Exploring barriers to and facilitators of preventive measures against infectious diseases among Australian Hajj pilgrims: cross-sectional studies before and after Hajj
Amani S. Alqahtani
a,b,*, Kerrie E. Wiley
a,b, Mohamed Tashani
a, Harold W. Willaby
b, Anita E. Heywood
c, Nasser F. BinDhim
d, Robert Booy
a,e,f, Harunor Rashid
a,e,faNationalCentreforImmunisationResearchandSurveillanceofVaccinePreventableDiseases(NCIRS),TheChildren’sHospitalatWestmead, CnrHawkesburyRoadandHainsworthStreet,Westmead,LockedBag4001,Westmead,NSW2145,Australia
bSchoolofPublicHealth,TheUniversityofSydney,Sydney,NewSouthWales,Australia
cSchoolofPublicHealthandCommunityMedicine,TheUniversityofNewSouthWales,Sydney,NewSouthWales,Australia
dHealthInformaticsDepartment,CollegeofHealthSciences,SaudiElectronicUniversity,Riyadh,SaudiArabia
eMarieBashirInstituteforInfectiousDiseasesandBiosecurity,SchoolofBiologicalSciencesandSydneyMedicalSchool,TheUniversityofSydney,Sydney, NewSouthWales,Australia
fWHOCollaboratingCentreforMassGatheringsandHighConsequence/HighVisibilityEvents,FlindersUniversity,Adelaide,Australia
1. Introduction
The transmission of infectious diseases is high at mass gatheringssuchastheannualHajjpilgrimageinMakkah,Saudi Arabia.1Hajjisthelargestannualmassgatheringontheplanet, with around two to three million people attending from over 180 countries. Intense congestion, shared accommodation, air
pollution, and compromised hygiene all contribute to the transmissionofinfectionsatHajj,mostnotablyacuterespiratory infections(ARIs).1,2
HajjpresentsapublichealthchallengeforSaudiArabia,asthe authoritiesneedtocaterforanincreasingnumberofpilgrimsand respondtoemerginginfectionssuchastheMiddleEastrespiratory syndromecoronavirus(MERS-CoV).3,4Itisalsochallengingforthe countries sending pilgrims, since these pilgrims can import epidemic diseases to their home countries upon return. In an efforttoreducetheriskofinfectiousdiseasesatHajj,anarrayof preventive measures have been recommended by the Saudi ARTICLE INFO
Articlehistory:
Received15December2015
Receivedinrevisedform29January2016 Accepted5February2016
CorrespondingEditor:EskildPetersen, Aarhus,Denmark
Keywords:
Facemask Hajj Handhygiene Massgathering Pre-travelhealthadvice
SUMMARY
Objective:For reasons that have yet to be elucidated,the uptake of preventive measures against infectiousdiseasesbyHajjpilgrimsisvariable.Theaimofthisstudywastoidentifythepreventive adviceandinterventionsreceivedbyAustralianpilgrimsbeforeHajj,andthebarrierstoandfacilitators oftheiruseduringHajj.
Methods:Twocross-sectionalsurveysofAustralianspilgrimsaged18yearswereundertaken,one beforeandoneaftertheHajj2014.
Results:Of356pilgrimswhocompletedthesurvey(responserate94%),80%hadtheinfluenzavaccine, 30%thepneumococcalvaccine,and30%thepertussisvaccine.ConcernaboutcontractingdiseaseatHajj wasthemostcitedreasonforvaccination(73.4%),andnotbeingawareofvaccineavailabilitywasthe mainreasonfornon-receipt(56%).Thosewhoobtainedpre-traveladviceweretwiceaslikelytobe vaccinatedasthosewhodidnotseekadvice.Of150pilgrimssurveyeduponreturn,94%reported practicinghandhygieneduringHajj,citingeaseofuse(67%)andbeliefinitseffectiveness(62.4%)asthe main reasons for compliance; university education was a significant predictor of hand hygiene adherence. Fifty-three percent used facemasks, withbreathing discomfort (76%) and a feeling of suffocation(40%)beingthemainobstaclestocompliance.
Conclusion:Thisstudyindicatesthattherearesignificantopportunitiestoimproveawarenessamong AustralianHajjpilgrimsabouttheimportanceofusingpreventivehealthmeasures.
