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Mass gatherings for sporting events, music shows, and religious needs continue to grow in our urban areas, requiring local authorities to develop safety procedures to mitigate the challenges of keeping the attendees safe. These challenges are even more pronounced at pilgrimage venues where social distancing and contact avoidance are difficult as pilgrims are required to perform various rituals in close proximity with others, in a sequential manner, either daily or weekly, as per their religious tenets. Over two million pilgrims attend the Hajj pilgrimage in Saudi Arabia annually. Keeping the local and visiting pilgrims safe from crowd crush, sunstroke, skin infections, recurrence of prior medical issues, and contagious diseases requires the Saudi government to allocate huge investments for health communication and prevention programs every year. However, there is no evidence to date that has empirically tested whether Hajj pilgrims' are able to receive such information and are subsequently adopting various health promoting behaviors. This study aims to do that by framing it within the Health Belief Model. Data collected and analyzed from 245 pilgrims in Makkah between September 9th-19th, 2017 suggests that roughly 48% of the pilgrims adopted all five protective measures. However, language barriers, limited health care facilities, and difficulties in purchasing prescription mediciens were cited as impediments to adopting healthy measures. The study concludes with recommendations for the KSA government agencies, Hajj authorities, Mission authorities and pilgrims, during various phases of travel-- i.e. pre-travel, during the pilgrimage and post-travel, in light of new emerging health threats.

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OBJECTIVE: To assess the job satisfaction of surgical healthcare professionals working during Hajj, and to determine the potential predictors of overall job satisfaction in Hajj and non-Hajj periods. METHODS: A multicenter cross-sectional study was conducted at King Abdullah Medical City, King Faisal Hospital and Al-Noor Specialist Hospital, Makkah, Saudi Arabia, from August 27 to September 5, 2018, which represented the period of 10 days following the Hajj season in that year. All surgeons who were employed during Hajj were interviewed regarding their job satisfaction in-Hajj versus non-Hajj periods using the Warr-Cook-Wall job satisfaction scale. A stepwise multiple linear regression was carried out to analyse predictors of overall job satisfaction in both Hajj and non Hajj periods separately. SPSS 16 was used for data analysis. RESULTS: Of the 146 participants, 28(19.18%) were consultants, 61(41.78%) specialists and 57(39.04%) were residents. Overall job satisfaction scores in Hajj period was 5.53 ±1.19 compared to 5.40±1.33 in non-Hajj period (p>0.05). During Hajj period, the participants were significantly more satisfied in terms of "amount of variety in work" (p<0.05), while they were significantly dissatisfied with regard to "physical work in g cond ition", "hours of work" an d "attention paid to suggestions" (p<0.05). CONCLUSIONS: The variety of cases encountered by surgeons during Hajj contributed significantly to job satisfaction. However, lack of attention to physicians' suggestions, extended hours of work and physical working condition during Hajj were potential factors causing less Job satisfaction during Hajj duty.

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The planned annual Hajj to the holy shrines in Makkah, Saudi Arabia, is recognized as one of the largest recurring religious mass gatherings globally, and the outbreak of infectious diseases is of major concern. We aim to study the incidence, etiology, risk factors, length of hospital stay, and mortality rate of pneumonia amongst pilgrims admitted to Al-Ansar general hospital, Madinah, Saudi Arabia during the Hajj period of December 2004-November 2013. A retrospective analysis of all patients diagnosed and admitted as pneumonia was done. Patients were assessed according to the CURB-65 scoring system and admitted to the ward or intensive care unit accordingly. Throat and nasopharyngeal swabs, sputum, and blood culture were collected prior to antibiotic treatment. 1059 patients were included in the study (23% of total hospital admissions and 20% of ICU admissions). The mean age of participants was 56.8 years, the Male:Female ratio was 3:1, and the lengths of stay in the ward and intensive care units were 5 and 14.5 days, respectively. The main organisms cultured from sputum were Klebsiella Pneumoniae, Streptococcus Pneumoniae, Haemophilus Influenzae, Staphylococcus Aureus, Pseudomonas aeruginosa, and community-acquired MRSA. The mortality rate in the ward was 2.4%, while the rate in the ICU was 21.45%. The organisms which caused pneumonia were found to be different during Hajj. The usual standard guideline for the treatment of pneumonia was ineffective for the causative organisms. Therefore, specific adjustments in the guidelines are needed. All efforts should be made to determine the infectious agent. Healthcare workers and pilgrims should adhere to preventive measures.

