a retrospective pre and post-study study conducted on all pilgrims attending the 2021 Hajj using the polymerase chain reaction (PCR) test surveillance with paired-swab samples (pre-Hajj and post-Hajj) to evaluate the risk potential of COVID-19 among Hajj pilgrims, the effectiveness of preventive measures and the potential effect of the Hajj ritual as a huge mass gathering on the epidemiological situation of the Saudi Arabian population.

RESULT

Forty-one cases had positive COVID-19 infections out of a total of 58,428 pilgrims who attended the 2021 Hajj season, as detected by nonmandatory pre- and post-Hajj PCR. Notably, the 2021 Hajj season achieved a decreasing leg of the COVID-19 pandemic curve. The adjusted incidence rate in KSA from July 11th to August 7th ranged from 19 to 24 cases per 100,000 population. In contrast, the incidence rate for the same duration in Hajj ranged from 3 to 7 cases per 100,000 pilgrims.

CONCLUSION

The Saudi mitigation plan ensured the safety of pilgrims and healthcare workers for Hajj, successfully limited the risk of COVID-19 transmission inside and contributed to global health security. The success story of Hajj in 2020 and 2021 during the pandemic represents a successful model for planning, achieving and managing future mass gatherings by integrating technology with global and national health policies and public health measures.

Escalating the 2022 Hajj during the third year of the COVID-19 pandemic

The escalation of the number of pilgrims for the 2022 Hajj season comes as KSA had succeeded in reaching an excellent percentage in vaccine coverage and subsequently eased the restrictions. KSA adopted an extensive surveillance, implemented risk mitigation, and maximized COVID-19 vaccines coverage.

The role of health systems for health security: a scoping review revealing the need for improved conceptual and practical linkages

BACKGROUND

Practical links between health systems and health security are historically prevalent, but the conceptual links between these fields remain under explored, with little on health system strengthening. The need to address this gap gains relevance in light of the COVID-19 pandemic as it demonstrated a crucial relationship between health system capacities and effective health security response. Acknowledging the importance of developing stronger and more resilient health systems globally for health emergency preparedness, the WHO developed a Health Systems for Health Security framework that aims to promote a common understanding of what health systems for health security entails whilst identifying key capacities required.

METHODS/ RESULTS

To further explore and analyse the conceptual and practical links between health systems and health security within the peer reviewed literature, a rapid scoping review was carried out to provide an overview of the type, extent and quantity of research available. Studies were included if they had been peer-reviewed and were published in English (seven databases 2000 to 2020). 343 articles were identified, of those 204 discussed health systems and health security (high and medium relevance), 101 discussed just health systems and 47 discussed only health security (low relevance). Within the high and medium relevance articles, several concepts emerged, including the prioritization of health security over health systems, the tendency to treat health security as exceptionalism focusing on acute health emergencies, and a conceptualisation of security as 'state security' not 'human security' or population health.

CONCLUSION

Examples of literature exploring links between health systems and health security are provided. We also present recommendations for further research, offering several investments and/or programmes that could reliably lead to maximal gains from both a health system and a health security perspective, and why these should be explored further. This paper could help researchers and funders when deciding upon the scope, nature and design of future research in this area. Additionally, the paper legitimises the necessity of the Health Systems for Health Security framework, with the findings of this paper providing useful insights and evidentiary examples for effective implementation of the framework.

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.

Social identity processes associated with perceived risk at pilot sporting events during COVID‐19

Previous research suggests that shared social identification and expected support from others can reduce the extent to which attendees of mass events perceive that others pose health risks. This study evaluated the social identity processes associated with perceived risk at UK pilot sporting events held during COVID‐19, including the government Events Research Programme. An online survey (N = 2029) measured attendee perceptions that other spectators adhered to safety measures, shared social identity with other attendees, expectations that others would provide support, and the perceived risk of germ spread from other attendees. Results indicate that for football attendees, seeing others adhering to COVID‐19 safety measures was associated with lower perceived risk and this was partially mediated via increased shared social identity and expected support. However, the sequential mediations were non‐significant for rugby and horse racing events. The decreased perceived risk for football and rugby attendees highlights the importance of understanding social identity processes at mass events to increase safety. The non‐significant associations between shared social identity and perceived risk and between expected support and perceived risk for both the rugby and the horse racing highlights the need to further research risk perceptions across a range of mass event contexts.

