Contents La Revue de Santé de la Méditerranée orientale Eastern Mediterranean Health Journal Vol. 19 Supplement 2 ½:nüÐØ{_UÐPL HnUÐ{dCÐr r Preface ...........................................................................................................................................................................................................................................................................................................................................................................Si Editorials Hajj and the public health significance of mass gatherings Ziad A. Memish ...........................................................................................................................................................................................................................................................................................................................................S5 Health preparedness and legacy planning at mass gatherings in the EMR: a WHO perspective Nicolas Isla and Isabelle Nuttall .......................................................................................................................................................................................................................................................................................................S7 Research articles 6TJOHIFBMUIFEVDBUPSTUPJNQSPWFLOPXMFEHFPGIFBMUIZCFIBWJPVSBNPOH)BKK QJMHSJNT A. Turkestani, M. Balahmar, A. Ibrahem, E. Moqbel and Z.A. Memish................................................................................................................................................................................................................S9 1BĨFSOPGNPSCJEJUZBOENPSUBMJUZJO,BSCBMBIPTQJUBMTEVSJOH"TIVSBNBTTHBUIFSJOHBU,BSCBMB *SBR F. Al-Lami, A. Al-Fatlawi, P. Bloland, A. Nawwar, A. Jetheer, H. Hantoosh, F. Radhi, B. Mohan, M. Abbas, A. Kamil, I. Khayatt and H. Baqir ..............................................S13 Preparedness and health risks associated with Moulay Abdellah Amghar moussem .PSPDDP m M. Youbi, N. Dghoughi, M. Akrim, A. Essolbi, A. Barkia, A.I. Azami, A.T. Fleischauer, D. Schneider and A. Maaroufi ........................................................................................................S19 Public health surveillance at a mass gathering: ursPG#BCB'BSJE 1BLQBĨBOEJTUSJDU 1VOKBC 1BLJTUBO %FDFNCFS S. Hassan, R . Imtiaz, N. Ikram, M.A. Baig , R . Safdar, M. Salman and R .J. Asghar ..................................................................................................................................................................................S24 .BTTHBUIFSJOHJO"RBCB +PSEBO EVSJOH&JE"M"EIB S. Abdullah, G. Sharkas N. Sabri, I. Iblan, M. Abdallat, S. Jriesat, B. Hijawi, R . Khanfar and M. Al-Nsour .................................................................................................................................S29 Patterns of diseases and preventive measures among domestic hajjis from Central, Saudi Arabia [complete republication] Fahad S. Al-Jasser, Ibrahim A. Kabbash, Mohammad A. AlMazroa, Ziad A. Memish .............................................................................................................................................................................S34 Review 1VCMJDIFBMUIDPOTJEFSBUJPOTGPSNBTTHBUIFSJOHTJOUIF.JEEMF&BTUBOE/PSUI"GSJDB .&/" SFHJPO M. AlNsour and A. Fleischauer .......................................................................................................................................................................................................................................................................................................S42 Supplement on Mass Gatherings
HCÐçPUph[UÐpdCÐPL HnUÐ{dCÐ 2:nüÐØ{_UÐ S5 Editorial Hajj and the public health significance of mass gatherings Ziad A. Memish 1 1Deputy Minister of Health for Public Health, Director of the World Health Organization Collaborating Centre for Mass Gathering Medicine & Professor, College of Medicine, Al Faisal University, Riyadh, Kingdom of Saudi Arabia (Correspondence to: zmemish@yahoo.com). Mass gatherings (MG) refer to groups of people measured in the thousands, some definitions suggest 25 000 and above [1,2]. MG present unique health challenges distinct from the average population cohort of the same size. Within the context of an exploding global population, widely accessible air travel and unprecedented frequency of MG, health issues relating to MG medicine are more commonly encoun- tered. Safeguarding individual and mass health at such gatherings is termed public health security [3]. MG-related infection is an emerg- ing subspecialty in global epidemiol- ogy and while an extensive body of information and experiences now exists, not all are published and acces- sible to MG planners and public health administrators,and vital information awaits dissemination [4]. Infectious dis- eases have long played a substantial part in shaping human history and continue to be an issue of pressing concern. In this era of the “flat world”, globaliza- tion facilitates the spread of numerous infectious agents to all corners of the planet. No locale is too remote for a threatening pathogen, be West Nile Virus arriving in the United States or Rift Valley Fever reaching the Arabian Peninsula [5]. Public health risks focus on infec- tious agents both specific to humans (which are broadly and uniformly distributed) and zoonoses (infectious agents transmitted from animals to humans) which tend to be far more localized in their geographical distribu- tion. Research has shown that emerging infectious diseases have roughly quad- rupled over the past 50 years, and pathogens that originate in wild animals (wildlife zoonoses) account for the ma- jority of such diseases. Further, the fre- quency of infectious disease emergence correlates highly with human popula- tion density, the density of mammalian species and human population growth. Some data exist indicating that emerg- ing diseases (specifically zoonoses) are more likely to be seen in tandem with progressive global warming [6]. The role played by travel, migra- tion, trade and human exchanges in the propagation of epidemic infectious dis- ease is well known. Almost one billion people cross international borders each year. In 2008, there were 924 million international arrivals, 16 million more than 2007 [7]. Travel-related infection is reaching previously uncharted di- mensions of scale and complexity and it is the Hajj experience that provides invaluable insights in predicting travel- related health challenges. Hajj is the largest and most long- standing annual MG event on earth. It is the site of some of the greatest crowd densities known to man. Following an exponential rise in the past decade, Hajj is now the most internationally, ethni- cally, demographically and clinically diverse assembly today. The numbers of non-Saudi pilgrims attending the Hajj routinely exceed 2 million people, travelling to Makkah from over 180 countries, pushing the Hajj congrega- tion towards the 3 million mark. The sheer dimensions of Hajj demand extraordinary imagination and agility from planners. Because of the wide global attend- ance, international partnerships and collaborations in this process are in- creasingly necessary, as countries send- ing pilgrims ensure their fitness for travel and, later, continue to monitor the impact of the returning pilgrims to their countries of origin. The scale and diversity of Hajj presents an enormous public health security challenge to Saudi Arabian authorities who, as functionar- ies to the Custodians of the two holy sites (Makkah Al Mukarramah and Medina Al Munnawarah) must provide extensive, multi-faceted programmes to serve the “Guests of God” [8]. Because of this remarkable scale, and its annual occurrence, preparations for the public health safety and security of this event are extraordinarily challeng- ing, requiring an intensely collaborative approach. Multiple domestic agencies must work together to prepare for Hajj within a matter of months. While most MG of this scale have the greater part of a decade to prepare, Saudi Arabia read- ies itself for the massive influx within a mere 11-month lead time demanding precision in organization and the surge deployment of massive semi-perma- nent infrastructures and manpower. Such efforts are accomplished through intense inter-Ministry col- laboration. Saudi authorities, including EMHJ r 7PM 4VQQMFNFOU &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF S6 References the Ministry of Health (MOH), the Ministry of Hajj, the Ministry of Inte- rior (MOI), the Saudi Red Crescent and other government health sectors, including the Saudi Arabian National Guard Health Affairs, the Ministry of Defence and Aviation (MODA) and the Security forces, come together with a common focus of public health security. Collectively these agencies have accumulated decades of experi- ence managing Hajj from every aspect, whether it be management and repa- triation of the sick at Hajj, anticipating crowd turbulence or handling the ar- rival of over a million and a half head of cattle for ritual sacrifice. With over 1.3 billion Muslims globally, many more seek to make Hajj than can be safely accommodated. In a delicate choreography of diplomacy and service, Saudi Arabia must balance the dual roles of both Custodian to the Holy Sites and Guardians to the Guests of God. Representatives of the Saudi authorities must safeguard Hajj for mil- lions annually while at the same time carefully controlling its access to main- tain public health safety and security. Note must be made of the im- portant work facilitated by the Saudi immigration authorities which safe- guards public health, possibly one of the largest public health interventions today. Saudi Arabia provides visas to every eligible pilgrim, setting an an- nual quota of 1000 visas per million populations for every country. Access to all holy sites is strictly limited to visa and permit holders. The visa applica- tion process facilitates enforcement of basic public health requirements by specifying visa eligibility based on evidence of mandatory immunization (including against polio and yellow fe- ver for pilgrims arriving from countries with active disease and meningococcal disease for all pilgrims, all important causes of disease at Hajj). Immigration thus becomes a tool facilitating public health security for such a massive gath- ering [9]. Given the complex, multi-factorial elements that comprise the prepara- tion for Hajj, Hajj medicine clearly falls within the realm of public health secu- rity and must be recognized as such. Further, because of the Kingdom’s ability to effectively surge public health resources at short notice, it is in a po- sition to make a unique contribution to other gatherings facing bioterror- ism or disaster preparedness demands through exchange of information and experiences. Surge capacity is integral to public health security in which the Kingdom has exceptional experience. It is for those reasons that Saudi Arabia was recognized and acknowledged to be a World Health Organization Col- laborating Centre for MG Medicine in September 2012 tasked with training, research and providing guidance and advice to MG administrators across the globe. 1. Arbon P, Bridgewater FHG, Smith C. Mass gathering med- icine: a predictive model for patient presentation and transport rates. Prehospital and Disaster Medicine, 2001, 16:150–158. 2. Mitchell JA, Barbera MD. Mass gathering medical care: a twenty-five year review. Prehospital and Disaster Medicine, 1997, 12:72–79. 3. Ahmed QA, Barbeschi M, Memish ZA. The quest for public health security at Hajj: the WHO guidelines on communica- ble disease alert and response during mass gatherings. Travel Medicine and Infectious Disease, 2009, 7:226–230. 4. Memish ZA et al.Emergence of medicine for mass gather- ings: lessons from the Hajj. Lancet Infectious Diseases, 2012, 12:56–65. 5. Balkhy HH, Memish ZA. Rift Valley fever: an uninvited zoono- sis in the Arabian peninsula [Review]. International Journal of Antimicrobial Agents, 2003, 21:153–157. 6. Blancou J et al. Emerging or re-emerging bacterial zoonoses: factors of emergence, surveillance and control. Veterinary Re- search, 2005, 36(3):507–522. 7. United Nations World Tourism Organization. UNWTO world tourism barometer (2009) (http://unwtp.orh/facts/eng/pdf/ barometer/UNWTP_barom09_1_en_excrept.pdf, accessed 1 October 2013). 8. Ahmed QA, Memish ZA. Hajj medicine for the Guests of God: a public health frontier revisited. Journal of Infection and Public Health, 2008, 1:57–61. 9. Memish ZA, Al-Rabeeah AA. Health conditions of travellers to Saudi Arabia for the pilgrimage to Mecca (Hajj and Umra) for 1434 (2013). Journal of Epidemiology and Global Health, 2013, 3:59–61. HCÐçPUph[UÐpdCÐPL HnUÐ{dCÐ 2:nüÐØ{_UÐ S7 Editorial Health preparedness and legacy planning at mass gatherings in the EMR: a WHO perspective Nicolas Isla 1 and Isabelle Nuttall 2 1Technical Officer, Global Alert and Response Operations, Global Capacities, Alert and Response, World Health Organization, Geneva, Switzerland. 2Director, Global Capacities, Alert and Response, World Health Organization, Geneva, Switzerland. As more countries commit to hosting large, international mass gatherings, health preparedness planning is requir- ing more research and collaborative efforts. A growing body of researchers and policy-makers view mass gatherings as important opportunities for positive legacy for the community and visitors. This special edition of the Eastern Medi- terranean Health Journal is a good exam- ple of a respected scientific publication offering its pages to researchers to share their experiences studying small, medi- um and large events; religious, sporting and cultural events; one-off events and events that recur in the same location year after year. This work, and the work of others, will help future hosts to assess options, to adapt and build existing sys- tems and to evaluate their effectiveness through the acquired experience and mounting evidence generated by past organizers. The Eastern Mediterranean Region (EMR) is host to some of the world’s largest mass gatherings. Each year the Kingdom of Saudi Arabia welcomes upwards of 3 million pilgrims from around the world; the Formula 1 motor racing championship is being held in two EMR countries in 2013 and Qatar is set to host the FIFA World Cup in 2022. There are a large number of other mass gatherings in the Region of all sizes and purposes, each with their own specific risks. The World Health Organization (WHO) continues to build an inter- disciplinary mass gathering programme that offers guidance, tools and expertise that public health authorities can use before planning an event. This man- date was provided by a decision at the 130th Executive Board Meeting in January 2012 advising the Secretariat to, among other activities, “multisectoral guidance on planning, management, evaluation and monitoring of all types of mass gathering events with specific emphasis on sustainable preventive measures including health education and preparedness”. In response, WHO has developed a three-point strategy for supporting countries with mass gather- ing health planning: r Capacity development and support for Member States and host organi- zations – protecting public health at mass gatherings r Establishment of governance, re- sources, tools and methodologies r Shaping the discipline: leadership and communication. WHO has worked with organizers of some of the largest events including the London Olympics and the 2012 UEFA European Football Champion- ship in Poland and Ukraine, Hajj and the World Youth Day. In addition, over the past year, a network of Col- laborating Centres on mass gatherings has been established to act as regional hubs for best practice in mass gathering health preparedness planning. These Collaborating Centres are working with WHO Regional and Country Offices to promote public health planning and positive legacy