Meningococcal, influenza virus, and hepatitis B virus vaccination coverage level among health care workers in Hajj

Healthcare Research in Mass Religious Gatherings and Emergency Management: A Comprehensive Narrative Review

Religious mass gatherings, especially pilgrimages of various faiths, involve overcrowding and the international movement of people, exposing individuals to significant health risks, such as the spread of infectious diseases, crowds, exposure to bad weather, physical stress, or risks due to pre-existing medical conditions. This paper aims to review the literature related to health care research on religious mass gatherings, with special reference to the role of awareness creation, training, and risk awareness for individuals during Hajj. The results indicated that the research on health risks associated with large-scale gatherings showed that some countries (which witness religious gatherings) follow effective preventive measures to reduce health risks, while some countries did not (and linked this to its poor infrastructure and the low standard of living in it, such as India). It also showed that most studies overlooked identifying the causes of infectious diseases and determining the perceptions of participants in mass gatherings. While it showed that environmental factors strongly influence the emergence of infectious diseases among individuals, the results also showed the scarcity of research that revolves around the awareness of community members, the health risks of mass gatherings, preventive measures against diseases, and the main effects on individuals' perceptions of risks. The results also showed a lack of research evidence on how pilgrims perceive risks, adopt information, and interact with their willingness to be trained in preventive measures.

National and regional differences in meningococcal vaccine recommendations for individuals at an increased risk of meningococcal disease

INTRODUCTION

Invasive meningococcal disease (IMD) is a severe, life-threatening condition caused by infection with Neisseria meningitidis. Currently available vaccines offer protection against the five most common meningococcal disease-causing serogroups and include monovalent and quadrivalent conjugate vaccines (MenA, MenC, MenACWY vaccines) and outer membrane vesicle- and/or recombinant protein-based vaccines (MenB vaccines).

AREAS COVERED

Country and regional immunization programs target populations susceptible to IMD and typically emphasize the highest-risk age groups (i.e., infants, adolescents/young adults, and the elderly); however, additional groups are also considered at an elevated risk and are the focus of the current review. Specific increased-risk groups include individuals with underlying immunocompromising medical conditions, university/college students, Indigenous people, laboratory workers, military personnel, men who have sex with men, and travelers to areas with hyperendemic IMD. This review compares established meningococcal vaccination recommendations for these vulnerable groups in Europe, the United States, Australia, New Zealand, Israel, Brazil, and Turkey.

EXPERT OPINION

Recommendations should be standardized to cover all groups at increased risk of IMD.

Seasonal influenza vaccination coverage and its association with COVID-19 in Saudi Arabia

Coronavirus Disease 2019 (COVID-19) pandemic is still on-going worldwide. The available information regarding the seasonal influenza vaccine (SIV) coverage during the COVID-19 pandemic and its impact on SARS-CoV-2 spread are limited. Moreover, it is argued that SIV may or may not lessen the COVID-19 severity. No previous studies have been revealed SIV coverage among COVID-19 patients and its association with COVID-19 spread and severity, especially in Saudi Arabia. Hence, this study aimed to estimate the influenza vaccine uptake in confirmed COVID-19 patients and investigate its impact on COVID-19 spread and severity. Accordingly, 1734 COVID-19 confirmed patients were included from three government hospitals in Saudi Arabia (SA). The data were collected electronically through a newly formed, self-administrated questionnaire. Among those patients, 335 were covered with SIV (19.31%), and the coverage rate of females and males was 23.4% and 15.8%, respectively. Severe COVID-19 cases were less in vaccinated patients than in non-vaccinated (2.69% vs. 3.5%, respectively). Additionally, the results showed a significant decrease in getting infected by SARS-CoV-2 after receiving SIV (P = 0.022). Even with the tremendous efforts to promote SIV uptake among the general population and high-risk groups, the SIV coverage in SA is not optimal yet. Nevertheless, there is a significant decrease in the probability of getting infected with SARS-CoV-2 after receiving SIV. Such findings with the continuous progression of the COVID-19 pandemic call for a novel approach regarding vaccination policies to increase SIV and COVID-19 vaccine uptake.

Knowledge, attitudes and uptake related to influenza vaccine among healthcare workers during the 2018-2019 influenza season in Tunisia

BACKGROUND

The influenza vaccine (IV) is considered the most effective strategy to prevent seasonal influenza infection and annual vaccination of healthcare workers (HCWs) is recommended by the World Health Organization given their high mixing with patients. We assessed IV uptake among HCWs in the 2018-2019 season and explored their knowledge and attitudes regarding influenza immunization.