Evaluating COVID-19 control measures in mass gathering events with vaccine inequalities

With the increasing global adoption of COVID-19 vaccines, limitations on mass gathering events have started to gradually loosen. However, the large vaccine inequality recorded among different countries is an important aspect that policymakers must address when implementing control measures for such events. In this paper, we propose a model for the assessment of different control measures with the consideration of vaccine inequality in the population. Two control measures are considered: selecting participants based on vaccine efficacy and restricting the event capacity. We build the model using agent-based modeling to capture the spatiotemporal crowd dynamics and utilize a genetic algorithm to assess the control strategies. This assessment is based on factors that are important for policymakers such as disease prevalence, vaccine diversity, and event capacity. A quantitative evaluation of vaccine diversity using the Simpson's Diversity Index is also provided. The Hajj ritual is used as a case study. We show that strategies that prioritized lowering the prevalence resulted in low event capacity but facilitated vaccine diversity. Moreover, strategies that prioritized diversity resulted in high infection rates. However, increasing the prioritization of participants with high vaccine efficacy significantly decreased the disease prevalence. Strategies that prioritized ritual capacity did not show clear trends.

The role of religion in mitigating the COVID-19 pandemic: the Malaysian multi-faith perspectives

Social distancing is crucial in breaking the cycle of transmission of COVID-19. However, many religions require the faithful to congregate. In Malaysia, the number of COVID-19 cases spiked up from below 30 in February 2020 to more than a thousand a month later. The sudden increase was mostly linked to a large Islamic gathering attended by 16,000 near the capital, Kuala Lumpur. Another large COVID-19 cluster was from a church gathering in Kuching, Sarawak. Within a few weeks, Malaysia became the worst hit country by COVID-19 in Southeast Asia. While religious leaders have advised social distancing among their congregants, the belief that "God is our shield" is often cited for gathering. There is a need to promote sound decision-making among religious adherents so that they will not prioritize their loyalty to the subjective interpretation of religion over evidence-based medicine. Malaysia, a multi-cultural and multi-faith country, is an example of how religious beliefs could strongly influence health behaviours at individual and community levels. In this article, we detail the religious aspects of COVID-19 prevention and control in Malaysia and discuss the possible role of religious organizations in encouraging sound decision-making among religious adherents in mitigating this crisis. We make recommendations on how to promote a partnership between the healthcare system and religious organizations, and how religion and faith could be integrated into health promotion channels and resources in the response of COVID-19 and future communicable diseases.

Cost-effectiveness and budget impact analysis of PPV23 vaccination for the Malaysian Hajj pilgrims

The potential occurrence of disease outbreaks during the hajj season is of great concern due to extreme congestion in a confined space. This promotes the acquisition, spread and transmission of pathogenic microorganisms and pneumococcal disease are one of the most frequent infections among Hajj pilgrims. This study aimed to assess the cost-effectiveness and budget impact of introducing the PPV23 to Malaysian Hajj pilgrims. A decision tree framework with a 1-year cycle length was adapted to evaluate the cost-effectiveness of a PPV23 vaccination program with no vaccination. The cost information was retrieved from the Lembaga Tabung Haji Malaysia (LTH) database. Vaccine effectiveness was based on the locally published data and the disease incidence specifically related to Streptococcus pneumoniae was based on a literature search. Analyses were conducted from the perspective of the provider: Ministry of Health and LTH Malaysia. The incremental cost-effectiveness ratios (ICER), cases averted, and net cost savings were estimated. Findings from this study showed that PPV23 vaccination for Malaysian Hajj pilgrims was cost-effective. The PPV23 vaccination programme has an ICER of MYR -449.3 (US$-110.95) per case averted. Based on the national threshold value of US$6,200-US$8,900 per capita, the base-case result shows that introduction of the PPV23 vaccine for Malaysian Hajj pilgrims is very cost-effective. Sensitivity analysis revealed parameters related to annual incidence and hospitalised cost of septicemia and disease without vaccination as the key drivers of the model outputs. Compared with no vaccination, the inclusion of PPV23 vaccination for Malaysian Hajj pilgrims was projected to result in a net cost saving of MYR59.6 million and 109,996 cases averted over 5 years period. The PPV23 vaccination program could substantially offer additional benefits in reducing the pneumococcal disease burden and healthcare cost. This could be of help for policymakers to consider the implementation of PPV23 vaccination for Malaysian performing hajj.