development as a key area of investment for mass gathering organizers. The Ministry of Health of Saudi Arabia, Public Health England in the United Kingdom, the Institute of Public Health of Vojvodina in Serbia and the Disaster Research Centre and Flinders University in Australia are cur- rently Collaborating Centres. WHO is also working closely with international sporting federations, such as the International Olympic Commit- tee, to encourage knowledge transfer between successive hosts and to make health preparedness a central pillar of any event. Health planning, however, is only one component of the complex cho- reography of preparedness that needs to be undertaken. WHO's efforts to support health authorities in mass gathering health planning is in line with the all-hazard and whole-of-society approaches driving public health risk management under the International Health Regulations(2005). Mass gath- erings, which are most often bound by immutable time frames, known years in advance, are test-beds for achieving bet- ter integration between sectors that can be applied in other public health con- texts and emergencies. Furthermore, WHO has developed a framework for legacy research based on four areas of health system improvement: r improved medical and hospital ser- vices r strengthened public health system r an enhanced living environment r increased health awareness. WHO has worked with a number of countries in the EMR including with the EMHJ r 7PM 4VQQMFNFOU &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF S8 Ministry of Health of Iraq with which a workshop on mass gathering health preparedness was held in Amman in October 2012. An international team of experts from WHO and a repre- sentative from Public Health England worked with responsible health au- thorities from the Ministry of Health and District Health authorities from Karbala to improve health prepared- ness in the areas of on surveillance, pre- hospital casualty management, food and water safety, risk communication, coordination, preparedness and social mobilization. Likewise, WHO is cur- rently working closely with Ministry of Health of the Kingdom of Saudi Arabia to manage risks associated with the emergence of the Middle East Res- piratory Syndrome Coronavirus in the context of Hajj. From the articles in this special edi- tion on mass gathering, the reader will understand the complexity involved in planning a mass gathering. This col- lection of papers will provide a sense of the research being undertaken in the EMR to better understand the risks associated with mass gatherings and potential solutions to prevent and mitigate these risks during the event and achieve a long-term benefit from the experience. WHO will continue to work closely with any Member State on mass gathering health preparedness and planning. Information sources 1. Resolutions and Decisions, Annexes. Executive Board, 130th Session, Geneva, 16–23 January 2012 (http://apps.who.int/gb/ ebwha/pdf_files/EB130-REC1/B130_REC1-en.pdf#page=17, accessed 7 October 2013). 2. Global Alert and Response (GAR).Communicable disease alert and response for mass gatherings [webpage](http://www. who.int/csr/mass_gatherings/en/, accessed 7 October 2013). 3. Global Alert and Response (GAR).Communicable disease alert and response for mass gatherings. Key considerations [web- page] (http://www.who.int/csr/mass_gathering/en/index. html, ,accessed 7 October 2013) 4. International Health Regulations [webpage] (http://www. who.int/topics/international_health_regulations/en/, ac- cessed 7 October 2013). HCÐçPUph[UÐpdCÐPL HnUÐ{dCÐ 2:nüÐØ{_UÐ S9 ABSTRACT The main objective of this study was to assess the short-term effect on health knowledge among pilgrims after being provided specific health education messages.A random sample of 6 entry-point buses was selected. A self-administered questionnaire was used to assess knowledge before and after intervention; 278 pilgrims completed the questionnaire.There was a significant increase in the proportion of participants who answered all questions correctly after the educational intervention (P<0.05). Almost all respondents stated that they benefited from the health education and that the health educator was successful in delivering the messages. Only 19 (7.2%) reported that they had already received relevant health education messages prior to their arrival in Saudi Arabia. Before the intervention just 50% of the respondents knew that safe shaving prevents dissemination of bloodborne diseases; this rose to 84.7% after the intervention. Direct health education to pilgrims is effective in improving short-term health knowledge. Using health educators to improve knowledge of healthy behaviour among Hajj 1432 (2011) pilgrims A. Turkestani,1 M. Balahmar,2 A. Ibrahem,2 E. Moqbel 2 and Z.A. Memish 3 1Department of Public Health, Mecca Regional Health Directorate, Mecca, Saudi Arabia. 2Department of Preventive Medicine, Jeddah Health Directorate, Jeddah, Saudi Arabia. 3Department of Public Health, Ministry of Health, Riyadh, Saudi Arabia (Correspondence to Z.A. Memish: zmemish@yahoo.com). L'éducation sanitaire pour améliorer les connaissances des pèlerins de la Mecque en 2011 (Hajj 1432) sur les comportements favorables à la santé RÉSUMÉ L'objectif principal de la présente étude était d'évaluer l’effet à court terme de certains messages d’éducation sanitaire sur les connaissances des pèlerins en matière de santé. Nous avons choisi comme échantillon aléatoire les personnes présentes à bord de six bus à l’entrée du site. Pour évaluer les connaissances avant et après l’intervention, nous avons utilisé un questionnaire auto-administré, que 278 pèlerins ont rempli. Le pourcentage de participants ayant répondu correctement à l’ensemble des questions était significativement plus élevé après l’intervention d’éducation sanitaire (P < 0,05). Presque tous les participants ont affirmé que cette intervention leur avait été utile et que l’éducateur avait bien fait passer les messages. Seules 19 personnes (7,2 %) ont déclaré qu'elles avaient déjà reçu des informations pertinentes en matière d’éducation sanitaire avant d’arriver en Arabie saoudite. Avant l’intervention, seuls 50 % des participants savaient qu’un rasage sans risque contribuait à prévenir la propagation des maladies à transmission hématogène ; ils étaient 84,7 % à le savoir après l’intervention. Communiquer des messages d'éducation sanitaire directement aux pèlerins est efficace pour améliorer les connaissances à court terme en la matière. 2011/1432r"ÐGX9ogZTÐÓmgScTm<Õm"ÐoQ|^XMTZTÐgaTÐ9McXm^TÐXÒØm`GøÐ ehYØnxÛºbYên[LºhwÐ}=ÎéØnLº}ed=ÒEfYº©nT}>ha"Ð{L [UÐ hbUÐ ýnHÚ Y phLi ýnHÚ x{b> {_= shdU ph[UÐ pR}_CÐ DL î{CÐ E[bUÐ }?úÐ hhb> OÎ pHÐÚ{UÐ ì|w qR{w oåÉ°#Ð B{UÐSgR}_YhhbUgaij=pHÐÚ{UÐ:ëTÚnZCÐìkdexðninhHÐpHÐÚ{UÐqY{HÐí ÓĆRn"ÐéB{Uànbi6YphýÐZLpfhLÓEBÐí h+DLphÉÓn=n@Î Ð=n@Ì x|UÐ NTÚnZCÐ pi :pKdY ÒØnxÛ ènfw qinTí ðn@nA278 ënhHøÐ Ð|w ecHÐ {Sí ì{_=í ahbUÐ [UÐhbUÐ:NdYn_UÐÖnf=ÐíØnRÌíº[UÐhbUÐYÐíØnaHйÌðnx}b>NhCÐ h+}TÙí P<0.05ahbUÐB{UÐ{_=pdþHúÐ B{UÐÐ|wSí pxØ_UÐph=}_UÐpcdeCÐOÎ4ÉíSphahb>phÉýnHÚðnadHÐbd>¹ÌbR%7.2ðn@nA19d=Ìí ýnH}UÐén[xÎ: %84.7OÎpfUÐì|wq_a>ÚÐíºê{UÐx}JLpUbfCÐßÐ}YúÐÚnZiÐYb>piYjCÐpSĆ"ÐëÌëR}_xNhCÐYbR%50ënTºahbUÐ E[bUÐî{CÐDLph[UÐpR}_CÐNĻ:hUn_RÕndU nCÐ[UÐhbUÐq?Ìí ahbUÐB{UÐ{_= EMHJ r 7PM 4VQQMFNFOU &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF S10 Introduction Health education has been described as a process by which individuals or groups learn to behave in a manner con- ducive to the promotion, maintenance or restoration of health[1].Communi- cation in relation to health education involves various modes, e.g. lectures, discussions, symposia, posters, public address, and radio and television mes- sages. Each mode has its own merits, drawbacks and scope of effectiveness. Messages may also have to overcome communication barriers (e.g. physio- logical, psychological, environmental and cultural). The effectiveness of a particular mode of health education varies according to the setting in which it is delivered[2,3]to a specific group [4]. It has been observed that different methods may be especially suitable for different groups of people depending upon their age, sex, educational quali- fication, background and the nature of their employment [1]. The Hajj has become the epicentre of the mass migration of millions of Muslims of various ethnic diversities. No other mass gathering can compare in scale or in regularity[5]. The prepared- ness plans made before the Hajj season ensure the optimum provision of health services for pilgrims to Saudi Arabia, and have been set up to minimize dis- ease transmission both during their stay in the country and upon their return home[6].Health education is one of the principal services provided for pilgrims from their arrival. Health education of pilgrims, through the Health Educa- tion Ambassadors (HEA) programme, which was launched as an innovative approach in 1428 AH (2007 CE), is one of the principal activities supporting those plans. The HEA module aimed at achiev- ing 2 specific objectives: r Provide effective health education to pilgrims in their mother tongue at their dormitories in the holy places. r Encourage medical students to ac- tively take a health education role during the Hajj. Both objectives were achieved through inviting medical and health science students to voluntarily enrol in an HEA team. Volunteers agreed to undergo a training programme focus- ing on communication skills, the ethics of volunteer work and the important health messages to be delivered to ar- riving pilgrims. The messages were basi- cally designed to cover issues related to healthy behaviour during the perfor- mance of the Hajj, for example, personal hygiene, measures protective against infectious respiratory droplets, avoid- ing exposure to direct sun, and proper ways of using razors. This programme benefited by making use of the students in Mecca who are often fluent in foreign languages in addition to Arabic. In Hajj in 1431 AH (2010 CE), the HEA programme was extended to cover pilgrims arriving at King Abdul Aziz International Airport, 19 km north of Jeddah, the main aviation entry port for pilgrims. The messages were deliv- ered to them in the Pilgrim’s City, just outside the Hajj terminal, while they waited aboard buses that would trans- port them to the holy places. Challenges to providing the training included the preoccupied state of pilgrims while completing their registration formalities on arrival. During Hajj 1432 AH (2011 CE), analysis of passenger flow within Pilgrim’s City showed that loading a bus takes about 4–6 minutes for pil- grims and up to 20–25 minutes for their luggage. This meant that the pilgrims waited in the stationary buses for about 20 minutes while waiting for luggage arrival and loading, prior to departure. This was determined to be the ideal time to deliver health messages. The HEA volunteers were organized into teams of 2: one volunteer was responsible for conveying messages aided by a picto- rial chart while the other distributed a copy of the multilingual health message pictorial leaflet to each pilgrim. This method of health education was intended to provide more effective health education. The executive com- mittee of the Hajj recommended study- ing this new educational approach to determine its effectiveness. Therefore, the main objective of this study was to assess the short-term effect on health knowledge among pilgrim after they had been given specific health educa- tion messages. Methods Through a pre- and post-intervention study design, a random sample of 6 buses was selected from a total of about 300 buses on the last day of work in the Pilgrims City at King Abdul Aziz Inter- national Airport. Sample size was calcu- lated to find a difference of at least 20% in improvement of level of knowledge of the participants after conducting the intervention. Considering a confidence level at 95% and a power of 80%, the estimated sample size was 244; this was increased to 300 to compensate for expected missing data. Since each bus accommodated about 50 pilgrims on average, 6 buses were adequate to satu- rate the estimated sample size,giving a total of around 300 pilgrims. The re- sponse rate was 92.7%: 278 completed questionnaires returned. The total number of pilgrims aboard these buses was 300. The health educators boarded the buses, described the purpose of the study, and then invited pilgrims to participate. Those who agreed were asked to fill out a self-administered questionnaire (pre-test). The questionnaire had been designed and validated for a similar trial carried out the previous year for the local authority to assess the knowl- edge of pilgrims about healthy behav- iour during Hajj (unpublished report). Reliability was assured by Cronbach’s alpha test which gave a value of 0.88; this is considered an acceptable reli- ability level. HCÐçPUph[UÐpdCÐPL HnUÐ{dCÐ 2:nüÐØ{_UÐ S11 Table 1 Knowledge of Hajj pilgrims arriving at King Abdul Aziz International Airport regarding healthy behaviour before and after a health education intervention, 1431 AH (2010 CE) Questionnaire item Pre-intervention Post-intervention % correct % correct Consulting a physician before travelling to the Hajj 69.1 83.6 Items that can be shared by ≥ 2 individuals 68.7 94.4 Health behaviour on coughing or sneezing 92.4 100.0 Medicines must be assured 91.4 97.0 Prevention of sunstroke 89.6 98.9 Frequency of hand-washing 79.1 95.5 Diseases prevented by safe shaving practices 50.0 84.7 The intervention included the health education messages provided through the HEA programme using a pictorial chart as well as the distribu- tion of pictorial pamphlets. This was followed by assessment of knowledge using the same questionnaire (post- test). Data were verified, assessed for quality, then analysed using SPSS, ver- sion 16.0. Results The response rate for completion of the pre-intervention questionnaire was 92.7% (n = 278) and 89.3% (n = 268) for completion of the post- intervention questionnaire. The proportion of pilgrims giving cor- rect answers showed a significant increase on the post-test (Table 1) (P < 0.05). While around two-thirds of respondents (69.1%) indicated that pilgrims,whether healthy or sick, should consult a physician before departing for the Hajj, the figure was more than 80% after the intervention. Similarly,before the intervention just over two-thirds (68.7%) said that toothpaste is the only item that can be shared between 2 or more individu- als; this increased to 94.4% after the intervention (Table 1). The greatest improvement in knowledge was seen for the item relating to shaving: only half of the respondents knew that safe shaving with disposable tools prevents dis- semination of some bloodborne dis- eases (e.g. HIV and hepatitis B) before intervention;this rose to 84.7% after the educational intervention (Table 1). Almost all pilgrims (99.6%) agreed the HEA programme aboard the buses was beneficial, with 98.9% evaluating the health educator as successful in delivering the health education mes- sages. When asked about the importance of receiving health education messag- es in their home countries before de- parting to the Hajj, the overwhelming majority of the participants (92.4%) supported the idea. However, only 7.2% (n =19) stated that they had al- ready received relevant health educa- tion messages in their home country. Discussion This study showed that using the educational intervention improved short-term knowledge in the popula- tion studied. Volunteers have been document- ed to be effective health education providers[7].The HEA programme depends on volunteers from various medical faculties and health institutes in the Mecca region; their enthusi- astic participation was essential to the health education programme. Student volunteer opinion, as well as that of mutawefs (guides), about the HEA programme was assessed during previous Hajj seasons (un- published report), but the impact of these messages on the knowledge of pilgrims was not assessed. Our find- ings showed significant improvement in the short-term knowledge level among intervention