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The interest in mass gathering and its implications has been increasing due to globalization and international travel. The potential occurrence of infectious disease outbreaks during mass gathering is most feared. In this context, respiratory tract infections are of great concern due to crowding in a limited space which facilitates and magnifies the potential of disease spread among attendees. Pneumococcal disease is best described among pilgrims to Makkah and vaccination is one of the methods for the prevention of this disease. Pneumonia was described in a mass gathering with a prevalence of 4.8/100,000 pilgrims and contributes to 15-39% of hospitalizations. Various studies showed that 7-37% of pilgrims are 65 y of age or older. The uptake of pneumococcal vaccine among pilgrims is low at 5%. There is no available data to make strong recommendations for S. pneumoniae vaccination of all pilgrims, it is important that a high risk population receive the indicated vaccination. We reviewed the available literature on the burden of pneumococcal infections during mass gathering and evaluate the available literature on pneumococcal vaccinations for attendees of mass gathering.

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BACKGROUND: Coronaviruses (CoVs) are large ribonucleic acid (RNA) viruses causing primarily respiratory disease in humans. A novel human coronavirus, subsequently named middle east respiratory syndrome coronavirus (MERS-CoV), was first reported in Saudi Arabia in September of 2012. With increasing numbers of infections and deaths from MERS-CoV, development of a rapid and reliable kit was crucial to prevent further spread of MERS-CoV. OBJECTIVES: In this study, we present two real-time reverse-transcription polymerase chain reaction (rRT-PCR) assays for in-house rapid and sensitive diagnostic testing of MERS-CoV, detecting the regions upstream of the envelope gene (upE) and open reading frame (ORF) 1b, respectively, for initial screening and final confirmation of MERS-CoV infection, as recommended by the world health organization (WHO). MATERIALS AND METHODS: In this experimental study, acquiring patient samples was difficult; thus, according to WHO recommendations and standard protocols, we synthesized RNA sequences of upE and ORF1b genes as the template signatures and TaqMan based-diagnostic rRT-PCR assays were carried out using these synthetic genes for detection of MERS-CoV. In this research, we also inaugurated a cell-free system to transcribe these RNA sequences using the DNA templates synthesized. RESULTS: The upE and ORF1b based one-step rRT-PCR assays were optimized by testing several times via different synthetic RNAs, and validation results were highly successful. The sensitivity obtained for upE was fewer than ten copies of RNA template per reaction and for ORF1b was 50 or fewer copies per reaction. CONCLUSIONS: This study showed that the developed rRT-PCR assays are rapid, reliable, reproducible, specific, sensitive, and simple tools for detection of MERS-CoV. Finally, a kit consisting of two assay signatures and controls was assembled, which can be distributed to public health laboratories in Iran to support international MERS-CoV surveillance and public health response.