What's new in travellers' diarrhoea: updates on epidemiology, diagnostics, treatment and long-term consequences

BACKGROUND

Travellers' diarrhoea (TD) is the most common clinical syndrome affecting travellers. This narrative review summarizes key discoveries reported in the last two years related to TD and suggests areas for future research.

METHODS

A PubMed literature search was conducted for novel data in TD research published between 12 January 2018 and 12 January 2020. Inclusion was based on contribution to epidemiology, aetiology, diagnostics, management and long-term consequences and relevance to public health, discovery and clinical practice.

RESULTS

The initial literature search yielded 118 articles. We retrieved 72 and reviewed 31 articles for inclusion. The findings support our understanding that TD incidence varies by traveller group and environment with students and military-travel remaining moderately high risk, and control of food and water in mass gathering events remain an important goal. The growth of culture-independent testing has led to a continued detection of previously known pathogens, but also an increased detection frequency of norovirus. Another consequence is the increase in multi-pathogen infections, which require consideration of clinical, epidemiological and diagnostic data. Fluoroquinolone resistant rates continue to rise. New data on non-absorbable antibiotics continue to emerge, offering a potential alternative to current recommendations (azithromycin and fluoroquinolones), but are not recommended for febrile diarrhoea or dysentery or regions/itineraries where invasive pathogens are likely to cause illness. Recent studies investigated the interaction of the microbiome in TD prevention and consequences, and while discriminating features were identified, much uncertainty remains. The prevalence of extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) acquisition and carriage is increasing. Finally, continued research documents the post-infectious consequences, whereas mechanisms of reactive arthritis and post-infectious IBS necessitate further investigation.

CONCLUSIONS

Globally, TD remains an important travel health issue and advances in our understanding continue. More research is needed to mitigate risk factors where possible and develop risk-based management strategies to reduce antibiotic usage and its attendant consequences.

Applying Human-Centered Design Principles to Digital Syndromic Surveillance at a Mass Gathering in India: Viewpoint

In the wake of the COVID-19 pandemic, digital health tools have been deployed by governments around the world to advance clinical and population health objectives. Few interventions have been successful or have achieved sustainability or scale. In India, government agencies are proposing sweeping changes to India's digital health architecture. Underpinning these initiatives is the assumption that mobile health solutions will find near universal acceptance and uptake, though the observed reticence of clinicians to use electronic health records suggests otherwise. In this practice article, we describe our experience with implementing a digital surveillance tool at a large mass gathering, attended by nearly 30 million people. Deployed with limited resources and in a dynamic chaotic setting, the adherence to human-centered design principles resulted in near universal adoption and high end-user satisfaction. Through this use case, we share generalizable lessons in the importance of contextual relevance, stakeholder participation, customizability, and rapid iteration, while designing digital health tools for individuals or populations.

Conducting mass gathering events during the COVID-19 pandemic: a case study of Kumbh Mela 2021 as a potential 'super spreader event'

BACKGROUND

With the emergence of novel pathogens, there is a worldwide debate on the cancellation or conduction of mass gathering events.

METHODS

In the current coronavirus disease-2019 (COVID-19) pandemic situation, this study assesses the challenges in the conduction of the recently held Kumbh Mela mass gathering (MG), which took place from 14th January 2021 to 29th April 2021 at Haridwar, the capital city of the state of Uttarakhand, India. The correlation between increased cases of COVID-19 and the Kumbh Mela MG has been highlighted through statistical analysis and growth curves using the available data.

RESULTS

The Kumbh Mela-2021 emerged as a potential super spreader event with an increase of 37 cases per day to 144 cases per day (276%) in the COVID-19 cases in Haridwar. An increase from 138 to 480 cases per day (236%) and from 45 600 to 92 754 cases per day (92%) was noted in Uttarakhand and India respectively during this MG. A very strong correlation of 'more than 0.99' was seen between the number of cumulative cases of COVID-19 in Uttarakhand and Haridwar, and Haridwar and India during the Kumbh Mela in the third wave of the pandemic.

CONCLUSIONS

The direct influence of Kumbh Mela on the increase in the overall number of COVID-19 cases is observed. Although, the socio-cultural, psychological and economical advantages of MGs are considerable in a developing nation like India, but organization of such events can be a huge health hazard. The lack of efficient implementation and observance of COVID-19 guidelines elevates the necessity of cancellation of such MGs to prevent the outbreak of diseases. Thus, a well-conducted risk assessment prior to the hosting of a MG event during a pandemic is required with strict application of precautionary measures towards prevention of super-spreader events.