METHODS

A cross-sectional study was conducted in 150 representative Tunisian health facilities from March to May 2019. We recruited 1231 HCWs with direct patient contact using self-weighted multistage sampling. Univariate and multivariate logistic regression analyses permitted to assess the factors associated with IV uptake in the 2018-2019 influenza season.

RESULTS

Among 1231 health professionals enrolled in this study, less than half (36.6, 95% confidence interval [CI]: 33.9-39.4) received the IV at least once in their lives and only 15.3% (CI: 13.3-17.4) were vaccinated against influenza in the 2018-2019 influenza season. High confidence regarding IV efficacy, belief about the mandatory character of influenza vaccination for HCWs, and IV uptake in the 4 years preceding the 2018-2019 influenza season were independently associated with higher IV uptake by multivariate analysis. However, participants with high educational level were less likely to receive the IV than those with the lowest educational level.

CONCLUSIONS

Our study revealed a low vaccination rate among Tunisian HCWs confirming the importance of tailored education programs targeting this population.

Antimeningococcal Vaccination Coverage Among Healthcare Workers in an Italian University Hospital

Introduction: Following an outbreak of meningococcal epidemic in 2015 and 2016 in Tuscany, we registered a higher demand for antimeningococcal vaccination (anti-Men ACWY) by Healthcare Workers of the University Hospital of Pisa [Azienda Ospedaliero Universitaria Pisana (AOUP)]. The purpose of this work is to analyze and discuss data on vaccination coverage resulting from this vaccination campaign.

Materials and Methods: We conducted a monocentric study about anti-Men vaccination in the healthcare workers of the AOUP following the outbreak of meningococcal meningitis that occurred mainly in the population of the Tuscan provinces of Pisa, Pistoia, Prato, and Florence. The variables under examination were age, sex, educational qualification, and job profile. Department healthcare workers were vaccinated with two types of conjugated tetravalent vaccines for the A, C, Y, and W135 strains. Data were analyzed using the SPSS software.

Results: The total population of the workers in AOUP was 7,188 subjects; the population considered in the study was 5,889. Between 2015 and 2017, a total of 2,423 subjects (41.1%) underwent anti-Men vaccination. Women, older HCWs, those with a lower educational qualification, doctors, and the HCWs of the maternal and child department, and imaging department recorded a statistically significant better vaccine compliance.

Discussion: The AOUP, implementing the program of the Tuscany Region of vaccination against Neisseria meningitidis, has contributed to reduce the incidence of invasive meningococcal disease. Some critical issues remain in the compliance of some sections of the population, despite the high level of adherence recorded in this case, probably also due to the great media coverage of the event.

Meningococcal and pneumococcal carriage in Hajj pilgrims: findings of a randomized controlled trial

BACKGROUND

Intense congestion during the Hajj pilgrimage amplifies the risk of meningococcal carriage and disease, and there have been many meningococcal outbreaks reported amongst pilgrims. Thus, a strict vaccination policy is enforced by the host country and either polysaccharide or conjugate quadrivalent meningococcal vaccines are mandatory. However, unlike conjugate vaccines, the polysaccharide vaccine is not thought to reduce pharyngeal carriage of meningococci.

METHODS

A single-blinded, randomized, controlled trial amongst pilgrims from Saudi Arabia and Australia during the Hajj seasons of 2016-2017 was conducted to compare MenACWY-Conjugate vaccine with MenACWY-Polysaccharide vaccine, to determine if the conjugate vaccine is more effective in reducing asymptomatic carriage of meningococci, and whether the effect may be long-standing. Oropharyngeal swabs were obtained pre-, immediately post- and 6-11 months following completion of Hajj and tested for the presence of meningococci.

RESULTS

Amongst 2000 individuals approached, only 1146 participants aged 18-91 (mean 37.6) years agreed to participate and were randomized to receive either the polysaccharide (n = 561) or the conjugate (n = 561) vaccine, 60.8% were male, and 93.5% were from Saudi Arabia. Amongst oropharyngeal swabs obtained before Hajj, only two (0.2%) tested positive for Neisseria meningitidis. Similarly, meningococci were identified in only one sample at each of the post-Hajj and late follow-up visits. None of the carriage isolates were amongst the serogroups covered by the vaccines. A post hoc analysis of the third swabs revealed that 22.4% of all participants (50/223) were positive for Streptococcus pneumoniae nucleic acid.