ß2016TheAuthors.PublishedbyElsevierLtdonbehalfofInternationalSocietyforInfectiousDiseases.
ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by- nc-nd/4.0/).
* Correspondingauthor.Tel.:+61298451489.
E-mailaddress:amani.alqahtani@health.nsw.gov.au(A.S.Alqahtani).
ContentslistsavailableatScienceDirect
International Journal of Infectious Diseases
j o urn a l hom e pa ge : ww w. e l s e v i e r. c om/ l o ca t e / i j i d
http://dx.doi.org/10.1016/j.ijid.2016.02.005
1201-9712/ß2016TheAuthors.PublishedbyElsevierLtdonbehalfofInternationalSocietyforInfectiousDiseases.ThisisanopenaccessarticleundertheCCBY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/4.0/).
ArabianMinistryofHealth(MoH),whichincludevaccinationand hygienemeasures(Table1).5However,studieshavedemonstrated thatvaccineuptakeandcompliancewithhygieneandprotective measuresarehighlyvariableamongpilgrims,6,7andthereasons behindthisvariabilityremainunclear.
Todatefewstudieshaveassessedtheknowledge,attitudes,and beliefsinrelationtopreventivemeasuresamongHajjpilgrims.A recent qualitative study of Australian pilgrims found that considerablemisconceptionsaboutpreventivemeasuresandthe risk of respiratory infections prevail among Hajj pilgrims.8 A Frenchstudy demonstratedthatless thanhalfofpilgrims were awareofsocialdistancingandfacemaskuseasprecautionsagainst respiratoryinfections,9butnostudyhasexploredthebarriersto andfacilitatorsoftheuptakeofpreventivemeasures.Toaddress these questions, two cross-sectional surveys were conducted amongAustralianpilgrims,onebeforeandoneaftertheHajj2014, to identify what preventive advice and interventions pilgrims receivedbeforetravel,andwhatfactorsinfluencedtheircompli- ancewiththesemeasureswhiletheywerethere.
2. Materialsandmethods
2.1. Studydesign
Two cross-sectional self-administered questionnaires were distributed among Australian Hajj pilgrims aged 18 years in 2014.The first survey was conductedon a group of departing
pilgrimsapproximately1monthbeforeHajj(pre-Hajjstudy).The second survey was conducted on a second, separate group of pilgrims immediately after their return to Australia (post-Hajj study).
2.1.1. Pre-Hajjsurvey
The pre-Hajj survey collected data on socio-demographic characteristics,Hajjitinerarydetails,andthereceiptofpre-travel advice,includingvaccinations.Thequestionnairealsoassessedthe pilgrims’ knowledge of and attitudes towards preventive mea- sures, and their risk perception of diseases occurring at Hajj, includinginfluenza,pneumonia,andblood-bornediseases.
2.1.2. Post-Hajjsurvey
The post-Hajj questionnaire assessed the actual compliance withinfectioncontrol measures(suchas theuseof facemasks, hand disinfectants, and handkerchiefs) during Hajj, and the barrierstoandfacilitatorsoftheuseofthosepreventivemeasures whileatHajj.ThesurveyswereprimarilyinEnglish,withArabic translations available for those who preferred to complete the surveyinArabic.