Ten public health strategies to control the Covid-19 pandemic: the Saudi Experience

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KSA plans during the pandemic in managing the healthcare system were robust and sustainable.

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Previous epidemics and mass gathering have helped to use the resources effectively.

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Digital health and the prompt response to pandemic warnings were factors of success

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Healthcare supplies and difficulties of online education were among the challenges.

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It is recommended to revise the disaster and emergency strategic plans in KSA.

Saudi Arabia plays an important strategic role within the Middle East and afar because of its geographical location, and being the host of one of the largest annual religious mass gatherings in the world “The Hajj”. During the recent coronavirus pandemic, the Kingdom of Saudi Arabia (KSA) developed a multisectoral plan that adopted multiple measures to limit the spread of Covid-19 transmission both domestically and internationally. In this article, we review all public health related policy decisions from the Saudi Ministry of Health, other government departments, and the private sector that contributed to limiting the severe consequences from Covid-19. Ten effective strategies are outlined and the challenges related to their implementation are explored. The strategies include: 1. Quarantine and travel restriction, 2. Expansion of serological screening, 3. Mask wearing (covering the face and nose) and social distancing, 4. Preparation of hospitals to deal with the influx of coronavirus cases, 5. Use of artificial intelligence, 6.Public assurance, 7.Removal of slum areas and re housing of its inhabitants, 8. Cancellation of the Hajj season, 9. Economic stimulus packages to safeguard the economy, and 10. fair and priority driven vaccine distribution.

Conclusion: The government of Saudi Arabia demonstrated responsibility at the highest level to prioritize the safety and well-being of its citizens and residents. Rapid early response to the pandemic warnings, extensive experience in previous epidemics and in mass gathering medicine, wise management of healthcare resources, and unprecedented harmonization of governmental and private sectors were significant factors for this success.

Transformation of urban mobility during COVID-19 pandemic - Lessons for transportation planning

INTRODUCTION

The coronavirus disease (COVID-19) pandemic is a global threat that started in Wuhan, China, in 2019 and spread rapidly to the globe. To reduce the spread of the COVID-19, different non-pharmacological control measures have been conducted in different countries, which include social distancing, distance working, and stay-at-home mandates. These control measures had affected global transportation and mobility significantly. This study investigated the short-term changes in urban mobility, tropospheric air pollution, and fuel consumption in two major cities of Saudi Arabia, namely, Riyadh and Jeddah.

METHODS

In this study, the dynamics of the number of trips and trip purposes in different provinces of the country were analyzed, focusing on the pandemic period and the lockdown program. These changes impacted fuel consumption and, consequently, air pollutants. The quantity of fuel consumption and its trend was projected considering a few possible fuel consumption and emission scenarios. It is also expected that fuel price plays a role in fuel consumption. The spatial and temporal distributions of the remote sensed tropospheric Nitrogen Dioxide (NO2) levels in different provinces were presented to depict the short 19 and long-term impact on the air quality due to the changes in mobility.

RESULTS

The significant reduction in urban mobility has been observed since the beginning of the first partial curfew in March 2020 compared to that in 2019. The air pollutant levels (such as NO2) in 2020 after the pandemic were generally less than those of 2019. The fuel consumption has been following a decreasing trend in 2020 starting from January due to dynamic fuel price and the additional influence of pandemic. Based on the current online shopping pattern, it is argued that there will be some permanent behavioral changes in urban mobility, which will decrease some shopping trips at least immediately after the recovery from the pandemic.

CONCLUSIONS

This study concluded that the availability of global urban mobility data, remote sensed based tropospheric air pollution data, and global fuel consumption database are important sources of information to investigate the impact of COVID pandemic, especially for the developing countries which suffer from scarcity of pertinent urban mobility information. It seems that, at least in the study area, the spread of COVID-19 is a complex phenomenon in which several exogenous factors, in addition to the curfew protocols, affect the spread of the virus.