recipients. This effect has been established in previous studies in similar settings, including India [1] and Saudi Arabia [4];the authors recommended that health education-focused programmes should be conducted in small groups, preferably via specific topic lectures. The low rate for receiving pre- departure health education messages among those affluent enough to af- ford to travel by air and participate in the Hajj indicated a notable lapse in pre-travel preparation in the study population, and a need for home country educational interventions. The limited time available to con- duct the current health education intervention presented a significant limitation. It was conducted on the last day that pilgrims were arriving at King Abdul Aziz International Airport, and most were Arabic speakers. This population was not representative of all pilgrims. Also, it was not possible to obtain directly-paired responses from each of the pilgrims, and statistical analysis was therefore based on the overall percentages of pre- and post- test correct questionnaire responses. EMHJ r 7PM 4VQQMFNFOU &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF S12 Recommendations r The HEA programme should con- tinue in the coming Hajj seasons with the inclusion of pilgrims at other por- tals of entry to Saudi Arabia, especially in Prince Mohammed Ibn Abdul Aziz International Airport in Medina. r A study of wider scope should be planned for the next Hajj season. r An additional study would be worth- while to determine whether or not the intervention actually resulted in any change in health among pilgrims dur- ing the Hajj and in the following weeks, compared with those who did not par- ticipate in the intervention, along with the specifics of any diagnosis. r Methods to provide standardized, pre-departure, health education to pilgrims scheduled to participate in the Hajj should be explored. Health education materials should be pre- pared in concert with the Ministry of Health. This could include infor- mation provided to foreign travel agencies, additional links to health education posts already provided within Saudi Arabia, and shared through working with air carriers and charter companies serving Hajj ports of entry to provide in-flight health education videos. r Consideration should be given to investigating methods of educating those who enter the country using other means of transportation, in- cluding ships. References 1. Saha A, Poddar E, Mankad M. Effectiveness of different meth- ods of health education: a comparative assessment in a scien- tific conference. BMC Public Health, 2005, 5:88. 2. Nishtar S et al. Posters as a tool for disseminating health re- lated information in a developing country: a pilot experience. Journal of the Pakistan Medical Association, 2004, 54:456–460. 3. Werner RT Sr, Wilson JM. Are health education conferences effective? An evaluation of knowledge gain in a three-day in- stitute. Health Education, 1981, 12:22–24. 4. Abolfotouh MA. The impact of a lecture on AIDS on knowl- edge, attitudes and beliefs of male school-age adolescents in the Asir Region of southwestern Saudi Arabia. Journal of Com- munity Health, 1995, 20:271–281. 5. Memish ZA. The Hajj: communicable and non-communicable health hazards and current guidance for pilgrims. Euro Sur- veillance : European Communicable Disease Bulletin, 2010, 15:19671. 6. Memish ZA et al. Establishment of public health security in Saudi Arabia for the 2009 Hajj in response to pandemic influ- enza A H1N1. Lancet, 2009, 374:1786–1791. 7. Haroun HM et al. Assessment of the effect of health education on mothers in Al Maki area, Gezira state, to improve homec- are for children under five with diarrhea. Journal of Family and Community Medicine, 2010, 17:141–146. HCÐçPUph[UÐpdCÐPL HnUÐ{dCÐ 2:nüÐØ{_UÐ S13 ABSTRACT Religious mass gatherings are increasingly common in Iraq and can harbour considerable public health risks. This study was aimed at determining morbidity and mortality patterns in hospitals in Karbala city, Iraq during the mass gathering for Ashura in 2010. We conducted a cross-sectional study on attendees at the 3 public hospitals in the city. The study period was divided into pre-event, event, and post-event phases. Morbidity and mortality data were obtained from hospital registry books and the coroner’s office. About 80% of the 18 415 consultations were at emergency rooms. Average daily emergency room attendance was higher during the event compared with pre- and post-event phases, while average daily admissions decreased. Compared with the pre-event phase, a 7-fold increase in febrile disorders and a 2-fold increase in chronic diseases and injuries were noted during the event phase. There was no difference between the 3 phases for average daily death rate,nor for cause of death. Pattern of morbidity and mortality in Karbala hospitals during Ashura mass gathering at Karbala, Iraq, 2010 F. Al-Lami,1 A. Al-Fatlawi,1 P. Bloland,2 A. Nawwar,3 A. Jetheer,1 H. Hantoosh,1 F. Radhi,1 B. Mohan,1 M. Abbas,1 A. Kamil,1 I. Khayatt 1 and H. Baqir 1 1Field Epidemiology Training Programme (FETP),Baghdad, Iraq(Correspondence to F. Al-Lami: farislami@gmail.com). 2Centers for Diseases Control and Prevention, Atlanta, Georgia, United States of America. 3Ministry of Health, Baghdad, Iraq. Tableaux de morbidité et de mortalité dans les hôpitaux de Karbala lors du rassemblement de masse pour l’Achoura, à Karbala (Iraq), 2010 RÉSUMÉ Les rassemblements religieux de masse sont de plus en plus courants en Iraq et peuvent engendrer des risques importants pour la santé publique. La présente étude visait à déterminer les tableaux de morbidité et de mortalité dans les hôpitaux de la ville de Karbala (Iraq) lors du rassemblement de masse pour l’Achoura en 2010. Nous avons mené une étude transversale sur la fréquentation dans trois hôpitaux publics de la ville. La période d’étude couvrait les trois phases suivantes : avant, pendant et après l'événement. Les données sur la morbidité et la mortalité ont été recueillies à partir des registres des hôpitaux et du bureau du médecin légiste. Le service des urgences a reçu près de 80 % des 18 415 consultations. La fréquentation journalière moyenne au service des urgences était plus élevée pendant l’événement qu’avant et après ce dernier, alors que le nombre moyen d’hospitalisations journalières a diminué au moment du rassemblement. On a constaté que, pendant l'événement, les accès de fièvre ont été multipliés par sept, et les maladies chroniques et traumatismes par deux, par rapport à la phase précédant le rassemblement. Il n’y avait pas de différence entre les trois phases pour ce qui concerne le taux moyen de mortalité journalière et les causes de décès. 2010ºçÐ|^Tкʰ<|SºÊÐÚHmKî|SÙ9ØY"ÐÊme>ÌÊ°<|SoewzXÓmg`YX9ÓmgQTÐíoÐ|BÐà5hÌ ºYnTÑnwUÐ{LºÜnLHYºënAYÚ{=ºĽÐÚÜÐ}RºÝfAÚ{hAºE@én_UÐ{LºÚÐi ̺{iød=Gh=ºïíndaUÐMLºYĆUÐÜÚnR }Sn=AºànhBënAÎ à5iÌ{x{ĻpHÐÚ{UÐì|wYæ{4ÐënTí phYe_UÐp[UÐDL}Jn8OÎß ¬}_ô>{SØZAwíºçÐ}_UÐ:phfx{UÐÓnHnfCÐ:ØZ"ÐØÐØ~>oåÉ°#Ð p}_ó ôYpHÐÚØëAnUÐî}@Ìí 2010ên_UÐ:ÊÐÚInLî}TÙÊnhAÎpHnfe=ØZ"ÐÊnf?̺çÐ}_Un=ºÊĆ=}Tpfx{e=ÓnhaZCÐ:ÓnhRUÐípÐ}CÐ q_õ ô+í pHnfCÐ{_=nYíÅn*ÐÙpHnfCÐÊnf?ÌíÅpHnfCÐSnYp?Ć?AÐ}YOÎpHÐÚ{UÐÒGRq óe ¬ôSí pfx{Cn=pYnLÓnhaZYp?Ć?DLxØØGCÐDL nwØ{LíÓÐÚnZHøÐY%80ëÌNAndUy\>Ðí LPUÐo]UÐÒ}ýÐØYíÓnhaZCn=ÒØ@CÐÓĆUÐYÓnhRUÐípÐ}Cn=pÉn#ÐÓninhUÐ ºnw{_=ípHnfCÐSnYNx}BúÐNdA}Cn=pi óÚnb ôYpHnfCÐÊnf?ÌDLÌÏÚÐ]UÐpR}QDLYhUÐØØGUÐHYënTí ÏÚÐ]UÐæ}Q:Ó}@{S18 415 SÐ=px e"ÐÓn=Ð}]øÐâna>ÚÐpHnfCÐÊnf?Ì õAôUºpHnfCÐDLpb=nUÐpdA}CÐ Ypi óÚnb ôY{b_=í ÓnhaZCn=YhUÐénBØüÐHYßnaiÐ Y ÔĆUÐAÐ}CÐN=nY:ÒnRUÐÑnHÌÓína>35TYhUÐÒnRUÐé{_YHYd¶3í Na_\UÐ SÐ=Ón=nÉüÐípfY~CÐßÐ}YúÐíºæn_Ìp_H EMHJ r 7PM 4VQQMFNFOU &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF S14 Introduction Mass gatherings are defined as pre- planned, public events held for a lim- ited time period and attended by large number of people, typically more than 1000, although some suggest more than 25 000 [1,2]. They can be held for political, social, religious, sports, and other reasons. Comprehensive reviews of mass gathering literature have con- cluded that medical needs were largely determined by the event type and dura- tion, attendance, weather, crowd mood and density, and other factors [3,4]. Mass gatherings can engender a lot of societal and governmental concerns and can result in health and socioeco- nomic consequences. They challenge public health vigilance and knowledge because they increase the epidemiologi- cal potential for the spread of disease to a maximum, increase the risk of injuries, and exacerbate pre-existing chronic conditions [5]. Mass gatherings add burden to the host countries and to trav- ellers’ countries of origin [6–8]. Public health systems become strained even if they are advanced and effective in preventing and controlling the endemic disease burden and even if the countries have the appropriate resources [9,10]. The mass gathering environment itself also impacts the host population by imposing added burdens on civilian infrastructures [11]. In the Middle East, the Hajj is the best known and most closely studied mass gathering. Many studies have been conducted on describing public health consequences associated with Hajj, par- ticularly outbreaks of communicable diseases and injuries [12–14]. In Iraq, several religious mass gath- erings are held throughout the year, mainly in Karbala, Najaf and Baghdad. Ashura is the third largest religious mass gathering in Karbala. It is com- memorated by Shi’a Muslims as a day of mourning for the martyrdom of Husayn ibn Ali, the grandson of the Prophet Muhammad at the Battle of Karbala in 61 AH (680 CE). It is attended by millions of Muslims from within and outside Iraq [15]; all should visit the holy shrines on this day. This can re- sult in extreme crowding, leading to increased risk of stampedes. For cultural or religious reasons, some attendees use self harm practices such as laceration of the scalp using sharp knives, etc. More importantly, owing to the high densities of people, international visibility, and symbolic means through which terror- ists might amplify the effects of their action,mass gatherings are often cited as targets for terrorism [16–18]. This is particularly true for Iraq, which has experienced a number of terrorist at- tacks, making the prevention of such attacks the focus of the government during mass gatherings. Religious mass gatherings follow the Islamic lunar calendar, so the date moves forward by 10–11 days every year, therefore presenting health risks associated with seasonal variation [19]. The public health impacts associ- ated with mass gatherings are inade- quately studied in Iraq. The objective of this study was to describe the pattern of morbidity and mortality in Karbala hos- pitals, with emphasis on emergency at- tendance, and type of diseases/injuries, during Ashura in 1431 Hijri (December 2010). Methods A cross-sectional study was conducted in the city of Karbala (population ap- proximately 500 000; located 100 km south-east of the capital, Baghdad) on all patients who were admitted to the hos- pital wards or attended the emergency room (ER) in all 3 public hospitals in Karbala (Al-Husainy General Hospital, the Obstetrical/Gynaecological Hospi- tal and the Paediatric Hospital) during 1–26 December 2010. Morbidity data were obtained from the registry books of the hospital wards and emergency rooms (ERs) of these hospitals. Mor- tality data were obtained from death certificates issued by the hospitals and from the provincial coroner’s office over the same period. Data were collected on a daily basis using standardized instrument that in- cluded basic patient demographic data and provisional diagnosis or primary cause of death. The study period was divided into three phases: “pre-event” (1–14 December), “event” (15–18 December), and “post-event” (19–26 December). Although Ashura is actu- ally a 1-day event, people usually attend 2 days earlier and stay 1 day afterwards. For planning purposes, the local gov- ernment considers this as the mass gathering period to take into account the arrival and departure of attendees. We used the same period to define the “event” phase. Because standardized case defini- tions or international disease classifica- tion standards are not routinely used in Iraq, we grouped provisional diagnoses into broad syndromic or body-system categories. As reliable denominator figures were not available and because the phases were of different lengths, we analysed the data through the 3 phases using average daily health-care contact rates (including hospital admis- sions, ER consultations, and deaths). Figures were rounded to the nearest whole number. On-way analysis of vari- ance (F-test),Tukey (HSD) test and chi-squared test were used to identify significant differences in average daily figures and frequency data between the 3 phases. Epi Info and SPSS were used for data entry and analysis. P < 0.05 was considered statistically significant. Results Data were collected on a total of 18 415 health-care contacts; Table 1 describes the basic characteristics of the study population. The majority (51%) of patients were in the 15–44 years age HCÐçPUph[UÐpdCÐPL HnUÐ{dCÐ 2:nüÐØ{_UÐ S15 Table 1 Demographic characteristics of people (n = 18 415) who attended 3 public hospitals before, during and after Ashura mass gathering, Karbala, 2010 Characteristic Phase Total P-value Pre-event Event Post-event No. % No. % No. % No. % Age (years) a < 1 643 7.5 247 6.9 505 8.2 1 395 7.6 1–4 832 9.7 663 18.4 763 12.4 2 258 12.3 5–14 600 7.0 623 17.3 510 8.3 1 733 9.5 < 0.001 15–44 4 687 54.5 1 476 41.1 3 188 51.8 9 351 51.0 45–64 1 380 16.1 423 11.8 911 14.8 2 714 14.8 65+ 451 5.2 163 4.5 273 4.4 887 4.8 Sex b Female 4 061 47.3 2 009 55.9 2 820 45.6 8 890 48.4 Male 4 527 52.7 1 586 44.1 3 366 54.4 9 479 51.6 < 0.001 Residence c Karbala 8 342 96.9 3 565 99.2 6 065 97.9 17 972 97.7 Other provinces 241 2.8 15 0.4 112 1.8 368 2.0 < 0.001 Other countries 23 0.3 15 0.4 15 0.2 53 0.3 Total 8 612 46.8 3 597 19.5 6 206 33.7 18 415 100.0 aAge missing on 77 records. bSex missing on 46 records. cResidence missing on 22 records. group; there was an almost equal male to female ratio, and more than 97% of people seeking care at the study sites were from Karbala province. The pro- portion of patients in the age group < 15 years was significantly higher in the event phase (42.6%) compared to the pre- (24.2%) and post-event phases (28.9%) (P < 0.001).While the number of males exceeded that of females in the pre-event (52.7%), and post-event (54.4%) phases, females predominated in the event phase (55.9%)(P < 0.001). The proportion of attendees from other provinces in Iraq constituted 2.8% in the pre-event, and 1.8% in the post- event, and only 0.4% in the event phase (P < 0.001). Across the study period, about 79% of contacts were reported from ERs; about 69.2% attended Al-Husainy General Hospital, 9.6% attended the Obstetrical/Gynaecologic Hospital, and 21.2% attended the Paediatric Hos- pital. The average daily attendance to Al Husainy and the Gyn/Ob hospitals increased during the event compared with pre- and post event phases, but this was not statistically significant (P ≥ 0.05)(Table 2). In the Paediatric Hospital there was an increase of more than 100% in average daily attendance during the event (257) compared with pre-event (109) (P< 0.001), and post- event (172) (P = 0.019). The average daily ER consultation rate was significantly higher during the event phase (772) compared with the pre-event (480) and post-event (607) phases (P < 0.001)(Table 2). The av- erage daily admissions to the hospital wards was lower in the event phase (127) compared with the pre-event (136) and post-event (169) phases, but the difference was not statistically significant(P = 0.907). According to provisional diagnosis, the average daily attendance for com- plications of diabetes was 3 times higher during the event phase compared with pre- and post-event phases (P < 0.001) (Table 3). Similarly, the average daily attendance for diagnoses of cardiovas- cular disease was significantly higher during the event phase than pre- (P = 0.016) or post-event (P = 0.025). Also, diagnosis of fever and febrile convul- sions was 7 times greater during the event than pre-event, and 4 times great- er than post-event phases (P < 0.001). Regarding injuries, the average daily attendance was significantly higher dur- ing the event compared to pre-event phase (P = 0.041). Although in general, the obstetrics/gynaecology attendance was not significantly different between the phases, average attendance for cae- sarean section was significantly higher during the post-event phase compared with the event (P = 0.002) and pre-event (P = 0.038) phases. “Other”, which mainly included less urgent cases, were significantly higher in the post event compared to event (P = 0.041) phases (Table 3). In general, in the pre-event phase, the ratio of noncommunicable diseases: communicable diseases: injuries was 2.4:3.7:1 for the ER, and 12.9:6.1:1 for hospital admissions. The correspond- ing ratio during the event phase was EMHJ r 7PM 4VQQMFNFOU &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF S16 Table 2 Average daily attendance of patients (n = 18 415) who attended 3 hospital departments, and average daily deaths according to event phase, Ashura mass gathering, Karbala, 2010 Variable Daily average (no.) P-valuea P-valueb Pre-event Event Post-event Pre- vs event Pre- vs post- Event vs post- Hospital Husainy 447 564 541 0.05 0.118 0.107 0.923 Gynaecology-Obstetrics 59 79 63 0.362 0.329 0.908 0.556 Paediatric 109 257 172 < 0.001 < 0.001 0.017 0.019 Hospital department Emergency 480 772 607 < 0.001 < 0.001 0.025 0.037 Admission 136 127 169 0.075 0.907 0.101 0.148 Deaths 7.4 9.8 10.9 0.786 0.993 0.774 0.911 Total 615 899 776 < 0.001 0.001 0.011 0.202 aF-test. bTukey (HSD). 