2.2. Participantrecruitment
MuslimsresidingintheGreaterSydneyarea,NewSouthWales (NSW) werethe target population for thestudy. NSW hasthe largestMuslimpopulation(50%)ofanystateinAustraliawiththe Table1
HealthrecommendationsfortravellerstoSaudiArabiaforHajj20145
Healthhazard Vaccine Countriesrequired Otherpreventivemeasures
Air-bornediseases
Meningococcaldisease Quadrivalentmeningococcal vaccine(ACYW135)
Compulsoryforallpilgrims Notapplicable
Influenza Seasonalinfluenza Recommendedforall,in
particularat-riskpilgrims
Notapplicable MERS-CoVandotherrespiratory
infections
Notavailable Recommendedforall Peopleaged65years,thosewithchronicdiseases, pregnantwomen,andchildrenaged<12years recommendedtopostponeHajj2014 Handwashingwithwaterordisinfectant Coughetiquette
Avoidinghandcontactwitheyes,nose,andmouth Avoidingcontactwithillpersons
Facemaskuse
Maintenanceofgoodpersonalhygieneandfoodhygiene PeopleatriskofseverediseasesduetoMERS-CoV areaskedtoavoidclosecontactwithanimalswhen visitingfarms
Complyingwithhygienemeasureswhiledealing withanimals
Avoidingcontactwithsickanimals
Diphtheria Diphtheria Remaininguptodate Notapplicable
Pertussis Pertussis Remaininguptodate Notapplicable
Measles Measles Remaininguptodate Notapplicable
Mumps Mumps Remaininguptodate Notapplicable
Food-andwater-bornediseases
Poliomyelitis OPVorIPV Compulsoryforpilgrimsfrom
endemiccountries Otherpilgrimsshould remainuptodate
Notapplicable
Soil-bornediseases
Tetanus Tetanus Remaininguptodate Notapplicable
Vector-bornediseases
Yellowfever Yellowfever Compulsoryforpilgrims
fromendemiccountries andthosetransitingthrough endemiccountries
Notapplicable
Healtheducation
Healthauthoritiesincountriesoforiginarerequiredtoprovidehealthinformationtopilgrimsoninfectiousdiseasesymptoms,modesoftransmission,andmeasuresfor prevention
MERS-CoV,MiddleEastrespiratorysyndromecoronavirus;OPV,oralpoliovirusvaccine;IPV,inactivatedpoliovirusvaccine.
majoritylivinginGreaterSydney.10AustralianHajjpilgrimsaged 18yearsandoverwhowereplanningtoattendtheHajj2014were eligibleforrecruitment.
Potential participants were approached through Hajj tour operators.Thelist of accreditedHajj travelagents in Australia, including their location/address, was obtained from the Saudi ArabianEmbassyinCanberra,Australia.Theselectionofpartici- pantswasbasedonthenumberofHajjvisasallocatedforagiven travelagent:travelagentswiththehighestquotaofHajjvisaswere approachedfirst, and thetravel agents who dealt withdiverse ethnicgroups,includingArabs,Africans,Indians,andMalays,were prioritizedtoensureadiversesample.
Forthepre-Hajjsurvey,departingpilgrimswereapproachedat weeklypre-Hajj seminarsrunbytravel agents betweenAugust 1andmid-September2014.Allpilgrimsattendingtheseminars wereinvitedtotakepartinthestudy.
Forthepost-Hajjsurvey,asecondgroupofpilgrims(separateto thefirst)wereapproachedinpersonatcommunitygatheringsand eventswithinweeksofreturninghomefromHajj(betweenmid- OctoberandtheendofDecember2014).Thestudywaspromoted usinganumberofmethods,includingthedistributionofbrochures atmosquesandcommunitycentresandbywordofmouth.
2.3. Samplesize
Aconsecutivesamplingplanwasusedtoensureasamplethat wasrepresentativeofpilgrimsresidinginNSW.Assumingthatat least70%ofrespondentswillhaveageneralknowledgeofinfection controlmeasures, and consideringan errormarginof 5%to be acceptable for this anonymous survey, a sample of 323 was considered to be sufficient for this study; assuming a non- completionrateofthesurveyof15–20%,atotalof380participants weretargeted.Thesamplesizeofthisstudyrepresentsapproxi- mately 10% of Australian pilgrims to Hajj 2014 (which is approximately 3500). Previous works studying the uptake of vaccinations among Australian Hajj pilgrims showed that a conveniencesampleof10%ofthetargetpopulationissufficient.
2.4. Dataanalysis
ThedatacollectedwereenteredintoanExcelspreadsheet.The statisticalanalysiswasperformedusingIBMSPSSStatisticsversion 19.0(IBMCorp.,Armonk,NY,USA).Pearsoncorrelationcoefficients andChi-squaretestswereusedtoassessvariablesanddetermine associationsandcorrelations.Univariatefactorswithp-valuesof
<0.25wereenteredintomultivariableregressionanalyses.Two-
tailedp-valuesof0.05wereconsideredstatisticallysignificantin themultivariablemodels.
2.5. Ethicsapproval
ThisstudywasreviewedandapprovedbytheHumanResearch EthicsCommittee(HREC)atTheUniversityofSydney(ProjectNo.
2014/599).