Digital Health Platforms in Saudi Arabia: Determinants from the COVID-19 Pandemic Experience

COVID-19 poses a significant burden to healthcare systems. Healthcare organisations with better health innovation infrastructures have faced a reduced burden and achieved success in curbing COVID-19. In Saudi Arabia, digital technologies have played a vital role in fighting SARS-CoV-2 transmission. In this paper, we aimed to summarise the experience of optimising digital health technologies in Saudi Arabia as well as to discuss capabilities and opportunities during and beyond the COVID-19 pandemic. A literature search was conducted up to September 2021 to document the experience of using DHTPs in Saudi Arabia in response to the COVID-19 outbreak. We also considered any published data, press briefings, and announcements by the MOH in Saudi Arabia. The findings were synthesised in narrative form. Health officials succeeded in optimising and maintaining a strategy to mitigate the spread of the virus via different digital technologies, such as mobile health applications, artificial intelligence, and machine learning. The quick digital response in Saudi Arabia was facilitated by governmental support and by considering users and technology determinants. Future research must concentrate on establishing and updating the guidelines for using DHTPs.

Preparedness of Primary Health Care Leaders During COVID-19 Outbreak, Riyadh, Saudi Arabia: A Qualitative Study

Purpose

Our study aims to explore the preparedness of the frontline leaders of the primary health care (PHC) centres in dealing with the COVID-19 pandemic and to understand their experiences in implementing preventive interventions necessary to routinise health care service delivery.

Methods

A qualitative exploratory study was conducted using in-depth interviews with the participants in English. The interviews were transcribed verbatim, and inductive coding followed by thematic analysis was performed using NVivo version 12.

Participants

Six participants in charge of managing their respective primary health care settings were included in the study. Purposive sampling was used to identify participants until saturation was reached. After agreement, the interviews were scheduled as per availability.

Results

The results were grouped into three major themes and nine subthemes. Most leaders reported that they were trained in pandemic preparedness, but there was a lack of focused readiness to handle a massive-scale, infectious disease outbreak or pandemic. The initial lack of guidelines specific to COVID-19 was a barrier in making decisions related to staff and patient care. Services were interrupted initially and there was lack of staff since many acquired COVID-19 and were isolated. The shortage of the staff was delt by repurposing staff from other departments to the essential care services. Fears related to pandemic was one of the main concerns reported among staff and patients. Several initiatives were taken to ensure staff safety and uninterrupted service delivery to patients. The use of technology was an effective mechanism in preparing for the pandemic.

Conclusion

This qualitative study helped in understanding the experiences of primary health care leaders during the COVID-19 pandemic. The facilities lacked overall preparedness at the beginning of the pandemic; however, many initiatives were taken in course of time to ensure smooth operations and continued service delivery to the patients.

Easy Access to Antibiotics; Spread of Antimicrobial Resistance and Implementation of One Health Approach in India

Antimicrobial resistance (AMR) is a global public health concern because of its fast spread. India, one of the world's top consumer of antibiotics and second most populated country has its unique constraints of social, cultural and economic strata. The continual self-medication, use of antibiotics for the growth promotion in animals, and accumulation of residual antibiotics in the environment challenge the implementation of AMR containment policy. Hence, the present review attempts to delineate the influence of antibiotics abuse on the human, animal and environmental health under the realm of one health. It was based on the literature search using public databases to highlight the rapid surge in the burden of AMR in India affecting various sectors and/or ecosystems in India. It was found that the irrational and overuse of antibiotics in different sectors have led to the emergence of extended antimicrobial resistance wherein the environment acts as a reservoir of antibiotic resistance genes (ARGs); completing the cycle of contamination and recontamination. There are efforts by government policy makers to reduce the burden of AMR in the country to reduce the health risks, through the One Health approach. Parallel efforts in educating healthcare professionals, strict legislation for pharmacies and pharmaceutical companies should be prioritize. At the same time surveillance of newly emerged AMR pathogens, prioritising research focusing on AMR, and awareness camps or programs among the local population is critical while addressing the consequences of spared of AMR in India.

Mass Gathering Medicine in Soccer Leagues: A Review and Creation of the SALEM Tool

Potential risks for public health incidents, outbreaks, and casualties are inferred at association football events, especially if event organizers have not taken appropriate preventative measures. This review explores the potential risks imposed by mass gathering (MG) football events, with particular emphasis on tools and methodologies to manage the risks of football MG events. Effective planning and implementation of MGs along with the mitigation of risks related to people’s health require special attention to all potential threats, especially in frequent and recurring MG events such as football leagues. The well-being of all participants can be compromised by ignoring a single risk. Healthcare systems should cooperate with all stakeholders and organizations who are involved in MG management and response. Provision of services during MG or a disaster must be performed by trained personnel or entities that have full access to available resources in accessible publicly known locations at the MG event site. Several MG assessment tools were developed worldwide; however, to adapt to the Saudi context, SALEM tool was developed to provide a guide for MG planning and assessment. SALEM assesses the risks of MG events with scores that help to categorize the risk of MG events by offering recommendations for required resources.