1.5:2.7:1 in the ER, and 13.8:9.4:1 for hospital admissions. For the post-event phase, the ratio was 2.4:4.2:1 for the ER and 10.7:4.8:1 for hospital admissions. Across the study period there were 230 deaths; 37 (16%) of these were re- ported from the provincial coroner’s of- fice, reflecting deaths occurring outside hospital. The proportion of deaths in the pre-event, event and post-event phases were: 45%, 17%, and 38%, respectively. Corresponding average daily deaths were: 7.4, 9.8, and 10.9, respectively but the differences were not statistically sig- nificant (P > 0.05) (Table 2).The most frequent causes of death throughout the study were cardiovascular disease (44.3%), respiratory disease (12.2%) and injuries (10.0%). Mortality analysis for cause, age, sex and residence across the 3 phases did not show any specific trends or statistical significance. Discussion Although many religious mass gather- ings are held in Iraq, to our knowledge this is the first study that describes pub- lic health issues related to such events in this country. We found a reduction in hospital admissions during the period of the event. This contrasts with the findings of other studies that showed excess hospital admissions during mass gath- erings in some neighbouring coun- tries [12–14]. This is likely due to the modification of the health-care delivery system during Ashura and similar mass gatherings: hospitals postponed all ser- vices for non-emergency conditions. Although new, simpler, mobile and fixed health-care delivery outlets are located very close to the scene of the mass gathering, still they provide only the basic ambulatory services and first aid; more serious cases that required more professional intervention are still referred to the hospitals. The new outlets help absorb the health burden attributed to less-serious conditions during the mass gathering, particularly for visitors who are not familiar with how to access the hospitals. This is sup- ported by the finding the majority of attendees to the 3 public hospitals in this study were local residents. Despite an overall reduction in hospital admissions during the event, there was still an increase in hospital consultations for a number of key condi- tions. There was an increase in morbid- ity attributed to acute febrile conditions, likely reflecting acute infections and respiratory illnesses. This is consistent with other studies on mass gatherings that documented excess admissions for infectious diseases associated with overcrowding [20]. Similarly, our study demonstrated an increase in consulta- tions for chronic diseases, particularly diabetes mellitus and cardiovascular dis- eases. The observed a 3-fold increase in attendance for complications of diabetes mellitus may be due to poor adherence to diet or medications during the event. In mass gatherings, noncommunicable diseases and injuries have caused more deaths and greater morbidity than have communicable diseases [21]. A 2-fold increase in injuries was not- ed; many were related to cultural habits such as intentional scalp lacerations practised by some attendees. Human stampedes are the most feared disaster during mass gatherings because they are frequent and are associated with a high fatality rate [22]. In Iraq in 2005 a stam- pede resulting in about 1000 deaths was triggered by the false rumour of a suicide bomber [23]. The increase in injuries recorded is consistent with previous studies conducted for other mass gatherings [24–26]. Conversely, the average daily admis- sion for caesarean section, and other conditions (mostly non-urgent cases) greatly declined during the event, but markedly increased after the event. Al- though this could be due to the planned postponement of admission for less- urgent conditions to after the event, hindered access to the hospitals or poor triage of more severe conditions should HCÐçPUph[UÐpdCÐPL HnUÐ{dCÐ 2:nüÐØ{_UÐ S17 Table 3 Average daily attendance at 3 hospitals according to provisional diagnosis and event phase, Ashura mass gathering, Karbala, 2010 Provisional diagnosis Daily average (no.) P-valuea P-valueb Pre-event Event Post-event Pre- vs event Pre- vs post- Event vs post- Complication of chronic disease 78.5 135.0 78.1 < 0.001 < 0.001 0.999 < 0.001 Cardiovascular disease 61.6 89.5 61.3 0.016 0.016 0.999 0.025 Diabetes mellitus 16.8 45.5 16.7 < 0.001 < 0.001 1.000 < 0.001 Fever/febrile convulsion 13.0 92.0 22.4 < 0.001 < 0.001 0.105 < 0.001 Gastrointestinal tract disease 173.0 199.7 210.4 0.475 0.785 0.496 0.967 Neuropsychiatric illness 23.0 41.5 39.4 0.039 0.123 0.073 0.974 Pregnancy-related disorder 57.5 68.3 60 0.719 0.696 0.968 0.832 Caesarean section 6.0 3.0 10.7 0.002 0.124 0.038 0.002 Normal vaginal delivery 27.0 34.0 28.7 0.69 0.939 0.794 0.705 Other gynaecological/ obstetric disorders 24.3 31.2 20.5 0.396 0.602 0.78 0.364 Respiratory illness 102.2 154.7 152.7 0.034 0.137 0.056 0.997 Injury 74.4 153.7 90.1 0.053 0.042 0.792 0.156 Other (general) 93.3 54.2 122.7 0.018 0.163 0.185 0.014 aF-test. bTukey (HSD). be still considered as a contributing factor. There was a slight non-significant increase in mortality in the post-event phase that could be attributed to an accumulation of excess morbidities in the event phase, particularly complica- tions of chronic diseases, infections and injuries. There were a number of limitations to this study. Because the temporary health outlets did not keep any health contact information, and data from other health outlets were not included, we were unable to accurately measure the overall burden during the event, especially the less-severe illnesses and injuries. There may have been some degree of misclassification of illnesses both due to the lack of the use of stand- ardized disease classification as well as the use of provisional instead of final diagnoses. To sum up, the mass gathering we studied was associated with an increase in ER attendance and consultations for febrile conditions, complications of chronic diseases, and injuries, besides a reduction in hospital admissions and no change in mortality. To facilitate better planning and response, we rec- ommend implementing public health surveillance during mass gatherings which covers all the health-care de- livery outlets and which is capable of identifying the burden and trend of various health disorders. Finally, it is recommended to implement use of the International Classification of Diseases 10 (ICD-10) in health facilities as this will help in better understanding the pattern and trend of morbidity and mortality and facilitate implementation and evaluation of control and preven- tive measures. References 1. Arbon P, Bridgewater FHG, Smith C. Mass gathering medicine: a predictive model for patient presentation and transport rates. 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EMHJ r 7PM 4VQQMFNFOU &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF S18 8. Memish ZA, Venkatesh S, Ahmed QA. Travel epidemiology: the Saudi perspective. International Journal of Antimicrobial Agents, 2003, 21:96–101. 9. Landry P, Slama S. Pilgrimage and other mass gatherings: epidemiology and prevention. Revue Medicale Suisse, 2008, 4:1192–1195. 10. Ahmed QA, Barbeschi M, Memish ZA. The quest for public health security at Hajj: the WHO guidelines on communicable disease alert and response during mass gatherings. Travel Medicine and Infectious Disease, 2009, 4:226–230. 11. Stergachis A, Agis DT. Overview and framework. In: Tsou- ros AD, Efstathiou PA, eds. Mass gathering medicine and public health: the Athens 2004 experience. Copenhagen, World Health organization Regional Office for Europe, 2007 (EU/07/5062470). 12. Gazzaz ZJ, Dhaffar KO, Shahbaz J. Hajj (1422H) In-patient Characteristics in Al-Noor Specialist Hospital. 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Emergence of medicine for mass gatherings: lessons from the Hajj. Lancet Infectious Diseases, 2012, 12:56–65. 20. Khan NA et al. Pattern of medical diseases and determinants of prognosis of hospitalization during 2005 Muslim pilgrimage (Hajj) in a tertiary care hospital. Saudi Medical Journal, 2006, 27:1373–1380. 21. Hsieh YH et al. Epidemiological characteristics of human stampedes. Disaster Medicine and Public Health Preparedness, 2009, 3:217–223. 22. Burkle FM Jr, Hsu EB. Ram Janki Temple: understanding human stampedes. Lancet, 2011, 377:106–107. 23. Iraq stampede deaths near 1,000. London, BBC News (website), 2005 (http://news.bbc.co.uk/2/hi/middle_east/4199618. stm, accessed 24 September 2013]. 24. Gautret P et al. Common health hazards in French pilgrims during the Hajj of 2007. Journal of Travel Medicine, 2009, 16:377–381. 25. Zeitz K, Zeitz C, Kadow-Griffin C. Injury occurrences at a mass gathering event. Journal of Emergency Primary Health Care, 2005, 3(1–2). 26. Wetterhall SF et al. Medical Care Delivery at the 1996 Olym- pic Games. Journal of the American Medical Association, 1998, 279:1463–1468. HCÐçPUph[UÐpdCÐPL HnUÐ{dCÐ 2:nüÐØ{_UÐ S19 ABSTRACT The objective of this study was to describe the risks and human health outcomes associated with attendance at the Moulay Abdellah Amghar moussem (a pre-planned mass gathering attracting more than 360 000 participants) for the purposes of public health prevention, planning, preparedness and response. We performed an environmental health risk assessment and retrospectively reviewed local health centre records before, during and after the event. In addition, standardized interviews with key stakeholders were performed to qualitatively evaluate local public health preparedness and response capacities. During the event, average daily health centre visits increased 5-fold. The sex ratio of health-care visits changed significantly from an average of 1.8:1 female:male visits per day to 1.2:1. The proportion of injuries varied from an average of 3.7% pre- and post- event to 14.8% (P < 0.01) during the event. A significant increase in digestive diseases was also observed during the event. Recommendations include increasing accessibility to free sanitation and hygiene facilities and improving health communications concerning hand washing and food and water safety. Preparedness and health risks associated with Moulay Abdellah Amghar moussem, Morocco, 2009–2010 M. Youbi,1 N. Dghoughi,1 M. Akrim,1 A. Essolbi,1 A. Barkia,2 A.I. Azami,3 A.T. Fleischauer,4 D. Schneider 5 and A. Maaroufi 1 1National Institute of Health Administration; 2Directorate of Epidemiology and Diseases Control, Ministry of Health, Rabat, Morocco (Correspondence to M. Youbi: youbimohammed@yahoo.fr). 3Regional Observatory of Health, Casablanca, Morocco. 4North Carolina Division of Public Health, Raleigh, North Carolina, United States of America. 5Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America. Préparation et risques sanitaires associés au moussem de Moulay Abdellah Amghar (Maroc), 2009-2010 RÉSUMÉ La présente étude avait pour objectif d’identifier les risques et les résultats sanitaires pour l'homme associés à la participation au moussem de Moulay Abdellah Amghar (un rassemblement de masse prévu à l'avance qui attire plus de 360 000 personnes) à des fins de prévention, de planification, de préparation et d'action dans le domaine de la santé publique. Nous avons évalué les risques environnementaux pour la santé et avons procédé à un examen rétrospectif des registres des centres de santé locaux avant, pendant et après l’événement. Nous avons également réalisé des entretiens standardisés avec les principales parties prenantes afin d’évaluer, en termes de qualité, les capacités locales pour la préparation et la riposte en matière de santé publique. Pendant le rassemblement, le nombre moyen de consultations journalières dans les centres de santé a été multiplié par cinq. Le rapport de masculinité pour les consultations médicales a évolué de manière significative, passant d’une moyenne journalière de 1,8 femme pour 1 homme à 1,2 femme pour 1 homme. Le pourcentage des traumatismes est passé d’une moyenne de 3,7 %, avant et après l’événement, à 14,8 % pendant le rassemblement (P < 0,01). On a aussi constaté une forte augmentation des maladies digestives pendant l’événement. Il est recommandé, entre autres, d'augmenter l’accessibilité des installations gratuites d’assainissement et d’hygiène et d'améliorer la communication en ce qui concerne l’hygiène des mains et la sécurité sanitaire de l’eau et des aliments. 2010-2009ºÑ|_BкÚm_XÌāÐzKïøXGd<o\=|BÐogZTÐ|ImBÐínv´iTÐ :í}_CÐ1}UÐ{LºÚ{xnfIniÐغÚZhdRëíÚnwºYÛÌ¢xÚØÎpfY˺phS}=~x~_UÐ{LºU[UÐpfhY̺x}TÌ{e7ºQQØpwÛiº-hUÐ{e7 ØÐ{LüÐï}«{ZAwíÚn`YÌāÐ{LïøYHYÚ\=p]>}CÐph[UÐýn["Ðí}JnCÐÉípHÐÚ{UÐì|wYæ{4ÐënT oåÉ°#Ð î}@Ì{Sí phYe_UÐp[UÐén6:p=nHøÐíow´jUÐí]#Ð íípxnSUÐßÐ}QúUÙíºèÚnZY360 000Y}TÌïgxíðnadHU qx õ}@ôÌ 5T nw{_=ínwÊnf?ÌípHnfCÐ ì|wSMCÐ[UÐ~T}Cn= ÒØ@CÐÓĆUÐ_@Ú}?j= Ð_@ÐÚíºpþhUÐ pÉ}JnC ð5hhb> ëAnUÐ ØÐÛ{Sí ðnheT ð5hhb>phYe_UÐp[UÐén6:p=nHøÐíow´jdUphdCÐÓÐÚ ô{ ôbUÐhhbUNhhý}UÐpd[CÐÑnÉÌ YphHnhSph[IÓĆ=nbY ºádYcZ=ÚT|UÐÔniüÐNf!ÐYÓÐÚnx~UÐpiÓ E`>í æn_Ìp2 SÐ=HCÐÊnf?Ì[UÐ~T}CÐOÎphYhUÐÓÐÚnx~UÐHY SHCÐ:%3 7YÓn=nÉüÐpiq>ína>í ÚT|UÐY1 2cUÒ{AÐíiÌOÎÚT|UÐY1 8cUÒ{AÐíiÌYÓÐÚnx~UÐì|wé{_YØÐ~R RÐ}YpAn>ÎÒØnxÛÓnhÉUÐqfe\>í HCÐÊnf?Ìe\4ÐÛng!ÐßÐ}YÌ:ÒETÒØnxÛq^ õAôUí HCÐÊnf?