3. Results
3.1. Pre-Hajjstudy 3.1.1. Demographics
Atotalof380respondentsagreedtoparticipateinthestudy,of whom 356 (94%) completed the survey questionnaires. Their demographicdetailsarepresentedinTable2.Eighty-twopercent ofpilgrims(291/356)wereattendingHajjforthefirsttime,andthe mediandurationoftheirstayinSaudiArabiawas27(range7–40) days.
3.1.2. Vaccineuptakeandassociatedfactors
Allrespondentsreportedreceivingmeningococcalvaccine;the majority (83%, 297/356) also received one or more other recommended vaccines (Table 3). Factors influencing vaccine uptakearelistedinTable3.Beingaged>40yearswassignificantly associatedwiththeuptakeofrecommendedvaccines(oddsratio Table2
Pre-andpost-Hajjsurveys:differencesinparticipantdemographiccharacteristics
Factors Pre-Hajjgroup
n(%)
Post-Hajjgroup n(%)
p-Valuea Age,years
Median(range) 39(18–79) 41(18–72) 0.50
Mean(SD) 40.6(13.2) 40.6(10.7)
Sex
Male 213(60) 71(47) 0.01*
Female 143(40) 79(53)
Countryofbirthb
Australia 102(32) 34(23) <0.01*
Lebanon 73(23) 22(15)
Indonesia 41(13) 50(35)
Pakistan 33(11) 8(5)
Bangladesh 24(7) 6(4)
Other 44(14) 27(18)
Notansweredc 39(11) 3(2)
YearsinAustralia
10years 48(22) 36(31) 0.08
>10years 167(78) 80(69)
Employed
Yes 230(65) 98(65) 0.87
No 126(35) 52(34)
Presenceofcomorbidities
Yes 76(22) 24(16) 0.16
No 280(78) 126(84)
Highesteducationlevelb
None 31(9) 5(3) <0.01*
Schoolcertificate 55(15) 12(3)
Highschoolcertificate 66(19) 24(16) Certificate/diploma 75(21) 32(21)
Universitydegree 89(25) 48(32)
Higheruniversitydegree 40(11) 29(19) NumberoftimesattendingHajj
Firsttime 291(82) 118(79) 0.42
>1time 65(18) 32(21)
a Asterisksindicateasignificantdifference.
b ByChi-squarefortrend.
c Excludedfromthetotalnumber.
Table3
Pre-Hajjstudy:uptakeofrecommendedvaccinesa Vaccinestatus(1vaccine)
Yes 297(84)
No 50(14)
Notsure 9(2)
Vaccinename
Seasonalinfluenzavaccine 283(80)
Pneumococcalvaccine 107(30)
Pertussis(whoopingcough)vaccine 107(30)
HepatitisAvaccine 59(17)
HepatitisBvaccine 61(17)
MMR(measles,mumpsandrubella)vaccine 36(10)
Typhoidvaccine 45(13)
Poliovaccine 28(8)
Reasonsforvaccinationb
Idon’twanttogetsick 218(73)
MyHajjtourgroupleaderrecommendedgettingthevaccine(s) 190(64) Mydoctoradvisedmetogetthevaccine(s) 158(53) Thevaccineiseffectiveinprotectingmeagainstdiseases 135(45) Reasonsfornotbeingvaccinatedb
Ididn’tknowaboutthem 28(56)
Idon’tthinkIwillgetadiseaseatHajj,I’munder‘Allah’sprotection16(32) Idon’tneedthembecauseIdon’thaveanychronicdisease 15(30)
Idon’tworryaboutgettingsick 13(26)
a Resultsarepresentedasthenumberandpercentage(%).
b Somepilgrimscitedmorethanonereason.
(OR)2.5, 95% confidenceinterval (CI)1.2–4.9, p=0.01),as was havingauniversityeducation(OR3.4,95%CI1.7–6.7,p=0.01).
3.1.3. Pre-traveladviceseekingandassociatedfactors
Approximately two thirds (236/356) obtained ‘professional travel health advice’ from one or more sources before Hajj, including57%(182/236)fromgeneralpractitioners(GPs),24%(55/
236)fromaspecialisttravelclinic,12%(27/236)fromaspecific Hajj website(e.g.,MoH website11), and 11% (25/236)from the
‘Smartraveller’website.12Ofthosewhoreceivedprofessionalpre- traveladvice,81%(191/236)reportedapositiveexperiencewith theadvice,whiletherestdescribedanegativeexperience.