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BACKGROUND: Cost-effective interventions are needed to control the transmission of viral respiratory tract infections (RTIs) in mass gatherings. Facemasks are a promising preventive measure, however, previous studies on the efficacy of facemasks have been inconclusive. This study proposes a large-scale facemask trial during the Hajj pilgrimage in Saudi Arabia and presents this protocol to illustrate its feasibility and to promote both collaboration with other research groups and additional relevant studies. METHODS/DESIGN: A cluster-randomised controlled trial is being conducted to test the efficacy of standard facemasks in preventing symptomatic and proven viral RTIs among pilgrims during the Hajj season in Mina, Mecca, Saudi Arabia. The trial will compare the 'supervised use of facemasks' versus 'standard measures' among pilgrims over several Hajj seasons. Cluster-randomisation will be done by accommodation tents with a 1:1 ratio. For the intervention tents, free facemasks will be provided to be worn consistently for 7days. Data on flu-like symptoms and mask use will be recorded in diaries. Nasal samples will be collected from symptomatic recruits and tested for nucleic acid of respiratory viruses. Data obtained from questionnaires, diaries and laboratory tests will be analysed to examine whether mask use significantly reduces the frequency of laboratory-confirmed respiratory viral infection and syndromic RTI as primary outcomes. CONCLUSIONS: This trial will provide valuable evidence on the efficacy of standard facemask use in preventing viral respiratory tract infections at mass gatherings. This study is registered at the Australian New Zealand Clinical Trials Registry (ANZCTR), ACTRN: ACTRN12613001018707 (http://www.anzctr.org.au).

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OBJECTIVE: The Middle East respiratory syndrome coronavirus (MERS-CoV) emerged in 2012 on the Arabian Peninsula and has caused severe respiratory disease with more than 800 laboratory-confirmed cases. The return of infected pilgrims to their home countries with a putative spread of MERS-CoV necessitates further surveillance. METHODS: A cross sectional study of 839 adult African Hajj pilgrims returning to Accra in Ghana, West Africa, was conducted in 2013 to assess the prevalence of respiratory symptoms as well as of MERS-CoV, human rhinovirus (HRV), respiratory syncytial virus (RSV) and influenza A virus (FLU A) infection. RESULTS: Six hundred and fifty-one (77.6%) pilgrims had respiratory symptoms. Tests were positive for at least one of the viruses other than MERS-CoV in 179 (21.3%) of all pilgrims, with 22.4% detection in symptomatic vs. 17.6% detection in asymptomatic pilgrims. No MERS-CoV was detected, although common respiratory viruses were prevalent, with positive findings for HRV in 141 individuals (16.8%), RSV in 43 individuals (5.1%) and FLU A in 11 individuals (1.3%). Results were positive for more than one virus in 16 (1.9%) individuals, including 14 (1.7%) RSV/HRV co-infections and 2 (0.2%) FLU A/HRV co-infections. A total 146 (22.4%) of the symptomatic returnees tested positive for at least one respiratory virus compared with 33 (17.6%) of the asymptomatic pilgrims who had at least one detectable virus in their sample. CONCLUSIONS: The prevalence of viral respiratory infections among Hajj pilgrims in both symptomatic and asymptomatic subjects was high. Although it is reassuring that MERS-CoV was not detected in the tested population, there is a need for active surveillance of Hajj pilgrims.

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BACKGROUND: Annually, Saudi Arabia is the host of the Hajj mass gathering. We aimed to determine the Middle East respiratory syndrome coronavirus (MERS-CoV) nasal carriage rate among pilgrims performing the 2013 Hajj and to describe the compliance with the Saudi Ministry of Health vaccine recommendations. METHOD: Nasopharyngeal samples were collected from 5235 adult pilgrims from 22 countries and screened for MERS-CoV using reverse transcriptase-polymerase chain reaction. Information regarding the participants' age, gender, country of origin, medical conditions, and vaccination history were obtained. RESULTS: The mean age of the screened population was 51.8 years (range, 18-93 years) with a male/female ratio of 1.17:1. MERS-CoV was not detected in any of the samples tested (3210 pre-Hajj and 2025 post-Hajj screening). According to the vaccination documents, all participants had received meningococcal vaccination and the majority of those from at-risk countries were vaccinated against yellow fever and polio. Only 22% of the pilgrims (17.5% of those ≥65 years and 36.3% of diabetics) had flu vaccination, and 4.4% had pneumococcal vaccination. CONCLUSION: There was no evidence of MERS-CoV nasal carriage among Hajj pilgrims. While rates of compulsory vaccinations uptake were high, uptake of pneumococcal and flu seasonal vaccinations were low, including among the high-risk population.

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