ÌP<0 01%14 8OÎì{_=íHCÐ ìnhCÐíÊÐ|`UÐpYĆHíx{hUÐ`=pÉn#Ðph[UÐphLUÐýnHÚNĻíºðnin6p[UÐíÖnÉüÐ EMHJ r 7PM 4VQQMFNFOU &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF S20 Introduction Moussems are an integral part of Mo- roccan culture. They are pre-planned, public, mass gathering events held for religious, social and cultural, and/or commercial purposes in urban and rural sites throughout the country. The term “moussem” comes from the Moroccan Arabic dialect and is related to the word “mawssim”, which, in classical Arabic, means “season”. Moussems are typically of short duration, held seasonally, and usually commemorate a saint. There are more than 300 annually, and the timing of many of these events corresponds to agricultural seasons (e.g. ploughing or harvest), well-known social events (e.g. the annual return of Moroccans who work abroad, holidays), and celebration of culture and art (e.g. festivals of roses, festival of engagements, spiritual music events). The Moulay Abdellah Amghar moussem, one of the largest events, annually attracts more than 360 000 people from across Morocco and in- ternationally for a period of 8 days. It is held in the summer in El Jaddida province, Doukkala-Abda region, in the western part of the country on the Atlantic coast. This moussem is held in honour of a religious saint, Moulay Abdellah, and includes music, sport, cultural and religious activities, and fan- tasia, traditional horse shows in which riders perform military re-enactments with firearms that use powder (gun- powder) explosive. Although there have been anecdo- tal reports of acute illnesses, outbreaks, and injuries associated with attendance at a moussem, the reports are typically not validated or surveyed by health officials. Environmental health risks and human health outcomes associ- ated with mass gatherings have been well documented, and include haz- ards resulting from crowding, traffic, violence and terrorism, adverse weather exposure, unlicensed food and water vendors, and poor access to sanitation and hygiene facilities [1,2]. Addition- ally, healthcare facilities may not have appropriate surge capacity to manage these events. Information on human health outcomes would help to inform event-based preparedness and re- sponse efforts; however, no systematic evaluation of health risks and outcomes associated with moussems has been per- formed in Morocco [3]. The objectives of this study were to describe the specific health risks and morbidity associated with the Moulay Abdellah Amghar moussem and to evalu- ate the healthcare infrastructure and public health preparedness capacity for this event. Methods We conducted a retrospective study to describe the human health risks and outcomes associated with attendance at the Moulay Abdellah Amghar moussem. To accomplish the study objectives, we compared healthcare encounters be- fore, during, and after the mass gather- ing from health centre medical records. Additionally, we conducted standard- ized interviews with key stakeholders to characterize the organizational and health preparedness aspects of this moussem. We reviewed medical records of all patients seen at the health centre in Moulay Abdellah Amghar during the pre-event period (–14 days to –7 days), the 8 days of the event and the post- event period (+7 days to +14 days) for the past 2 annual moussems (2009 and 2010). periods were selected because they are outside the period when at- tendees congregate at the event site (visitors begin to arrive several days before the event and stay several days after). Health centre visits were cat- egorized as digestive disorders (acute gastrointestinal symptoms and/or gastroenteritis), acute respiratory disor- ders, other infectious diseases (e.g. phar- yngitis, sexually transmitted diseases, rash, conjunctivitis, fever of unknown origin), heat-related illness (e.g. heat exhaustion, sunburns, sun stoke, and dehydration), scorpion bites, accidents attributable to the fantasia (e.g. falls from horses, injuries from the explosives), violence, road traffic injuries, burns, jel- lyfish stings, and drowning. All other visits such as chronic conditions were classified as “other.” A semi-structured questionnaire was administered to key stakeholders including health workers (provincial directorate, hygiene team health cen- tre), an official from the Economic and Control unit of the Ministry of the Interior at the provincial level, repre- sentatives of the moussem organizers and the captain of the provincial civil protection unit. Questions included characteristics of the moussem, social and behavioural risks (e.g. animal sac- rifice, ritual dancing in a state of trance, and other rituals specific to the Moulay Abdallah Amghar moussem), oganiza- tional attributes, and the health system structure in place. Data analysis Medical records and questionnaire data were collected and entered into a Micro- soft Excel spreadsheet. Statistical testing using the chi-squared test to compare proportions was performed using Epi Info, version 6. Ethical considerations All aspects of this study, including ac- cess to medical records, were approved by the Ministry of Health of Morocco. Interviews were conducted after having obtained informed consent. Informa- tion obtained from medical records and other health service providers was kept strictly confidential and no names or other identifying informa- tion on patients was collected. The key stakeholders and their supervisors were contacted in advance to explain the objectives of the study and official permissions were obtained prior to the interviews. HCÐçPUph[UÐpdCÐPL HnUÐ{dCÐ 2:nüÐØ{_UÐ S21 Figure 1 Reasons for health centre visits pre-event, post-event and during the Moulay Abdellah Amghar moussem, 2009 and 2010 (Dig = digestive disorders; Resp = acute respiratory disorders; Infect = other infectious diseases; Heat = heat- related illness; Scorp = scorpion bites; visits for reasons classified as “other”, e.g. chronic conditions, are not shown on this chart) Results Health outcomes associated with the Moulay Abdellah Amghar moussem The average number of health centre visits during the moussem period in 2009 and 2010 was 1577 per year. While the average daily number of visits was 36 outside the moussem period, it increased to 197 during the event. The average daily ratio of female to male health centre visits during the moussem was 1.2. This ratio in the pre- and post-event time periods was 1.8, indicating an increase in health centre visits by males during the moussem. Among the 3153 health centre vis- its during the event in 2009 and 2010, 704 (22%) were potentially due to an infection other than a respiratory or gastrointestinal illness, 467 were classi- fied as accidents and injuries, 448 were for digestive disorders, 188 were likely an acute respiratory illness (Figure 1). Other chronic and acute conditions accounted for the unclassified (“other”) health centre visits (42%). Comparing the average for the pre- and post-event time periods with the event time period, a significant in- crease was observed during the event for digestive disorders (10.9% pre- and post-event vs 14.2% during the event, P < 0.05) and accidents and injuries (3.7% vs 14.8%, P < 0.01). In contrast, a significant decrease was recorded for the number of acute respiratory disorders (9.4% vs 6.0%, P < 0.001) (Figure 1). During the moussem, men were nearly twice as likely to be injured or involved in an accident compared with women [331 (70.9%) visits vs 136 (29.1%) visits, P < 0.01], while women were more likely to be seen for digestive disorders [286 (63.8%) visits vs 162 (36.2%) visits, P < 0.01] and infections other than acute gastrointestinal or res- piratory infections [402 (57.1%) vs 302 (42.9%), P < 0.01]. Risk assessment and event planning analysis The Moulay Abdellah Amghar moussem typically attracts approximately 360 000 national and international attendees each year for 8 days in July or August. Approximately 40 000 (11%) of these stay in the area for the duration of the moussem either, in tents or in rented houses. The moussem is hosted in a small rural village of 9000 residents, located on the coast near a small fishing port. The site is only accessible by a single 10 km secondary road (1 lane in either direction) from a main highway. Potable well water is provided by water fountains equipped with many faucets; the well water is treated and monitored by a hygiene team from the Ministry of Health. However, private unregulated vendors selling well water can be found throughout the site. Bath- room and shower facilities are avail- able for a fee, but few people use them because of the cost. Many attendees relieve themselves outdoors without the use of hand washing stations. Food is prepared by the attendees themselves in their tents and rented rooms. However, many small restaurants are available on site, often without the minimum requirements for food storage and con- servation, including refrigerators. Solid waste is handled by the city’s waste management service and garbage collection is carried out twice a day. A private company is contracted to pro- vide insect and rodent control. The hy- giene team from the Ministry of Health, in collaboration with the Ministry of the Interior and the Ministry of Agriculture, inspect and manage the animal slaugh- ter facilities and ensure food safety. The local health centre is trans- formed into an emergency care facil- ity during the moussem and operates 24 hours a day during the event. This health centre has 4 beds for short-term observation. Three clinical teams, each consisting of 2 general practitioners and 4 nurses, work 8-hour shifts. During the moussem, the health centre is equipped with surge capacity of common phar- maceuticals and medical equipment. In addition, 2 ambulances and staff are co-located with the health centre. Planning for the moussem begins each year in January and is managed and coordinated by a provincial committee led by the governor of El Jadida province. EMHJ r 7PM 4VQQMFNFOU &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF S22 The provincial committee designates 7 specific commissions (Equipment and Site Management, Fantasia and Folklore, Safety and Security, Surveil- lance and Consumer Protection, Heath and Hygiene, Communication and Co- ordination, and Religious Activities). These commissions are charged with all organizational and planning aspects. The Health and Hygiene Commission is supervised by the Ministry of Health. Coordination is done through meetings and periodic reports sent to the gover- nor. During the moussem, the event site is divided into 6 areas, each of which is overseen by the head of the local au- thority (caïd). A coordinating centre is established and daily meetings are held to discuss and assess the activities and problems. Discussion Moussems are culturally important and widely popular mass gatherings held throughout Morocco. This was the first study to conduct a risk assessment and identify human health outcomes associ- ated with a moussem, specifically Moulay Abdellah Amghar, the most popular one in Morocco. The finding that there was an in- crease in the average number of daily visits to the health centre confirms the large increase in workload during the event and amply justifies the implemen- tation of a continuous, 24-hour, service. The sex ratio of persons seeking healthcare has changed significantly in favour of males during the moussem, suggesting a high male predominance among the attendees. This finding could explain the increase in the pro- portion of health centre visits for ac- cidents and injuries during the event. In fact, a large proportion of these ac- cidents were related to falls from horses and from exploding firearms during the fantasia performances, which are exclusively male activities. Several other accidents and injuries, such as drowning and intentional injuries, are much more attributed to males and could be explained by the use of drugs and alcohol reported by all interviewed stakeholders in our study. We also found that during the moussem, digestive disorders increased overall, particularly among females. This was likely a result of poor sanitation or water and food contamination, despite the sanitation and hygiene measures implemented by the organizers. In fact, the supply sources of private water ven- dors, as well as storage and distribution conditions, may be very suspect. Other aspects of hygiene may also be a source of suspicion, especially preparation of food in the many small restaurants on the site and their storage conditions. The most important source of suspicion could be, however, the limited access to sanitation facilities because they are only available for a fee; this would have lead to deficiencies in personal hygiene, including a lack of hand washing. In this study, we expected greater proportion of digestive disorders during the moussem compared with accidents and injuries, but surprisingly, this was not the case. This finding is concordant with a descriptive study of all moussems in Morocco that was conducted in parallel to this one [Akrim M et al., unpublished report]. Otherwise, it is possible that the number of cases reported during the event was a significant underestimate since the incubation period of many acute illnesses is longer than the dura- tion of time spent at the moussem. Limitations The quality of our results may have been affected by certain limitations, especially in relation to the informa- tion abstracted from medical records. Firstly, the reasons for health centre visits (e.g. complaints and diagnoses) were recorded by the clinical teams using different medical notations and abbreviations that do not refer to any specific criteria or uniform standards. Secondly, no international standard was used to validate illnesses and injuries categories for classing patients during data compilation for our study; there- fore, selection bias could have been introduced. Thirdly, we were unable to epidemiologically link the reasons for the visits to the health centres absolutely to the event, and specifically we were unable to confirm etiologies for most acute illnesses. Additionally, and owing to the lack of reliable data on the population distri- bution of the attendees, we were unable to calculate specific incidence rates of different health problem categories, especially by age and sex, in order to compare them with outside the event. Despite these limitations, the results of our study allow us to make some recommendations for the attention of decision-makers, moussem organizers and officials of the health system for better preparedness and management of the event with a view to minimizing health risks. Recommendations To minimize the risk of acute gastro- intestinal illness during moussems, we recommend that the health and hygiene committee enhance their public health interventions targeting hygiene and sanitation, especially through increasing accessibility to sanitation and hygiene facilities and making such facilities free to the public. Unregulated water sellers should be prohibited. If this proves to be impos- sible, their sources must be identified and treated and containers should be checked and treated if necessary. Small restaurants and food vendors should also be controlled and particular attention should be paid to the condi- tions of preparation as well as storage. Connection of their facilities to electric- ity should be provided by the organ- izers and the availability of refrigerators should be mandatory. HCÐçPUph[UÐpdCÐPL HnUÐ{dCÐ 2:nüÐØ{_UÐ S23 1. Ahmed QA, Arabi YM, Memish ZA. Health Risks at the Hajj. Lancet, 2006, 367:1008–1015. 2. Lucas N. Surveillance épidémiologique de l’Armada de Rouen [Epidemiological surveillance of Rouen Armada]. Saint- 3. Maurice, France, Institut de Veille Sanitaire, 2004 (http:// www.invs.sante.fr/publications/2004/armada_rouen/ar- mada.pdf, accessed 20 September 2013). 4. Kadiri N et al. Morocco. In: Francoer RT, Noonan RJ, eds. The Continuum Complete International Encyclopedia of Sexuality. New York, Continuum International Publishing Group, 2004. 5. Memento manifestations publiques [Memento public events]. Puy-de-Dôme, France, Sapeurs Pompiers,2010 (GSMOO/ GSPR Version N°3). References 6. Rassemblements mondiaux de masse : répercussions et opportu- nitéspour la sécurité sanitaire mondiale, Rapport du Secrétariat [Global mass gatherings: implications and opportunities for global health security, Report by the Secretariat]. Geneva, World Health Organization, 2012 (A65/18) (http://apps.who. int/gb/ebwha/pdf_files/WHA65/A65_18-fr.pdf, accessed 20 September 2013). 