Onethird(120/356)didnotseekany‘professionaltravelhealth advice’ before Hajj. Reasons for not seeking pre-travel advice includednotrecognizingtheneedtoseeksuchadvice(47%,56/
120),preferenceforothersources,i.e.,friends,familymembers, andtravelagents(32%,39/120),relianceonpreviousexperience/
knowledge(14%, 17/120), and previous negativeexperience of seekingpre-traveladvice(7%,8/120).Beingwithintheagebandof 34 to 49 years was the only factor associated with receiving professionalpre-traveladvice(OR2.5,95%CI1.5–4,p=0.01).
Additionalpre-travelhealthadvicesourceswerealsoreported, includingHajjtravelleaders(66%,235/356),familymembersand friendswhohadpreviousexperienceofperformingHajj(45%,161/
356),and‘generalwebsites’ontheInternet(17%,59/356).Forty- six percent (164/356) were aware of the annual Hajj health recommendationsissuedbytheSaudiMoH.
Additionally,pilgrimswhosoughtpre-traveladvicefromGPs (OR1.9,95%CI1–3.5,p=0.03)ortourgroupleaders(OR2.1,95%CI 1.1–3.8,p=0.01)beforetravellingtoHajjweretwiceaslikelytobe vaccinatedasthosewhodidnot.
3.1.4. Riskperceptionofdiseases
Pilgrimswerereportedlyconcernedaboutfoodpoisoning(61%, 217/356), diarrhoea (59%, 210/356), influenza (58%, 206/356), blood-bornediseases(49%,173/356),skindiseases(45%,160/356), andpneumonia(33%,117/356).However,therewasnoassociation between thelevel of concern aboutinfluenza, pneumonia, and blood-bornediseases andtheuptake oftheinfluenza,pneumo- coccal,andhepatitisBvaccines,respectively(allp-values>0.2).
3.2. Post-Hajjstudy 3.2.1. Demographics
A total of 150 returned pilgrims were surveyed. Their demographic characteristics are presented in Table 2. A large proportionofpilgrims(79%,118/150)hadperformedHajjforthe firsttime.Theyhadstayedforamediandurationof25(range 7–35)days.
3.2.2. Participants’perceptionsoftheeffectivenessofpreventive measures
The majority of participants, 71% (107/150), believed hand washing(withwater only)tobethemosteffectivemeasure to protect oneself from respiratory infections, while the uses of alcoholichandrubs(37%,56/150)and facemasks(35%,52/150) were considered to be less effective. Only beliefs about the effectivenessoffacemasksandhandwashingwithwaterandsoap were significantly associated with their actual use (p<0.01) (Table4).
3.2.3. Compliancewithpreventivemeasuresandassociatedfactors Halfofthepilgrims(53%,80/150)usedfacemaskstoprotect themselves from infectious diseases during Hajj at least three times a day. Participants described three major reasons for facemask use: protection fromdisease (76%,61/80), protection
from air pollution (58%, 46/80), and belief that facemasks are effectiveinpreventingARIs(41%,33/80).Lessthanhalf(47%,70/
150)didnotuseafacemask.Thereasonsfornon-compliancewere breathingdiscomfort(76%,53/70),feelingofsuffocation(40%,28/
70),andthinkingitwasnotnecessary(31%,22/70).Inaddition, none of the demographic characteristics were associated with facemaskcompliance(allp-values>0.25)andthereforethesewere notenteredintomultivariableregressionanalyses.
Asubgroupofwomen(n=76)answeredquestionsontheiruse oftheniqab(traditionalfaceveil);ofthosewhoresponded,49%
(37/76)usedonlyfacemasks,34%(26/76)usedonlytheniqab,and 20%(15/76)usedbothafacemaskandtheniqab.Ofthosewhoused theniqab(eitheraloneorwithafacemask),51%(21/41)reported thattheydidsobecauseitis‘airy’andeasiertobreatheand39%
(16/41)feltthatitwascomfortabletouse.