CONCLUSION

The low overall carriage rate of meningococci found amongst Hajj pilgrims in 2016 and 2017 demonstrates a successful vaccination policy, but neither supports nor refutes the superiority of meningococcal conjugate ACWY vaccine over the polysaccharide vaccine against carriage. Although an association could not be established in this study, molecular epidemiology would help to establish the role of Hajj in facilitating transmission of pneumococci and inform vaccination policy.

Review of seasonal influenza vaccination in the Eastern Mediterranean Region: Policies, use and barriers

Vaccination is the main control measure for influenza and its severe complications. To better understand the influenza vaccination situation in the Eastern Mediterranean Region, we conducted an extensive review of literature published between 2006 and 2016 in the region on influenza vaccine policies, use, recommendations and coverage. Forty-eight articles met the inclusion criteria. These originated from 11 of the 22 countries of the region, with most being from Saudi Arabia and Iran. The review revealed knowledge gaps and misconceptions about influenza and its vaccines even among healthcare workers. Most of the papers reviewed reported low coverage in the target populations. Limited literature on the number of countries with concrete national influenza vaccination policies was available, which may not accurately represent the situation in the Region. In conclusion, lack of awareness and knowledge are the main barriers to influenza vaccination, which remains very low in the Eastern Mediterranean Region. Countries of the region need to promote and invest in research on influenza vaccination, which is critical to inform evidence-based programmes and policies to improve vaccination rates and control influenza.

Meningococcal Vaccine for Hajj Pilgrims: Compliance, Predictors, and Barriers

Background: Major intercontinental outbreaks of invasive meningococcal disease associated with the Hajj occurred in 1987, 2000, and 2001. Mandatory meningococcal vaccination for all pilgrims against serogroups A and C and, subsequently, A, C, W, and Y controlled the epidemics. Overseas pilgrims show excellent adherence to the policy; however, vaccine uptake among domestic pilgrims is suboptimal. This survey aimed to evaluate meningococcal vaccine uptake among Hajj pilgrims and to identify key factors affecting this. Methods: An anonymous cross-sectional survey was conducted among pilgrims in Greater Makkah during the Hajj in 2017–2018. Data on socio-demographic characteristics, vaccination status, cost of vaccination, and reasons behind non-receipt of the vaccine were collected. Results: A total of 509 respondents aged 13 to 82 (median 33.8) years participated in the survey: 86% male, 85% domestic pilgrims. Only 389/476 (81.7%) confirmed their meningococcal vaccination status; 64 individuals (13.4%), all domestic pilgrims, did not receive the vaccine, and 23 (4.8%) were unsure. Among overseas pilgrims, 93.5% certainly received the vaccine (6.5% were unsure) compared to 80.9% of domestic pilgrims (p < 0.01). Being employed and having a tertiary qualification were significant predictors of vaccination adherence (odds ratio (OR) = 2.2, 95% confidence interval (CI) = 1.3–3.8, p < 0.01; and OR = 1.7, CI = 1–2.5, p < 0.05, respectively). Those who obtained pre-Hajj health advice were more than three times as likely to be vaccinated than those who did not (OR = 3.3, CI = 1.9–5.9, p < 0.001). Lack of awareness (63.2%, 36/57) and lack of time (15.8%, 9/57) were the most common reasons reported for non-receipt of vaccine. Conclusion: Many domestic pilgrims missed the compulsory meningococcal vaccine; in this regard, lack of awareness is a key barrier. Being an overseas pilgrim (or living at a distance from Makkah), receipt of pre-Hajj health advice, and employment were predictors of greater compliance with the vaccination policy. Opportunities remain to reduce the policy–practice gap among domestic pilgrims.

Acquisition of respiratory and gastrointestinal pathogens among health care workers during the 2015 Hajj season

BACKGROUND

Data on the risk of transmission of infection to health care workers (HCWs) serving ill pilgrims during the Hajj is scarce.

METHODS

Two cohorts of HCWs, the first serving Hajj pilgrims in Mecca and the second serving patients in Al-Ahsa, were investigated for respiratory and gastrointestinal symptoms and pathogen carriage using multiplex polymerase chain reaction before and after the 2015 Hajj.