7. Surveillance for early detection of disease outbreaks at an out- door mass gathering - Virginia, 2005. Morbidity and Mortality Weekly Report, 2006, 55(3):71–74. These measures should be comple- mented by appropriate health education on hygiene of water and food, particu- larly on hand washing. A variety of com- munication channels should be used, such as interpersonal communication, audio messages and pamphlets. The installation of a dedicated moussem radio station could be useful for the dissemi- nation of health education messages. To reduce the number and severity of accidents and injuries, safety and secu- rity measures need to be strengthened. They should focus on the regulation of access to the site and the management of the public, traffic control and maintain- ing permanent access for emergency ve- hicles, prevention of risks related to the use of gas and electric equipment and facilities [4]. Special attention should be paid to improving safety related to the organization of fantasia shows, in par- ticular storage conditions of explosive powder and loading guns. All these measures should be planned during the preparation phase while providing simulations to test and make the necessary improvements, ac- cording to World Health Organization recommendations [5]. Additionally, an annual risk assess- ment prior to and during the mous- sem should be conducted in order to identify potential health hazards and to implement specific public health inter- ventions. In this context, and having regard to the intensity of the workload at the health centre during the event, it is recommended that health authorities strengthen the systems in place, includ- ing both human and material resources. Particular attention should be given to drugs and equipment needed to care for trauma and injury. Because of the difficulties we expe- rienced understanding the information contained in the health centre regis- ters, we recommend implementing a surveillance system using appropriate surveillance forms and specific case defi- nitions to rapidly identify and respond to adverse health outcomes during this moussem [6]. Acknowledgements This study would not have been pos- sible without the support and help of Dr N. Ben Chama, Chief of Medicine, Provincial Service of Infrastructure and Ambulatory Activities, and Interim Chief of Medicine, Ministry of Health Delegation of El Jadida province. We also wish to thank Mr Allal Mechbouh and Mme Soumya Belhamdounia from SIAAP, Mr Tahar Halam, Chief of service “Action Economique et de Contrôle”, El Jadida province, Le Capitaine Kamal, Commander of “Campanie provinciale de la Protection Civile”, Dr Mohammed Kanar, Chief of Medicine, My Abdellah Health Centre, Mr Mohammed Erramch, Major, My Abdellah Health Centre and Mr Abder- rahmane Moustaïd, SIAAP driver, El Jadida. EMHJ r 7PM 4VQQMFNFOU &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF S24 ABSTRACT The objective of this study was to identify health related problems encountered during an annual mass gathering in Pakpattan, Pakistan, the anniversary of the death (urs) of Baba Farid, and to make recommendations for planning and prevention activities. A surveillance system was established to capture health related data for the event. A list of reportable diseases was developed. Data were collected pre-, during, and post-event by health care workers trained for the purpose. A total of 5918 people reported to the 15 health care facilities providing services during the event; 58% of consultations were because of communicable diseases, 21% of which were respiratory tract infections and 26% gastrointestinal illness. Injuries accounted for 31% of cases and noncommunicable diseases for 11%. Prevalence of reportable disease during the event showed sizeable increases. No major disease outbreak was observed. Public health surveillance at a mass gathering: urs of Baba Farid, Pakpattan district, Punjab, Pakistan, December 2010 S. Hassan,1 R. Imtiaz,1 N. Ikram,1 M.A. Baig,1 R. Safdar,1 M. Salman 1 and R.J. Asghar 1 1Field Epidemiology and Laboratory Training Programme, Ministry of Health, Islamabad, Pakistan (Correspondence to S. Hassan: dr_shoaib@ hotmail.co.uk). Surveillance de santé publique lors d’un rassemblement de masse : l’anniversaire de la mort de Baba Farid, dans le district de Pakpattan, au Pendjab (Pakistan), décembre 2010 RÉSUMÉ L’objectif de la présente étude était d’identifier les problèmes de santé rencontrés lors d'un rassemblement de masse annuel à Pakpattan (Pakistan), en l'occurrence l’anniversaire de la mort (urs) de Baba Farid Ganj Shakar, et de formuler des recommandations pour les activités de planification et de prévention. Un système de surveillance a été mis en place afin de relever les données sanitaires pour l’événement. La liste des maladies à déclaration obligatoire a été établie. Les données ont été recueillies en trois phases (avant, pendant et après l'événement) par des agents de santé formés dans ce but. Au total, 5918 personnes se sont rendues dans l’un des quinze établissements de santé qui fournissaient des services pendant l'événement. Les maladies transmissibles étaient à l’origine de 58 % des consultations, dont 21 % pour des infections des voies respiratoires et 26 % pour des maladies gastro-intestinales. Les traumatismes et les maladies non transmissibles représentaient respectivement 31 % et 11 % des cas. L'évolution de la prévalence des maladies à déclaration obligatoire pendant l’événement a enregistré une hausse significative. Toutefois, aucune flambée épidémique majeure n’a été constatée. éíúÐëhmSºëmSm<ºÑmeTкSm<o^ImaXºzw|Qm<m<ÒmQToweTÐî|S{TÐØY"Ðz@Ì9ogXd^TÐoZTÐzÉ´|= 2010EdwØ }`ÉÐØÐ@niÐÚºë5dH êºÚÐ{aÉniÚºsh=EYÌÐÛEYºêÐ}TÎx{iºÛnhYÐniÚºAoh_I pfx{e=} óc óIsin@{x}Rn=n=ÒnRUpxfUÐî}T|UÐÊnhAüïfUÐ{Z"ÐÊnf?ÌÔ{ĻUÐph[UÐÓĆcZCÐDLæ}´_UÐOÎpHÐÚ{UÐì|wæ{*oåÉ°#Ð ì|)pÉn#Ðíp[Un=p]>}CÐÓninhUÐhU{É´GdUðnYn^iëAnUÐ í{Sí pxnSUÐíh]UÐp]ZiÌ:{haô> ÓnhÉ> RÚíºënTn=ºTn= n*nhUn_RéĆBípHnfCÐì|wÓnhUn_RçĆ]iÐSÓninhUÐ e=ë= Ú{ ôYëhÉëdYnLênSí ngfLãĆ=üÐo@ÐUÐßÐ}Yún=peýnSÓ { õLôÌ5T pHnfCÐ o=ÓÐÚnZHøÐY%58ënTíÅpHnfCÐì|wéĆBn*nY{Bê ¬{bô>UÐph[UÐpxnL}UÐRÐ}YYðnbR}Y15DLðÐØ}R5918<n+ÎØØ}>{Sí ngýngiÐ{_=í ßÐ}YúÐqdY5fh=ºÓøn"ÐY%31Ón=nÉüÐqdYí e\4ÐÛng!ÐßÐ}YÌo=%26íº¢afUÐÛng!Ðîí{Lo=ngfY%21pxÚnUÐßÐ}YúÐ 3í pxÚnUÐßÐ}YúÐ:ÒETÒØnxÛpHnfCÐì|4ÔĆUÐAÐ}CÐ:ngfLãĆ=üÐcexUÐßÐ}YúÐÚnZiÐé{_Y:ÓÐE´`UÐ} õg^ô>í %11pxÚnUÐEQ ßÐ}YúÐY ĄïúÒETphInRÔí{A óAĆôx HCÐçPUph[UÐpdCÐPL HnUÐ{dCÐ 2:nüÐØ{_UÐ S25 Introduction Event history Pakpattan is located 180 km from Punjab’s provincial headquarters, Lahore. According to district health department data, the population is 150 000. The anniversary of the death (urs) of Baba Farid (Hazrat Faridud- din Mas'ud Ganjshakar) is observed in this city during the first 10 days of the Islamic calendar month Muhar- ram. Bahishti Dawaza (the Gate of Paradise) at the shrine of the saint is the centre of the event. This gate is open from sunset to sunrise dur- ing 5–9 Muharram. Thousands of devotees form long queues that may extend up to 5 km. The 768th urs was celebrated from 12 to 16 December 2010. The actual celebrations started on 8 December 2010 (1 Muharram). Devotees from across the world started arriving in the city as early as 3 December. The Bahishti Dawaza was opened at sunset 12 December and closed each morning before sunrise. This practice continued till 16 De- cember 2010. Previous experiences The event is celebrated every year but there is no record of disease frequen- cies or injuries for previous years. There have been reports, however, from local health clinicians of increased numbers for a range of diseases, particularly gastrointestinal conditions, respira- tory illnesses, and injuries. In previous years there has been no established surveillance system for such events in Pakistan, so most health events went unrecognized and uninvesti- gated. In 2001, 27 people lost their lives in a stampede and another 125 were injured [1]; afterwards extensive security arrangements were made to prevent any such occurrence in the future. Temporary gates and walls are installed before the urs to control all roads leading to the shrine. This is done to manage human as well as automobile traffic. Narrow passages are constructed using metallic bars leading to Bahishti Dawaza so peo- ple can safely walk through the door. These gates and walls are removed after the event. On 25 October 2010 (around 6 weeks before this event), about 6 peo- ple died and more than a dozen were injured in a bomb blast at the shrine [2]. Due to the intensity of religious senti- ments attached to events such as these, there is always a threat of terrorism, and this can pose serious issues in regard to public health response. Public health importance Mass gatherings over extended periods of time pose unique challenges to the existent systems [2]. The urs of Baba Farid attracts people from all walks of life; the local health administration es- timates about 500 000 people attended the event in 2010. Large gatherings such as this one held in small towns or cities strains the local administra- tion, which has to allocate additional resources to manage the event [3]. A large number of security personnel from adjacent districts are deputed to ensure the security and safety of at- tendees. The numbers and diversity of the population attending the event poses many challenges. Such large numbers gathered in close quarters for variable periods of time pose a risk of spreading communicable diseases, particularly respiratory and gastrointestinal ail- ments. There is a high risk of outbreaks in such gatherings. Overcrowding of the streets with people and vehicles leads to road traffic accidents. Many hotels in the city are booked to capac- ity forcing people to stay on the pave- ments on open streets. People with various diseases visit the shrine in the belief that they will be cured. People are obliged to eat on the roadside, buy- ing food from mobile vendors. Such practices make them susceptible to gastrointestinal problems. Aim The aim of this study was to determine the prevalence of communicable and noncommunicable diseases and injuries important to public health at this annual event. This information could be used to prevent both diseases and injuries and therefore may lead to healthier and safer mass gatherings in future. Specifi- cally, we aimed to: r identify stakeholders and include them in surveillance implementation and response; r prioritize diseases under surveillance and collect data from selected sites; r analyse the collated data and dissemi- nate information for timely action; r make recommendations for future events. Methods After gaining approval from the local administration to carry out surveil- lance at this mass gathering event, a list of stakeholders was prepared. The local administration and the health and rescue departments were involved in implementing this surveillance system. Representatives of the security agencies were also an integral part of the system. Stakeholders agreed to a high prior- ity risk assessment exercise and daily evening coordination and debriefing meetings. The local health department ran a campaign on disease prevention and hygiene. A pre-event risk assessment exer- cise was undertaken a few weeks prior to the urs; this included reviewing any data available at local health depart- ment and local administration office from previous experience. The most important considerations were dis- eases prevalent in the area, especially those with an outbreak potential, and environmental factors, which included both weather conditions and the na- ture/characteristics of the crowd, e.g. enormous crowds performing rituals EMHJ r 7PM 4VQQMFNFOU &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF S26 and activities both indoors and out- doors, extended exposure, and mobil- ity in large open spaces and in small closed areas. Security and terrorism threats during the event were also con- sidered. The initial assessment exercise resulted in a breakdown of priority dis- eases into 3 main groups of reportable diseases/conditions: communicable diseases, noncommunicable diseases, and physical trauma and injuries. Re- portable conditions were: r respiratory tract-related illness r chronic obstructive pulmonary disease r asthma r gastrointestinal tract-related illness r diarrhoea r dyspepsia/gastro-oesophageal re- flux disease r febrile illness r malaria r fevers other than malaria r chronic disease r ischaemic heart disease r hypertension r diabetes r injury resulting from: r road traffic crashes r falls r riots. Based on the priority disease list, a hybrid syndromic and injury surveil- lance procedure was established. All 15 health facilities providing health care around the locations of this event were selected for collection of data: 8 public, 6 private and 1 nongovern- nmental (NGO)-based. Public health sector facilities were established within and near the shrine area as usual for this event and these were provided with medicines and first aid kits by the local health department. Health facil- ity counters established the purposes of this survey were made prominent with banners and signboards. Staff at these facilities had pre-event training on tasks like case definitions and pa- tient data recording and sharing. After initial medical care, patients could be referred to the main district hospital if necessary. Patients were treated even if they were not willing to participate in the survey or share their information. Almost all those treated agreed to participate and all were as- sured that their identity would remain confidential and would not be shared without their consent. Everyone attending the selected health care facilities, irrespective of their permanent place of residence, was included in this study. Case definitions Case definitions were developed based on history and clinical examina- tion, discussions with general physi- cians, and consultation of standard references [4,5]. Case definitions were pre-tested at the district health facility as a part of the pre-event phase Table 1 Case definitions used for patients presenting at participating health facilities during the mass gathering for the urs of Baba Farid, Pakpattan, December 2010 Condition Case definition Acute respiratory illness < 4-hour history of cyanosis or dyspnoea, plus Breathing rate (for age group): ō 40/min (< 1 year) ō 30/min (1–5 years) ō 20/min (> 5 years) Asthma At presentation history of at least 2 recurrent episodes of: ō cough ōdyspnoea ōwheeze Chronic obstructive pulmonary disease At presentation history of at least 2 recurrent episodes of: ō cough ō sputum ō history of smoking Dyspepsia At presentation having at least 2 recurrent episodes of: ō anorexia ō vomiting ō tender epigastrium Diarrhoea Presenting with complaint of > 2 loose stools in 1 day Hypertension Having a single record of blood pressure > 140/90 at the time of presentation Ischaemic heart disease History of ischaemic heart disease or complaining of chest pain on exertion at presentation Diabetes mellitus Presenting with history of diabetes or blood sugar levels recorded as: ō fasting blood sugar > 7 mmol/L ōor random blood sugar > 11.1 mmol/L Malaria History of episodes of fever with chills and malaria positive confirmed by rapid diagnostic tests at health facility counter Other febrile cases Fever recorded as > 100 °F due to any illness except malaria HCÐçPUph[UÐpdCÐPL HnUÐ{dCÐ 2:nüÐØ{_UÐ S27 and edited based on the diversity of symptoms encountered (Table 1). For injury surveillance at this venue, road traffic accidents, falls, riots or stampedes during the event were recorded. Data collection and analysis On-site, temporary health facility coun- ters were established to provide health care and surveillance. Staff at these facilities were trained to carry out the survey. A central data collection unit was established in the control room at the executive district health office and all the public health surveillance activities were coordinated there. In consideration of the outbreak potential, increased numbers (more than the usual levels) of high impact events like food- or waterborne illnesses and mass injuries had to be reported by telephone as early as possible. Daily data collation and the database were managed using Microsoft Excel. Results A total of 5918 consultations were recorded at the 15 selected health facilities. Most of the patients (76.2%) reported at the 8 public sector fa- cilities, 18.5% reported at the 6 private facilities, while 5.3% reported at the 1 NGO facility. Case definitions were agreed for 4896 of the patients. About 80% of the complaints were about reportable, high priority diseases. The majority (67%) of the reporting pa- tients were male. Among the reportable diseases, ob- served frequency 58% of consultations were for communicable diseases dur- ing the event