3.2.4. Handhygiene
Almostall(94%,141/150)practisedsomekindofhandhygiene duringHajj.Thisincludedhandwashingwithsoap(73%,110/150), handwashingwithwateronly(55%,82/150),andalcoholichand disinfectant (31%, 46/150). Reasons influencing the pilgrims’
decisiontousethesemethodsincludedbeliefintheeffectiveness ofhandhygieneinpreventinginfectious diseases(67%,94/141) and convenience and ease of use(62.4%, 88/141).Additionally, thosewitha universityeducationweremorelikelytousehand hygienemeasuresthanthose without(OR7.9,95% CI1.4–42.9, p=0.01).
3.2.5. Othermeasures
Respondentsreportedusingotherpreventivemeasuresinclud- ing disposable handkerchiefs (53%, 79/150), avoiding dense crowding (29%, 43/150), avoiding contact with symptomatic people(39%,58/150),andpracticinghandwashingaftertouching theill(30%,45/150).
4. Discussion
This appears to be the first in-depth quantitative study comparingthehealthknowledgeattitudes,beliefs,andpractices of departing and returning Hajj pilgrims regarding preventive measures against infectious diseases. This study found that Table4
Post-Hajjstudy:associationbetweenparticipants’beliefsabouttheeffectivenessof preventivemeasuresandcompliancewithpreventivemeasures
Pilgrims’perceptionof effectiveness
Compliance n(%)
Non-compliance n(%)
p-Valuea
Facemask
Veryeffective 39(75) 14(27) <0.01*
Alittletosomewhateffective 37(48) 40(52) Noteffectiveatall 4(19) 16(76) Handwashingwithwateronly
Veryeffective 64(60) 43(40) 0.02*
Alittletosomewhateffective 18(46) 21(54)
Noteffectiveatall 0 4(100)
Useofsoap-basedhanddisinfectant
Veryeffective 70(80) 17(20) 0.02*
Alittletosomewhateffective 37(70) 16(30) Noteffectiveatall 3(30) 7(70) Alcoholichanddisinfectant
Veryeffective 23(41) 33(59) 0.06
Alittletosomewhateffective 17(28) 44(72) Noteffectiveatall 6(18) 27(82) Avoidingcontactwithillpeople
Veryeffective 19(26) 54(74) 0.18
Alittletosomewhateffective 16(24) 51(76)
Noteffectiveatall 0 10(100)
a ByChi-squarefortrend;asterisksindicateasignificantdifference.
receivingpre-traveladvicefromGPsandtourgroupleaderswas themainfacilitatorofcompliancewithpreventivemeasures.Not recognizingtheneedtoreceivepre-traveladvicewasidentifiedas an important barrier. This survey found the influenza vaccine coveragerateamongAustralianHajjpilgrimsin2014tobehigh (80%).Thisisconsistentwithfiguresreportedsince2012,13,14and muchhighercomparedtorecentdatafromsomeothercountries suchasTurkeywherethevaccinationratewasonly7.1%duringthe Hajj2015,14andFrancewherethevaccinationratefor2014was zeroduetovaccinenon-availability,15andcompareswellwiththe overallvaccinationratesamonginternationalpilgrimsoverrecent decades,whichrangebetween0.7%and100%.6,16
Influenza vaccine aside, the uptake of other recommended vaccines was low. For instance, the uptake of pneumococcal vaccine was only 30%. Previous Australian and international surveyshavereportedcoverageratesrangingfrom2.5%to36%.6,17 This is concerning because pneumonia is the leading cause of hospitaladmissionandanimportantcauseofmortalityatHajj.18–20 Furthermore,surveys haveshown thatmany pilgrimswere not aware that pneumonia is transmissible21 and preventable by vaccination.22ThereiscurrentlynoformalguidancefromtheSaudi MoHontheuseofpneumococcalvaccineforHajjpilgrims,which maypartlyexplainthisapparentlackofawareness(Table1).23
Theuptakeofpertussisvaccinewas30%,comparedwith10.6%
amongFrenchHajjpilgrimsin2005.24Additionally,thecoverage forhepatitisAandBvaccineswereeach17%,whichishigherthan the11.5%uptakeforhepatitisAreportedamongFrenchpilgrimsin 2005,24andthe6%eachforhepatitisAandBamongSaudipilgrims in 2010.25 While a large proportion of Hajj pilgrims are from countries with intermediate to high hepatitis B virus (HBV) prevalence, the risk of contracting HBV at Hajj is not well studied.26,27Itisknownthatasignificantproportionofpilgrims engage in high-risk behaviours;for example it was foundthat about 43% of male pilgrims shaved their heads with reused razors,28 or had their heads shaved by non-professional (unli- censed) barbers.25 Other studies have also reported high-risk behavioursthatincreasetheriskofhepatitisA,includingbuying andeatingfoodfromstreetvendors.29Despitethis,hepatitisAand BvaccinesarenotlistedintheSaudiMoHrecommendationsfor Hajjpilgrims(Table1).23
In this study, polio vaccine uptake was 8%, which is low comparedwiththeuptakeamongFrenchpilgrimsin2006(15%),30 andtheuptakeamongpilgrimsfromothernon-endemiccountries in2013(43%).31Typhoidvaccinecoveragewas13%inthisstudy, which compares well with the uptake rate of 9% among internationalpilgrims in 2002.32 The present study appears to reportMMR(measles,mumps,andrubella)vaccineuptake(10%) forthefirsttime.