RESULTS

A total of 211 HCWs were enrolled of whom 92 were exposed to pilgrims (Mecca cohort), whereas 119 were not exposed (Al-Ahsa cohort). Symptoms were observed only in HCWs from the Mecca cohort, with 29.3% experiencing respiratory symptoms during the Hajj period or in the subsequent days and 3.3% having gastrointestinal symptoms. Acquisition rates of at least 1 respiratory virus were 14.7% in the Mecca cohort and 3.4% in the Al-Ahsa cohort (P = .003). Acquisition rates of at least 1 respiratory bacterium were 11.8% and 18.6% in the Mecca and Al-Ahsa cohorts, respectively (P = .09). Gastrointestinal pathogens were rarely isolated in both cohorts of HCWs and acquisition of pathogens after the Hajj was documented in only a few individuals.

CONCLUSIONS

HCWs providing care for pilgrims both acquire pathogens and present symptoms (especially respiratory symptoms) more frequently than those not working during Hajj.

MERS-CoV, influenza and other respiratory viruses among symptomatic pilgrims during 2014 Hajj season

More than two million Muslims visit Makkah, Saudi Arabia, annually to perform the religious rituals of Hajj where the risk of spreading respiratory infections is very common. The aim here was to screen symptomatic pilgrims for Middle East respiratory syndrome coronavirus (MERS-CoV) and other viral etiologies. Thus, 132 nasopharyngeal samples were collected from pilgrims presenting with acute respiratory symptoms at the healthcare facilities in the holy sites during the 5 days of the 2014 Hajj season. Samples were tested using real-time reverse transcription polymerase chain reactions and microarray. Demographic data including age, sex, and country of origin were obtained for all participants. While we did not detect MERS-CoV in any of the samples, several other viruses were detected in 50.8% of the cases. Among the detected viruses, 64.2% of the cases were due to a single-virus infection and 35.8% were due to the coinfections with up to four viruses. The most common respiratory virus was influenza A, followed by non-MERS human coronaviruses, rhinoviruses, and influenza B. Together, we found that it was not MERS-CoV but other respiratory viruses that caused acute respiratory symptoms among pilgrims. The observed high prevalence of influenza viruses underscores the need for more effective surveillance during the Hajj and adoption of stringent vaccination requirements from all pilgrims.

Mandatory meningococcal vaccine, and other recommended immunisations: Uptake, barriers, and facilitators among health care workers and trainees at Hajj

AIM

To evaluate the uptake of a mandatory meningococcal, a highly recommended influenza, and an optional pneumococcal vaccine, and to explore the key factors affecting vaccination rate among health care workers (HCWs) during the Hajj.

METHODS

An anonymous cross-sectional online survey was distributed among HCWs and trainees who worked or volunteered at the Hajj 2015-2017 through their line managers, or by visiting their hospitals and healthcare centres in Makkah and Mina. Overseas HCWs who accompanied the pilgrims or those who work in foreign Hajj medical missions were excluded. Pearson’s χ² test was used to compare categorical variables and odds ratio (OR) was calculated by “risk estimate” statistics along with 95% confidence interval (95%CI).

RESULTS

A total of 138 respondents aged 20 to 59 (median 25.6) years with a male to female ratio of 2.5:1 participated in the survey. Only 11.6% (16/138) participants reported receiving all three vaccines, 15.2% (21/138) did not receive any vaccine, 76.1% (105/138) received meningococcal, 68.1% (94/138) influenza and 13.8% (19/138) pneumococcal vaccine. Females were more likely to receive a vaccine than males (OR 3.6, 95%CI: 1.0-12.7, P < 0.05). Willingness to follow health authority’s recommendation was the main reason for receipt of vaccine (78.8%) while believing that they were up-to-date with vaccination (39.8%) was the prime reason for non-receipt.

CONCLUSION

Some HCWs at Hajj miss out the compulsory and highly recommended vaccines; lack of awareness is a key barrier and authority’s advice is an important motivator. Health education followed by stringent measures may be required to improve their vaccination rate.