period. This was up from 51% during the week prior to the event (Table 2). Among the communicable diseases, respiratory tract infections ac- counted for 21% and gastrointestinal in- fections for 26% during the event phase. Although the majority of the pa- tients reported at the public sector health facilities, the data from the private and NGO sectors were also important (approximately 24% of the total record- ed encounters). There were participants of all ages, but the majority (62.3%) were aged 15–49 years. The second largest group was those aged 50+ years (23.3%). Prevalence of acute respiratory illness showed the most dramatic in- crease, rising from 6.7 per 100 000 in the week before the event to 167.0 per 100 000 during the event (Table 3). Prevalence of diarrhoea and dyspep- sia increased considerably, from 6.0 and 4.0 per 100 000 to 82.0 and 114.0 per 100 000 respectively. Among the chronic diseases, the greatest increase in prevalence was for hypertension, from 12.0 per 100 000 in the week prior to the event to 66.0 per 100 000 during the event. Malaria prevalence showed no appreciable change, however, during the event period, prevalence of fever other than malaria was reported as 72 per 100 000 (Table 3). Discussion Communicable diseases accounted for the greatest number of visits to healthcare facilities in all 3 phases of the event. There were some small clusters reporting identical health related complaints; district health departments and other response units were informed on a real-time basis, but no outbreaks or common sources were found. There were mo- bile vendors selling food in the city without any inspection of hygiene practices or food quality. Failure of various efforts to capture any com- mon source for the gastrointestinal- related conditions may be because these vendors changed location frequently as well as the huge influx of people and overcrowding during the event. Before the event started, the city experienced a great influx of vehicles. This not only put a strain on the traf- fic system but also contributed to air pollution. The number of road traffic accidents and respiratory tract-related illnesses are also a result of the heavy traffic influx. This study had certain limitations. As health facilities were scattered around the event centre over different parts of the city, this may have resulted in some cases reporting to more than 1 facility to seek support at various times during the course of the same illness. Owing to resource limitations, we had a limited workforce available for case Table 2 Distribution of medical conditions according to type recorded during the three phases of the mass gathering for the urs of Baba Farid, Pakpattan, December 2010 Type of disease/condition Pre-event (n = 74) During event (n = 4719) Post-event (n = 103) Total (n = 4896)a No. % No. % No. % No. % Communicable 38 51 2742 58 49 48 2829 58 Noncommunicable 23 31 504 11 33 32 560 11 Injury 13 18 1473 31 21 20 1507 31 Pre-event (phase 1) = the week before the event. During event (phase 2) = over the 10 days of the event. Post event (phase 3) = the week after the event. aOf the 5918 patients recorded and treated in total, case definitions were agreed for 4896. EMHJ r 7PM 4VQQMFNFOU &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF S28 1. Fatal stampede at Pakistan festival. London, BBC News (web- site), 2001 (http://news.bbc.co.uk/2/hi/south_asia/1254207. stm, accessed 13 October 2013). 2. Khan OF. Bomb blast at Sufi shrine in Pakistan kills 6, injures 16. Ahmedabad, Times of India (website), 2010 (http:// articles.timesofindia.indiatimes.com/2010-10-25/paki- stan/28254457_1_pakpattan-shrine-abdullah-shah-ghazi, ac- cessed 13 October 2013). 3. Polkinghorne BG et al. Prevention and surveillance of public health risks during extended mass gatherings in rural areas: the References experience of the Tamworth Country Music Festival, Australia. Public Health, 2013, 127(1):32–8. 4. 2010 National notifiable infectious conditions. Atlanta, Geor- gia, Centers for Disease Control and Prevention, 2010 (http://wwwn.cdc.gov/NNDSS/script/ConditionList. aspx?Type=0&Yr=2010, accessed 13 October 2013). 5. Colledge NR, Walker BR, Ralston SH (eds). Davidson's prin- ciples and practice of medicine, 20th ed. Edinburgh, Churchill Livingstone, 2010. follow-up, active case finding and con- tact or source tracing. It is possible there were more cases who did not report to the health facilities or who sought over- the-counter treatment. The source of the significant rise in acute respiratory infections during the event could not be verified because of the limited labo- ratory resources available. An improved traffic control plan, put in place prior to the event, may serve to decrease traffic-related injuries. Local health and other related depart- ments should collaborate to improve sanitation and food quality for this mass gathering. In future, during such events laboratory services should be considered part of the surveillance systems. It is necessary to have surveil- lance mechanisms in place so that the health events are both recorded and responded to. The participation of a trained epidemiologist may prove helpful in case investigations of report- able diseases during future events. Although we did not directly ex- perience a terrorist attack during our study, considering the current wave of such attacks, local administrative and health departments should be trained for disaster management in order to deal with any unforeseen event. Lastly, surveillance should con- tinue, not only for this event, but for other mass gatherings in Pakistan and a comparative study over the coming years needs to be implemented so that common health problems at mass gath- erings are seen holistically. The data collected would lead to the implemen- tation of adequate preventive measures that would improve community health and make such gatherings safer. Acknowledgements We wish to thank the following people for their support during this study: r Provincial Secretary for Health, Gov- ernment of Punjab, Lahore; r Director General for Health, Govern- ment of Punjab, Lahore; r District Coordination officer, Pakpat- tan District; r Executive District Officer Health, Pa- kpattan District; r Executive District Officer Health, Muzafar Garh District; r Medical Superintendent, District Headquarter Hospital, Pakpattan District; r Medical Superintendent, Tehsil Headquarters Hospital Ali Pur, Mu- zafar Garh District; Table 3 Prevalence (per 100 000) of selected conditions treated at 15 healthcare facilities providing services for the mass gathering for the urs of Baba Farid, Pakpattan, December 2010 Condition Pre-event During event Post-event Acute respiratory illness 6.7 167.0 7.3 Asthma 4.7 3.5 6.0 Chronic obstructive pulmonary disease 2.0 13.5 3.0 Hypertension 12.0 66.0 14.0 Malaria 2.0 5.0 0.0 Other fever 0.0 72.0 0.0 Diarrhoea 6.0 82.0 8.7 Dyspepsia 4.0 114.0 7.0 Pre-event (phase 1) = the week before the event. During event (phase 2) = over the 10 days of the event. Post event (phase 3) = the week after the event. HCÐçPUph[UÐpdCÐPL HnUÐ{dCÐ 2:nüÐØ{_UÐ S29 ABSTRACT During the 5-day Eid Al Adha holiday, Aqaba is the site of one of the largest mass gatherings in Jordan. Public health concerns during this holiday included: food- and waterborne diseases, drowning, injuries by marine creatures, road traffic crashes, and pressure on emergency departments at hospitals. This cross-sectional study was carried out in Aqaba during the period 16–20 November 2010 and aimed to identify and prioritize the major public health risks and to overview the preparedness plans of the Health Directorate during previous Eid events in Aqaba. All related stakeholders participated in the study. An exploratory visit to Aqaba was made and an introductory workshop was conducted for participants. Relevant data were collected and compared with the figures for the week prior to the event. No food poisoning outbreaks were reported during the event. There was a 23% increase in emergency department attendance, a 33% increase in hospital admissions, and road traffic crashes increased by more than 300%. More males were affected than females. Mass gathering in Aqaba, Jordan, during Eid Al Adha, 2010 S. Abdullah,1 G. Sharkas2 N. Sabri,2 I. Iblan,2 M. Abdallat,1 S. Jriesat,3 B. Hijawi,3 R. Khanfar 4and M. Al-Nsour 4 1Communicable Disease Directorate; 2Jordan Field Epidemiology Training Programme;3Primary Health Care Administration,Ministry of Health, Amman, Jordan (Correspondence to A. Sultan: sultanmabdalla@yahoo.com). 4Eastern Mediterranean Public Health Network (EMPHNET), Amman, Jordan. Rassemblement de masse à Aqaba pendant l’Aïd Al-Adha (Jordanie), 2010 RÉSUMÉ Pendant les cinq jours de l’Aïd Al-Adha, Aqaba est le théâtre d’un des plus grands rassemblements de masse en Jordanie. Durant ce congé, les problèmes de santé publique sont notamment les suivants : maladies d’origine alimentaire et hydrique, noyades, blessures causées par des animaux marins, accidents de la circulation routière et surcharge des services des urgences dans les hôpitaux. La présente étude transversale avait pour but d’identifier et de hiérarchiser les principaux risques pour la santé, et de présenter les grandes lignes des plans de préparation établis par la Direction de la Santé lors des précédentes fêtes de l’Aïd à Aqaba. Toutes les parties prenantes ont participé à cette étude. Une visite d'exploration a eu lieu à Aqaba et un séminaire-atelier préliminaire s’est tenu à l'intention des participants. Des données pertinentes ont été recueillies et comparées avec les chiffres de la semaine précédant l’événement. Pendant le rassemblement, aucune flambée épidémique due à une intoxication alimentaire n'a été signalée. La fréquentation au service des urgences a augmenté de 23 %, les hospitalisations de 33 % et les accidents de la route de plus de 300 %. Davantage d'hommes que de femmes ont été affectés. 2010ºëØÚúкoa^TÐoewzd<ºúÐzgKÓøm`@Ð9ØY"Ð ÚfUÐ{fgYº}afBnIÚºïínAên=ºÓn[x}@}HºÓø{_UÐ{e7ºëĆ=ÎhwÐ}=κïFÉhiºT ïÛnQºāÐ{Lën]dH ì|wÊnf?ÌphYe_UÐp[UÐæín8pdYÌYí ëØÚúÐ:pxEw5!ÐÓn_eUÐFTÌY{AÐípb_UÐ èÚnCÐúÐ{hLpd]LênxÌ5éĆBoÉ°#Ð DL`Ø@ííºx}]UÐDLEUÐÔØÐAíºpx}UÐÓnfýncUÐo=Ón=nÉüÐíºç}`UÐíºìnhCÐípx|QúÐx}JLpUbfCÐßÐ}YúÐpHnfCÐ ên^i í YºpxUíúÐoAngh>}>ípb_UÐ:úÐ{hLÊnf?Ìphhý}UÐ}JnCÐDLæ}´_UÐOÎpHÐÚ{UÐæ{*í ÓnhaZCn=ÏÚÐ]UÐênSÌ 2010FeRi ©nUÐxP>20OÎ16YÒGaUÐ:pb_UÐpfx{Y:ÓnLn]bdUpdYnIpHÐÚØqx õ}@ôÌ{Sí phhý}UÐphYe_UÐp[UÐæín8{É´GU NTÚnZedUphax}_>phdeLpbdAÐí{bLíºpb_UÐpfx{YOÎphRnZcHÐÒÚnxÛëAnUÐî}@Ì5T ëhf_CÐpd[CÐÑnÉÌpRnTpHÐÚ{UÐì|w:èÚnIí {hLédASpd ôCÐênSÚún=sýnfUÐqi õÚôS{Sí pHÐÚ{UÐì|4ðn[h[BnweeÉÓÐÚ5HÐêÐ{Hn=pd[UÐÓÐÙÓninhUÐÐ_+í pHÐÚ{UÐ: %33íºÏÚÐ]UÐSDLØØGUÐ:%23ÚÐ{be=ÒØnxÛènfwqinTí {h_UÐÒGRÊnf?ÌýÐ|`UÐedUÓnhInRïÌLãĆ=üÐx3í âHj=úÐ ph[UÐæínCn=ÔniüÐYðÐ}?j>}TÌÚT|UÐënTí %300DL{x~x5=pxÚí}CÐÔØÐ"Ðq_a>ÚÐ5TºÓnhaZCn=énBØüÐé{_Y: EMHJ r 7PM 4VQQMFNFOU &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF S30 Introduction Mass gatherings are characterized by large crowds of spectators and partici- pants, and are an increasingly common feature in many cultures. There is growing recognition of public health concerns in mass gatherings. These include water and sanitation manage- ment, emergency preparedness, trans- portation, crowd management and bioterrorism. All of these are challenges to control during mass gatherings [1]. Enhanced surveillance is needed to detect events in a timely manner and to communicate information on public health concerns. Other methods of surveillance during mass gatherings include additional community-based systems and setting up event-specific surveillance [2]. Integration and coI- ordination of surveillance systems is critical to ensuring comprehensive and coherent results[3]. Extensive planning and prepared- ness are required in the provision of public health services for mass gather- ings, and important to the planning is a thorough knowledge of the inci- dence and types of health problems that may occur [4]. Studies have been done at mass gathering events in many countries. In Virginia, United States of America, health authorities conducted a daily syndromic surveillance to monitor diseases symptoms and injuries at a sport summer camp. Gastroenteritis outbreaks and heat-related injuries were recorded [5]. A study conducted at a 9-day agricultural and horticultural show in Australia in 2002 demonstrated the high injury burden and the increased strain this placed on medical services [6]. Another study in Australia during a World Youth Day celebration in 2008 showed that implementing continuous re-evaluation of case definitions and ongoing laboratory testing helped in the early identification of an influenza outbreak among attendees [7]. All this suggests a definite role for planning strategies to reduce injury outcomes, including live surveillance of injury type and cause, risk management and public education. Many mass gatherings are held in the Middle East and North Africa re- gion, however only the Hajj has been addressed in the literature [8,9].This is one of the largest mass gathering events in the world: millions of pilgrims from almost every country gather annually over several days. Throughout its long history, Hajj has been witness to a series of major health issues, with respiratory infections the most frequently reported complaints [10].There is also the poten- tial for further spread infectious diseases when participants return home from mass gatherings. This was demonstrated after Hajj 2000 and 2001,when clusters of meningococcal cases (serogroup W135) were reported [11]. These were linked to either a history of recent re- turnees from the Hajj or of household contact with returned pilgrims. The lack of information regarding other mass gatherings in the region has highlighted the importance of concen- trating on this ignored area, which is of great consequence to public health. Jordan has a population of 6 million [12]. It has a stable political, social, and economic situation that encourages hundreds of thousands of people to visit the country. Annually, many mass gathering events are held, including re- ligious, cultural, and recreational events. To the best of our knowledge, no stud- ies have been conducted to investigate public health concerns during such mass gatherings in Jordan. Aqaba, population 70 000, is the only coastal city in Jordan. It is located on the Red Sea 350 km south of the capital, Amman. It is visited by large number of people, mainly young adults and families, from Jordan, the region, and other countries for tourism. Aqaba is also a duty free zone, and is visited for trading purposes. The number of visitors increases greatly during Eid, a Muslim religious occasion, and a na- tional holiday in Jordan. Eid Al Adha (5 days) occurs during the Hajj. The timing depends on the Islamic (Hijri) calendar, which is 11–12 days shorter than the solar year. The majority of visitors come to Aqaba by car via the Dead Sea highway and the Desert highway. Visitors participate in a number of activities including swim- ming, cruising, and shopping. The aims of this study were to over- view the preparedness plans executed by Aqaba Health Directorate and other stakeholders during previous Eid events in Aqaba and review the success, effec- tiveness, and limitations of these plans. We also aimed to identify, prioritize, and analyse public health risks during the Eid mass gathering, and create tools for the surveillance of public health concerns that are not included in the current Jordanian surveillance system, e.g. drowning. Methods Eid Al Adha vacation lasted for 5 days (16–20 November) in 2010. The expected number of visitors to Aqaba during this period ranges from 30 000 to 70 000. Our study was multisectoral; stake- holders (partners in this project) in- cluded: the Communicable Diseases Directorate; Aqaba Health Directorate; the Islamic Hospital; the Modern Aqa- ba Hospital; Princess Haya Hospital; Aqaba Governorate; the Police Direc- torate; the Civil Defence Directorate; Aqaba Special Economic Zone Author- ity; and the Tourism Directorate. The existing surveillance system in Jordan is basically passive (notification