The participants cited several reasons for not receiving the recommendedvaccines,themostcommonbeingthattheywere unawarethatthevaccineswererecommended.Theseresultsare consistentwiththefindingsofMemishetal.,whoreportedalack of knowledge tobe a significantfactor for poor uptake of the seasonalinfluenzavaccineamongpilgrims.33Conversely,previous Australianstudieshavereportedrelianceonnaturalimmunityas themainreasonfornotbeingvaccinatedagainstinfluenzain2011, whilelowriskperceptionofcontractinginfluenzawasthemain reasonin2012.13
Auniquefindingofthisstudyisthatpilgrimswhoreceivedpre- traveladvicefromGPsandHajjtourgroupleadersweretwiceas likelytobevaccinatedasthosewhodidnotreceivesuchadvice.
Barasheed et al. found that receiving advice from Hajj group leaderswasthemainmotivatorfortheuptakeofinfluenzavaccine amongAustralianHajjpilgrimsin2012.13
Thissurveyalsorevealedthatolderpilgrims(aged>40years) weremorelikelytotakeuptherecommendedvaccines.Similarly,
Gautret et al. demonstrated that influenza vaccine coverage increased with age in French pilgrims.24 This could be due to thefactthatolderpeoplearemoreawareoftheirhealth,oritcould beduetoanincreasingnumberofpre-existingillnessesaspeople age. Another study among French pilgrims found that ‘at risk’
pilgrims weresignificantlymore likelytobeadvisedtoreceive pneumococcal vaccinethanthosewhowerenot‘atrisk’.22This mayexplainwhyvaccineuptakehasbeenfoundtoincreasewith ageinsomestudies.24,34
Althoughrespiratoryinfectionsarethemostcommondiseases duringHajj,1theparticipantsinthisstudyweremoreconcerned about food-borne illness than ARIs. Limited knowledge and perceptionofdiseases amongpilgrims hasbeenfoundinother studies; an Australian study found that 42% of pilgrims in 2014 were not aware that pneumonia can be transmissible.21 Similarly,Frenchpilgrimsin2014didnotperceivepneumoniaasa severecondition,andwerenotawareoftheexistenceofavaccine againstit.22
Noassociationwasfoundbetweenthediseaseriskperception forinfluenza,pneumonia,andhepatitisBand theuptakeofthe respective vaccines. Thiscontradicts otherdata, which demon- stratedthatanincreasedriskperceptionofpandemicinfluenzaA (H1N1)wassignificantlyassociatedwithinfluenzavaccineuptake amongUSpilgrimsin2009.35
Almostalloftheparticipantsinthepresentstudyusedsome kind of hand hygiene; this was higher compared with French pilgrims in 2013 (50%).36 More than half of thepilgrims used facemasks in this study, similar to French pilgrims in 2013.36 Nevertheless,previousstudieshavereportedthatonlyhalfofthe participantswereawareoftheavailabilityofnon-pharmaceutical preventivemeasuresagainstrespiratoryinfections.9,33
Belief that hand hygiene is easy to use and effective in preventinginfectionswerethemainreasonsforuptakeamongthe presentsample.Conversely,facemaskswerelessaccepted.Among non-users,discomfortanddifficultyinbreathingwerebarriersto their use. Those who used facemasks believed that they were effective in preventing infectious diseases. Similar quantitative findings have been reported among members of the general Singaporean community,37 but not previously among Hajj pilgrims. Anotherimportantfactor identifiedasa driverforthe useoffacemaskswasprotectionfromairpollution.Arecentstudy found that the air pollution level in Makkah during the Hajj consistently exceedsinternationallyacceptablestandards,38and thereforethis perceptionisprobablyjustified andcouldinform healthpromotionpolicy.