Review of seasonal influenza vaccination in the Eastern Mediterranean Region: Policies, use and barriers

Vaccination is the main control measure for influenza and its severe complications. To better understand the influenza vaccination situation in the Eastern Mediterranean Region, we conducted an extensive review of literature published between 2006 and 2016 in the region on influenza vaccine policies, use, recommendations and coverage. Forty-eight articles met the inclusion criteria. These originated from 11 of the 22 countries of the region, with most being from Saudi Arabia and Iran. The review revealed knowledge gaps and misconceptions about influenza and its vaccines even among healthcare workers. Most of the papers reviewed reported low coverage in the target populations. Limited literature on the number of countries with concrete national influenza vaccination policies was available, which may not accurately represent the situation in the Region. In conclusion, lack of awareness and knowledge are the main barriers to influenza vaccination, which remains very low in the Eastern Mediterranean Region. Countries of the region need to promote and invest in research on influenza vaccination, which is critical to inform evidence-based programmes and policies to improve vaccination rates and control influenza.

Influenza vaccine uptake, determinants, motivators, and barriers of the vaccine receipt among healthcare workers in a tertiary care hospital in Saudi Arabia

BACKGROUND

Influenza vaccination of healthcare workers (HCWs) is essential for patient safety, their own safety, and hospital operation. However, despite its strong recommendation, studies indicates a low rate of vaccine uptake.

AIM

To assess rates of, and factors affecting, influenza vaccine uptake among HCWs.

METHODS

A cross-sectional survey was carried out during October 1^st to 16^th, 2015, among HCWs in King Abdullah Medical City in Makkah, Saudi Arabia. A self-administered, anonymous questionnaire was distributed to HCWs; this included questions on demographic characteristics, vaccine uptake, and knowledge, beliefs, attitude, and concern about influenza vaccine.

FINDINGS

Out of 500 HCWs approached, 447 returned valid self-reported questionnaires with response rate 89.4%. Overall, 88.3% of the participants reported receiving vaccination during the 2014/15 season, higher than during the 2013/14 (61.2%) and 2012/13 (54.5%) seasons. Self-protection (81.5%) was the main reason for vaccination, whereas 73.4% of HCWs reported vaccination to protect patients. The main reasons for vaccination avoidance were misconception that the vaccine causes influenza (38.5%) and concern about vaccine efficacy (32.7%). Logistic regression analysis revealed that the following were independently associated with vaccine receipt among HCWs: awareness of vaccine guidelines; intention to receive the vaccine next season; nurses and other HCWs compared to physicians; longer practice; and age >40 years.

CONCLUSION

A good uptake of influenza vaccine was achieved during the 2014/15 season following adoption of mandatory vaccination policy. Awareness programmes are needed to correct HCWs' misconceptions about the vaccine. Efforts need to focus especially on physicians, younger staff and new recruits.

Vaccination in Hajj: An Overview of the Recent Findings

Background:

About two million people annually travel to Kingdom of Saudi Arabia to perform Hajj. The pilgrims may be at risk of exposure to communicable diseases in this mass gathering and their vaccination against contagious diseases can prevent many morbidities and mortalities. The aim of our study was to review the papers which evaluated effectiveness and compliance of the vaccines applied in Hajj.

Methods:

We used PubMed and Scopus to search international medical databases. The key words were as follows: Hajj, Haj, vaccine, vaccination, and immunization. The time interval of the search was from the beginning of 2010 to May 23, 2016. One hundred and thirty papers were extracted, and their contents were subsequently reviewed after title and abstract screenings. The original articles were included in the study and non-English articles were excluded from the study.

Results:

Considering the extracted papers, almost all pilgrims were vaccinated against meningococcal diseases. Using of influenza and pneumococcal vaccine rates were different among the pilgrims. The other vaccines have been taking according to specific conditions.

Conclusions:

The findings regarding influenza vaccine effectiveness are contradictory. A few studies confirmed the flu vaccine effectiveness while some others rejected its usefulness. Meningococcal immunization is an effective preventive tool with high compliance for Hajj pilgrims. Further investigations are recommended for the other vaccines.

Hajj-associated infections

BACKGROUND

The Hajj is the largest annual mass gathering event in the world, thus favoring the transmission of various infections: 183 different nationalities, high temperatures, coincidence with the start of the flu season in the Northern hemisphere, a long barefoot walk, tent-type accommodation, communal toilet facilities, absence of food control, and sharing of razors. Infections are the first cause of hospital admission, which often occurs in the home country of pilgrims.

METHODS

Literature review on PubMed from 1952 to November 2015 on the epidemiology and prevention of infections contracted during the Hajj, using the keywords "Hajj" and "infections".