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.

Recommencement of Sport Leagues With Spectators at the Adelaide Oval During the COVID-19 Pandemic: Planning, Experience, and Impact of a Globally Unprecedented Approach

Non-pharmaceutical interventions including physical distancing and restriction on public gatherings were the cornerstone in controlling the COVID-19 pandemic, in the absence of effective vaccines and available treatment options. Many sport mega-events and sport leagues were canceled or indefinitely postponed, leaving stadiums globally empty or converted to be used as part of the COVID-19 response. There were calls for exit strategies to be developed. With the early containment of COVID-19 in South Australia, various restrictions were lifted in a staged and controlled manner, including the reopening of the Adelaide Oval for recommencement of sport leagues with spectator attendance. This involved the collaboration between public health authorities, other governmental agencies, Adelaide Oval Stadium Management Authority, various sporting leagues etc. Recommencement of sport leagues with staged increase in number of attending spectators allowed various measures to be introduced, revisited, and implemented accordingly, demonstrating that a case-by-case risk assessment can be conducted for mega-events during COVID-19, accounting for the epidemiological context at the time. Economic impacts and non-economic benefits of this recommencement were documented. This globally unprecedented, staged and controlled approach in returning spectators to sporting events during the COVID-19 pandemic could inform the reopening strategy of stadiums, recommencement of sport leagues and mega-events all over the world before herd immunity is achieved or in the event of future outbreaks.

Agent-Based Modeling of the Hajj Rituals with the Possible Spread of COVID-19

With the coronavirus (COVID-19) pandemic continuing to spread around the globe, there is an unprecedented need to develop different approaches to containing the pandemic from spreading further. One particular case of importance is mass-gathering events. Mass-gathering events have been shown to exhibit the possibility to be superspreader events; as such, the adoption of effective control strategies by policymakers is essential to curb the spread of the pandemic. This paper deals with modeling the possible spread of COVID-19 in the Hajj, the world’s largest religious gathering. We present an agent-based model (ABM) for two rituals of the Hajj: Tawaf and Ramy al-Jamarat. The model aims to investigate the effect of two control measures: buffers and face masks. We couple these control measures with a third control measure that can be adopted by policymakers, which is limiting the capacity of each ritual. Our findings show the impact of each control measure on the curbing of the spread of COVID-19 under the different crowd dynamics induced by the constraints of each ritual.

Lack of Zika Virus and Other Recognized Flaviviruses among the Mosquito Vectors during and Post the Hajj Mass Gathering

Makkah city, Kingdom of Saudi Arabia (KSA), contains many of the world’s mosquito vectors of parasitic and arboviral disease and is the site of the Hajj mass gathering. As such there is a risk of exportation and globalization of vector-borne viruses, including the re-emerging Zika virus (ZIKV). There was international concern regarding the introduction of ZIKV to KSA and potential international spread of the virus following the 2016 Hajj which took place few days after the Rio summer Olympics at the height of the ZIKV pandemic. We aimed to detect flaviviruses, including ZIKV, circulating among mosquito hosts in the city of Makkah during and post the 2016 Hajj pilgrimage. Mosquitos (adults and larvae) were sampled from 15 sites in Makkah city during and post the 2016 Hajj and identified to species by morphological keys. Mosquitos were pooled according to date of collection, location, and species. A Pan-Flaviviruses RT-PCR assay that enables identification of 51 flaviviruses species and three tentative species was used to detect flavivirus RNA directly from mosquito homogenates. Between the 10 September and 6 October 2016, 9412 female mosquitos were collected. Of these, 81.3% were Aedes aegypti, 18.6% were Culex species, and 0.1% were Anopheles species. Of the total 493 mosquito pools generated, 242 (49%) were positive by the Pan-Flaviviruses primer set. Sequence analysis revealed that none of the mosquitos carried a pathogenic flavivirus, including ZIKV, but were infected with a novel insect-specific flavivirus. We found no pathogenic flaviviruses circulating in Makkah city during and post the 2016 Hajj and no evidence of introduction of ZIKV through the pilgrimage. Enhanced vector-borne diseases surveillance, prevention, and control are crucial in KSA especially during international mass gatherings such as the annual Hajj to prevent outbreaks and the spread of viruses with epidemic and pandemic potentials.