Thirty-fourpercentoffemalepilgrims inthepresentsample preferred to usea traditional face cover (niqab) toa facemask duringHajj.Incontrast,otherstudiesfoundthathigherpropor- tions (over 70%) of Saudi women preferred the niqab over facemasksatHajj2002and2003.39,40Intheexplorationofwhy somewomenpreferusingtheniqab,itwasfoundthatcomfortand breathabilitywerecontributingfactors.
Inthis study,twothirdsofpilgrimssoughtpre-traveladvice fromhealthprofessionals;thisissimilartotheresultsofasurvey thatfoundthat65%ofArabpilgrimsreceivedhealthadvicebefore departingtoHajj.41GPswerethemostcitedsources,followedby specialist travelclinics.Thisresultissupported bya studythat foundGPstobethemosttrustedsourcesofhealthadviceamong Australianpilgrimsin2014.21Interestingly,only12%ofthepresent samplesoughtadvicefromtheSaudiMoHwebsite.Thisisdifferent tothefindingsofastudythatshowedtheSaudiMoHtobethe main source of health information among pilgrims from Arab countries(69%).41Thisdifferencemaybeduetolanguagebarriers.
Notrecognizingtheneedtoseekpre-travelhealthadviceand thepreferenceforotherinformationsources(i.e.,friends,family members,and travelagents)werethemain barrierstoseeking
professionalpre-traveladvice.Theseresultssupportthefindingsof arecentAustralianstudy,whichalsodemonstratedahighlevelof confidenceinadvicefromnon-healthprofessionalsourcessuchas family,friends,and travel agents.8 Thepresent studyidentified that beingaged between 34 and 49 years wasthe only factor significantly associated with seeking pre-travel health advice.
Therefore, enhancing awareness among other groups of Hajj pilgrims, especially elderly adults and those with pre-existing illnesses,abouttheimportanceofseekingprofessionalpre-travel advicecouldbeanimportantstrategy toimprovetheuptakeof preventive measures. Moreover, providing GPs with culturally appropriate health information on Hajj and the preventive measuresrecommendedby theSaudiMoHcouldalsofacilitate uptake.42
This studyhassomelimitations.Twodifferentgroupswere surveyed and the groups showed significant differences in demographiccharacteristics,particularlyinsex,educationlevel, andcountryofbirth.Also,thesamplesizeofthepost-Hajjgroup wassmallerthanintended.Thesecouldlimitthegeneralizability ofthefindingsofonegrouptotheother.Theselimitationsare being addressed by a second, larger cohort study among Australian pilgrims during Hajj2015, and a qualitative study amongGPsandtourgroupleadersis underway.Despitethese limitationsthisstudyhasuniquelyidentifiedthebarrierstoand facilitatorsoftheuptakeofpreventivemeasuresamongAustra- lianHajjpilgrims, providing important preliminarydata upon whichtobuild.
This study shows that there are significantopportunities to improveawarenessamongHajjpilgrimsabouttheimportanceof usingpreventivehealthmeasuresandindicatestheneedforbetter communicationofofficialhealthinformationfromtheSaudiMoH toabroaderinternationalaudience.
Conflictofinterest:ProfessorRobertBooyhasreceivedfunding fromBaxter,CSL,GSK,Merck,Novartis,Pfizer,Roche,Romark,and Sanofi Pasteurfor theconduct of sponsoredresearch, travel to presentatconferences,orconsultancywork;allfundingreceivedis directed to research accounts at The Children’s Hospital at Westmead.DrAnitaE.Heywoodhasreceivedgrant fundingfor investigator driven research from GSK and Sanofi Pasteur. Dr Harunor Rashid received fees from Pfizer and Novartis for consulting or servingon an advisory board. The otherauthors havenocompetingintereststodeclare.
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