RESULTS

Respiratory tract infections, ENT infections, influenza, pyogenic pneumonia, whooping cough, and tuberculosis are most frequently observed during the Hajj. Outbreaks of meningococcal meningitis have been reported in pilgrims and their contacts. Waterborne infections such as gastroenteritis and hepatitis A are common, despite the improvement of health conditions. Pyoderma and furuncles are also frequently observed. Recently, dengue fever, Alkhumra hemorrhagic fever, and Rift Valley fever have emerged but no case of MERS-coronavirus, appeared in Saudi Arabia in 2012, have yet been observed during the 2012-2014 Hajj.

CONCLUSION

Prevention is based on compulsory meningococcal vaccination, vaccination against seasonal influenza and pneumococcal infections for pilgrims at high risk of contracting the infection, and on vaccination against hepatitis A. Updating immunization for diphtheria/tetanus/poliomyelitis/pertussis and measles/mumps is also crucial and pilgrims must comply with hygiene precautions.

Prevention of meningococcal disease during the Hajj and Umrah mass gatherings: past and current measures and future prospects

The Kingdom of Saudi Arabia (KSA) has a long history of instituting preventative measures against meningococcal disease (MD). KSA is at risk of outbreaks of MD due to its geographic location, demography, and especially because it hosts the annual Hajj and Umrah mass gatherings. Preventative measures for Hajj and Umrah include vaccination, targeted chemoprophylaxis, health awareness and educational campaigns, as well as an active disease surveillance and response system. Preventative measures have been introduced and updated in accordance with changes in the epidemiology of MD and available preventative tools. The mandatory meningococcal vaccination policy for pilgrims has possibly been the major factor in preventing outbreaks during the pilgrimages. The policy of chemoprophylaxis for all pilgrims arriving from the African meningitis belt has also probably been important in reducing the carriage and transmission of Neisseria meningitidis in KSA and beyond. The preventative measures for Hajj and Umrah are likely to continue to focus on vaccination, but to favour the conjugate vaccine for its extra benefits over the polysaccharide vaccines. Additionally, the surveillance system will continue to be strengthened to ensure early detection and response to cases and outbreaks; ongoing disease awareness campaigns for pilgrims will continue, as will chemoprophylaxis for target groups. Local and worldwide surveillance of the disease and drug-resistant N. meningitidis are crucial in informing future recommendations for vaccination, chemoprophylaxis, and treatment. Preventative measures should be reviewed regularly and updated accordingly, and compliance with these measures should be monitored and enhanced to prevent MD during Hajj and Umrah, as well as local and international outbreaks.

Respiratory tract infection during Hajj

Respiratory tract infection during Hajj (pilgrimage to Mecca) is a common illness, and it is responsible for most of the hospital admissions. Influenza virus is the leading cause of upper respiratory tract infection during Hajj, and pneumonia can be serious. Taking into account the close contacts among the pilgrims, as well as the crowding, the potential for transmission of M. tuberculosis is expected to be high. These pilgrims can be a source for spreading infection on their return home. Although vaccination program for influenza is implemented, its efficacy is uncertain in this religious season. Future studies should concentrate on prevention and mitigation of these infections.

Establishment of public health security in Saudi Arabia for the 2009 Hajj in response to pandemic influenza A H1N1

Mass gatherings of people challenge public health capacities at host locations and the visitors' places of origin. Hajj--the yearly pilgrimage by Muslims to Saudi Arabia--is one of the largest, most culturally and geographically diverse mass gatherings in the world. With the 2009 pandemic influenza A H1N1 and upcoming Hajj, the Saudi Arabian Ministry of Health (MoH) convened a preparedness consultation in June, 2009. Consultants from global public health agencies met in their official capacities with their Saudi Arabian counterparts. The MoH aimed to pool and share public health knowledge about mass gatherings, and review the country's preparedness plans, focusing on the prevention and control of pandemic influenza. This process resulted in several practical recommendations, many to be put into practice before the start of Hajj and the rest during Hajj. These preparedness plans should ensure the optimum provision of health services for pilgrims to Saudi Arabia, and minimum disease transmission on their return home. Review of the implementation of these recommendations and their effect will not only inform future mass gatherings in Saudi Arabia, but will also strengthen preparedness efforts in other settings.

Virological investigation of four outbreaks of influenza B reassortants in the northern region of Taiwan from October 2006 to February 2007

Background

From October 2006 to February 2007, clinical specimens from 452 patients with symptoms related to respiratory tract infection in the northern region of Taiwan were collected. Real-time PCR and direct immunofluorescent antibody tests showed that 145 (32%) patients had influenza B virus infections. Subsequently, nucleotide sequence analyses of both hemagglutinin (HA) and neuraminidase (NA) genes of 39 isolates were performed. Isolated viruses were antigenically characterized using hemagglutinin inhibition (HI) test.

Findings

Phylogenetic tree analysis showed that all the isolates belonged to the B reassortant lineage with HA gene belonged to the B/Victoria/2/87 lineage and the NA gene belonged to the B/Yamagata/16/88 lineage. In addition, a group of children aged between 6 to 8 years old resided in Yilan county were infected with a variant strain. Hemagglutinin inhibition (HI) tests confirmed that all the reassortant influenza B viruses were B/Malaysia/2506/04-like viruses. Pre- and post-immunized serum samples from 4 normal volunteers inoculated with 2007 influenza vaccine were evaluated for their HI activity on 6 reassortant B isolates including two variants that we found in the Yilan county. The results demonstrated that after vaccination, all four vaccinees had at least 4-fold increases of their HI titers.

Conclusion

The results indicate that the 2006–2007 seasonal influenza vaccine was effective in stimulating protective immunity against the influenza B variants identified in Yilan county. Continuous surveillance of emerging influenza B variants in the northern region of Taiwan is important for the selection of proper vaccine candidate in the future.

Severe sepsis and septic shock at the Hajj: etiologies and outcomes

BACKGROUND

The Hajj represents the largest mass migration on earth, during which several million Muslims travel across the planet to descend on specific holy sites at Makkah in the Hijaz area of the Kingdom of Saudi Arabia. Since sepsis syndrome is a major worldwide cause of morbidity and mortality we decided to study the incidence, etiologies, complications and outcome of severe sepsis and septic shock among Hajjees patients in two major intensive care units (ICUs) in Makkah for the Hajj season 2004.

METHOD

A prospective observational study was conducted during the 2004 Hajj season between 8 January and 21 February in two major hospitals in Makkah.

RESULTS

Severe sepsis and septic shock accounts for 25.4% of admission to the ICU during Hajj. The mean age of hajjees was 65.45 (+/-14.0) years. Chronic respiratory illness was the leading comorbidity present in more than 70% of hajjees and pneumonia was the leading cause of sever sepsis and septic shock. Gram-negative organisms were the most frequently isolated pathogen in this subset of patients. Acute renal failure is common among pilgrims who presented with septic shock, and carries high mortality.

CONCLUSION

Septic shock is a major cause of admission to the ICU during Hajj and carries a poor outcome. More studies are needed to evaluate modifiable factors that are associated with this high mortality.

Viral respiratory infections at the Hajj: comparison between UK and Saudi pilgrims

A high incidence of respiratory infection, including influenza, has been reported at the Hajj in Mecca, Saudi Arabia. Reported rates of influenza have been higher among UK than among domestic pilgrims, but this could be explained by methodological differences among studies. Accordingly, the present study compared the frequencies of respiratory viruses among UK and Saudi pilgrims using the same study design. Pilgrims with upper respiratory tract symptoms were recruited from Mecca and the neighbouring valley Mina during the Hajj 2006. Nasal swabs were used for point-of-care influenza testing and real-time RT-PCR (rtRT-PCR) tests for influenza virus, rhinovirus, parainfluenza virus, adenovirus, human metapneumovirus and respiratory syncytial virus. Of 260 pilgrims investigated, 150 were from the UK and 110 were Saudi; of these, 38 (25%) UK pilgrims and 14 (13%) Saudi pilgrims had respiratory infections detectable by rtRT-PCR (p 0.01). In the UK group, there were 19 (13%) cases of rhinovirus infection, 15 (10%) cases of influenza virus infection, two (1%) cases of dual infections with influenza virus and rhinovirus, one (3%) case of parainfluenza virus infection, and one (1%) case of respiratory syncytial virus infection. Fifty-six (37%) UK pilgrims had been vaccinated against influenza virus, with the rates of influenza in the vaccinated and unvaccinated group being 7% and 14%, respectively (p 0.19). In the Saudi group, there were three (3%) cases of rhinovirus infection and 11 (10%) cases of influenza. Only four (4%) Saudi pilgrims had been vaccinated against influenza virus, and none of these was infected with influenza virus. Overall, a significantly higher proportion of the UK pilgrims had detectable respiratory infections (25% vs. 13%, p 0.01). Influenza rates were similar in both groups, but the reported rates of influenza vaccination differed.