by health facilities), and is monitored by the Ministry of Health Directorate of Communicable Disease. The list of about 45 notifiable diseases and events is divided into 2 groups: Group A, diseases which must be notified to the public health authorities within 24 HCÐçPUph[UÐpdCÐPL HnUÐ{dCÐ 2:nüÐØ{_UÐ S31 hours (e.g. cholera, food poisoning) and Group B, diseases and events that must be notified via the weekly report (e.g. chicken pox, hepatitis) [13]. For surveillance purposes,health centres, clinics, and hospitals report to one of the 21 reporting sites, which in turn report to the Directorate of Communicable Diseases. Health facilities in Aqaba include 1 military hospital (127 beds), 2 private hospitals (40 beds each), 4 Ministry of Health health centres and many private clinics. All of these facilities report to Aqaba Health Directorate. Aqaba Special Economic Zone Au- thority is responsible for food safety, and during Eid the authority strength- ens the measures on food safety in the city to prevent food poisoning outbreaks. In the event of an outbreak food poisoning, the epidemiological investigation is done by the surveil- lance department in Aqaba Health Directorate under the supervision of the Directorate of Communicable Diseases, while food and environ- mental investigation is done by the Aqaba Special Economic Zone. The Food and Environmental Depart- ment in Aqaba Health Directorate is responsible for water safety in the city in collaboration with the Directorate of Environmental Health in Amman. Sources for drinking water and the water network are tested chemically and biologically. Once contamina- tion is detected, provision of water is discontinued immediately till the contamination is removed. Preparedness The main stakeholders in Aqaba, such as hospitals, the Health Directorate and the police administration, were visited by the Field Epidemiology Training Programme study team on 20 October, 2010. These visits aimed to examine the experiences of all part- ners during previous Eid holidays, the expected number of visitors, and the preparedness of each partner for the coming Eid holiday. Visits also targeted hospitals to check their capacity to deal with expected events. An introductory workshop was conducted on 20 Octo- ber 2010, where the study objectives, its importance to public health, and cooperation between stakeholders were addressed and discussed. The available data from hospitals, police administration, and Civil De- fence administration for the Eid events during the previous 2 years were analysed to assess public health con- cerns during the holiday. These data included the number of patients who attended emergency departments, numbers admitted to hospital, and numbers of road traffic crashes and drownings. Preventive measures were also identified. These were discussed and agreed upon by stakeholders so they could be implemented during Eid Al Adha 2010. Surveillance system for the Eid event, 2010 This cross-sectional study was approved by the Ministry of Health and Aqaba Governorate. Surveillance activities began 14 days before the event and extended until 10 days afterwards. An enhanced surveil- lance system was conducted between 2 and 30 November 2010. The existing surveillance system was enhanced by: r operating an additional paper-based reporting system from hospitals, po- lice administration, and Civil Defence administration; r increasing the frequency of reporting from weekly to daily (case definitions were the same as in the surveillance guidebook); r including drowning in the system; r enhancing laboratory capacity and reporting by facilitating the immedi- ate delivery of laboratory samples to Amman in cases (e.g. meningitis and food poisoning) where the local laboratory is not qualified to perform the tests; r enhancing awareness among clini- cians during visits of the FETP team to hospitals; r training clinicians on the new paper- based surveillance system and case definitions of diseases; r strengthening ties with clinicians and other partners; r collecting data on a form specifical- ly designed for the purposes of the study, covering age, sex, nature and time of the concern, and outcome. During Eid Al Adha, the Jordan Field Epidemiology Training Programme team as well as the Ministry of Health focal point were present in Aqaba. Daily meetings to follow the situation with relevant focal points, receiving and re- viewing daily reports, and daily visits to health facilities were among the team activities during the event. Post event activities A closeout workshop was held in Aqaba on 3 December, 2010 to present the study. Previous data review No baseline data could be drawn up owing to the poor quality of the information in there porting forms. The reports from hospitals, the police administration and the Civil Defence administration during 2008 and 2009 were in the main administrative rather than epidemiological. Risk assessment Through reviewing the reports as well as from discussions with stakeholders, the following public health issues were given priority since all are of high likeli- hood and have urgent consequences: r food- and waterborne diseases, r drowning, r injuries by marine creatures which are present in the Red Sea, r road traffic crashes, r pressure on emergency departments at hospitals. EMHJ r 7PM 4VQQMFNFOU &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF S32 Table 2 Distribution of public health concerns according to sex, Eid Al Adha, Aqaba, 2010 Incident Males Females No. % No. % Emergency room attendance 905 53 861 47 Hospital admission 39 52 36 48 Drowning 5 71 2 29 Injury caused by marine creatures 19 87 3 13 Road traffic crash 36 92 3 8 Preventive measures The following preventive measures were introduced: r strengthening of control measures on food and drinks street vendors to pre- vent food- and waterborne diseases; r preparedness of health facilities includ- ing health personnel, equipment, etc.; r establishing a mobile health station on the beach to deal with emergency cases promptly and effectively; r advising people to swim in safe places and only where lifeguards are avail- able (health messages were delivered via signs/signals placed on beach); r banning driving in specific streets identified (based on previous experi- ence) as being crowded with pedes- trians; r banning visitors from camping in the streets and other areas in the city. Results During the 5 days of the event, the weather was moderate with tempera- tures ranging between 15 °C and 29 °C. The number of drownings increased from 0 in the previous week to 7 during the event. There was a more than 3-fold increase in road traffic crashes. No food poisoning outbreaks were detected dur- ing the study period. The main public health events are shown in Table 1. Males accounted for 92% of road traffic crash victims, 87% of injuries by marine creatures, and 71% of drownings (Table 2). There were 39 road traffic crashes during the Eid period. Collisions were the most common type (69%) followed by being run over (18%) (Table 3). All the preventive measures that were introduced were implemented except preventing camping in the streets. Discussion For this study, the reviewed data and reports from previous similar events in Aqaba demonstrate the poor capacity of the existing surveillance system to identify cases of public health con- cern during mass gathering events. To ensure public health safety during mass gatherings, the surveillance sys- tem must provide sufficient numerical findings to plan, implement, and evalu- ate public health actions related to the event. Our results showed a considerable increase in the occurrence of certain public health risks during the Eid holiday in Aqaba even though many preventive measures had been implemented. Large numbers of participants in mass gather- ings usually lead to increased demand on food vendors;consequently, the in- cidence of foodborne diseases often in- creases. A study in Saudi Arabia showed that diarrhoea was the third most com- mon cause of hospitalization during the Hajj [14]. Many factors may contribute to this problem including inadequate standards of food hygiene, shortage of water, the presence asymptomatic car- riers of pathogenic bacteria, and inap- propriate storage of food. However,the strict monitoring measures on food and water safety in force during the event we studied may explain the absence of food poisoning outbreaks. The health authorities responded appropriately Table 1 Variation in public health concerns during Eid Al Adha, Aqaba, 2010 Incident No. of cases in week before Eid No. of cases during Eid Increasea Road traffic crash 11 39 345% Hospital admission 56 75 33% Emergency room attendance 1442 1766 23% Injurycaused by marine creatures 0 22 +22 Drowning 0 7 +7 Food poisoning 0 0 0 aExpressed as percentage or absolute number. HCÐçPUph[UÐpdCÐPL HnUÐ{dCÐ 2:nüÐØ{_UÐ S33 1. ThackwayS et al.Should cities hosting mass gatherings invest in public health surveillance and planning? Reflections from a decade of mass gatherings in Sydney, Australia. BMC Public Health, 2009, 9:324. 2. Kaiser R, CoulombierD. Epidemic intelligence during mass gatherings. Eurosurveillance, 2006, 11(51):21. 3. Communicable disease alert and response for mass gather- ings. Key considerations. Geneva, World Health Organization, 2008. 4. Tsouros AD,Efstathiou PA (eds). Mass gatherings and public health. The experience of the Athens 2004 Olympic games.Co- penhagen, World Health Organization Regional Office for Europe, 2007. 5. Surveillance for early detection of disease outbreaks at an outdoor mass gathering – Virginia, 2005. MMWR, 2006 55(3):71–74. 6. Zeitz K, Zeitz C, Kadow-Griffen C.Injuryoccurrences at a mass gathering event. Journal of Emergency Primary Health Care (on- line), 2005, 3(1-2) (Article No. 990098). 7. Blyth CC et al. Influenza outbreaks during World Youth Day 2008 mass gathering.Emerging Infectious Diseases. 2010 May; 16(5):805–819. References 8. Shafi S et al. Hajj: health lessons for mass gatherings. Journal of Infection and Public Health, 2008, 1:27–32. 9. Al-Azeri A et al. Meningococcal carriage among Hajjis in Makm- kah, 1421 H. Saudi Epidemiology Bulletin, 2002, 9(1). 10. Shafi S et al. Hajj: health lessons for mass gatherings. Journal of Infection and Public Health, 2008, 1:27–32. 11. Aguilera JF et al.; W135 Working Group. Outbreak of sero- group W135 meningococcal disease after the Hajj pilgrimage, Europe, 2000. Emerging Infectious Diseases, 2002, 8:761–767. 12. Department of Statistics [Jordan] and ICF Macro . Jordan Popu- lation and Family Health Survey 2009. Calverton, Maryland, USA: Department of Statistics and ICF Macro, 2010. 13. [Jordan Surveillance Guidebook]. Amman, Directorate of Com- municableDiseases, Ministry of Health, 2010 [in Arabic]. 14. Al-Ghamdi SM et al. Pattern of admission to hospitals duri- ing Muslim pilgrimage (Hajj). Saudi Medical Journal, 2003, 24(10):1073–1076. to the increased population during the Eid event. The number of hospital admissions and emergency cases increased notice- ably during the Eid period. The location of Aqaba so far from other cities may also have increased the load on the city health facilities. Swimming is one of the main ac- tivities enjoyed by visitors, since the Gulf of Aqaba is the foremost place in Jordan for outdoor swimming. Many visitors, however,go swimming without adequate training. These are the most likely reasons for the increase in drown- ing cases and injuries by marine crea- tures during the Eid event. This would, of course, be reflected in the increase in hospital admissions. Most of the participants use their own cars to visit Aqaba. Thus, the vastly increased number of vehicles within a small confined area resulted in the huge increase recorded in the number of traf- fic crashes, again having an effect on the hospital admission figures. There was a predominance of males in the public health conse- quences during Eid in Aqaba, particu- larly for drownings, injuries caused by marine creatures and road traffic crashes. The greater numbers of males taking part in these activities is likely to be the reason for this. Recommendations There is a need to strengthen the pre- ventive measures during the Eid holiday period in Aqaba. The enhanced surveil- lance system that was put into place was effective in linking the related sectors with the public health situation on a daily basis. r A permanent committee should be established headed by the health au- thorities to deal with public health issues during Eid. r This study should be shared with decision-makers to highlight the im- portance studies on mass gatherings. r Rigid control measures on food and water safety should be continued. r Educational pamphlets should be prepared for future Eid events target- ing road traffic crashes, downing, and injuries by marine creatures. These pamphlets should be distributed to visitors before they arrive in Aqaba. r Assess the safety of beaches and the possibility and efficacy of employing lifeguards. Table 3 Distribution of road traffic crashes according to type, Eid Al Adha, Aqaba, 2010 Type No. % Collision 28 72 Run over 7 18 Overturning 4 10 Total 39 100 EMHJ • Vol. 19 Supplement 2 2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale S34 ABSTRACT Objectives: To identify the occurrence of upper respiratory tract infections (URTI), diarrheal diseases and trauma during the Hajj season, and the practice of some preventive measures by pilgrims. Methods: A cohort study during November and December 2009 among hajjis registered while visiting Primary Health Care Centers of Riyadh, Kingdom of Saudi Arabia to get mandatory meningococcal meningitis vaccination. On return from hajj, hajjis were contacted on telephone to collect information on occurrence of URTI and diarrhea along with other associated activities in Hajj. Results: Out of 1507 hajjis, 54.7% developed symptoms; 97% reported upper respiratory tract symptoms, and 9.3% reported diarrheal symptoms. Those <40 years of age were more likely to develop an URTI. The incidence of diarrheal diseases or trauma was not statistically associated with age. No statistical difference for educational level was found for URTI or trauma, but there was a statistically significant difference for diarrheal diseases. There was no statistical difference for nationality in relation to diarrheal diseases and trauma, but there was a statistically significant difference for URTI. There was a statistically significant difference of URTI between those pilgrims who used the face mask most of the time and those who used it sometimes. Conclusion: Upper respiratory tract infections is a common health problem among studied domestic hajjis. Generally, there is room for improvement in the adoption of preventive measures by hajjis; and there is still limited information on the use of facemasks in spite of the fact that using it significantly decreases the risk for URTI. N=p_CÐphýnSUÐÓÐÊÐ}@üÐís"ÐHYÊnf?ÌÓn=nÉüÐíéngHüÐíïd_UТafUÐÛng!ÐßÐ}YÌÔí{Aé{_Y{x{ĻæÐzvúÐoåÉ°#Ð phUíúÐph[UÐpxnL}UÐ~TÐ}e=NdCÐÕn"ÐN=ê2009FexØOÎFeRiYÒGaUÐéĆBph_]bCÐpHÐÚ{UÐì|wqx}@ôÌoaw|\TÐ Õn"Ð p=nÉüÐL4ÐkH>rhA>n4ÐéĆBYs"ÐY*ØLÚRÕn"ÐYÓninhUÐ +>{Sí ýnUÐÑngUøÐh_]>DLé[dU gfY%54.7p=nÉÎN>ÕnA1507N=YrýmeTÐ s"ÐÊnf?Ìp_CÐphýnSUÐÓnhTdUÐOÎpRnün=ºéngHüÐíºïd_UТafUÐÛng!ÐßÐ}Yj= p}L}TÌwðnYnL40LwÚ5LÌb>x|UÐÕn"ÐënT{bU éngHÎÓønA%9.3íïd_UТafUÐÛng!n=ngfY%97ënTíºph}YßÐ}Lj= pSĆLØ@íAĆx3í éngHüÐÔí{Aí}e_UÐN=pÐíphýn[AÎpSĆLUnfwcx3iÌ EQºïd_UТafUÐ Ûng!ÐßÐ}Yj=p=nɳU îYN=pxf_YpUøØíÙàn>ÚÐènfwënT5fh=ºÓn=nÉüÐíÌïd_UТafUÐÛng!ÐßÐ}YÌÔí{Aíhd_UÐîYN=pÐíphýn[AÎ pÐíphýn[AÎpSĆLënT5fh=ºÓn=nÉüÐíéngHüÐÔí{Aíphf!ÐN=pÐíphýn[AÎpSĆLØ@íNx35T éngHüÐÔí{Aíhd_UÐ pÐíphýn[AÎp@Ú{=dbxÒ}eYÒÚ[=iúÐíaUÐânfSé5_HÐëÌ ðn\xÌN>5T ïd_UТafUÐÛng!ÐßÐ}YÌÔí{Aíphf!ÐN= x|UÐÕn"ÐN=p_ýnIípYnwpdcZYïd_UТafUÐÛng!ÐßÐ}YÌëj=pHÐÚ{UÐì|wÓ}gKÌo/mA ïd_UТafUÐÛng!ÐßÐ}YÌÔí{AY YhdbUÐ:>ÊnaTYQ}UÐDLðÐØí{7éÐÛnYiúÐíaUÐânfSêÐ{HÐëÌøÎphýnSUÐÓÐÊÐ}@ün={h@cZ=gYÐ~UÐpYnLÒÚ[=y\>Ð ïd_UТafUÐÛng!ÐßÐ}Yj=p=nÉüÐÔí{A Patterns of diseases and preventive measures among domestic hajjis from Central, Saudi Arabia [complete republication] Fahad S. Al-Jasser, Ibrahim A. Kabbash, Mohammad A. AlMazroa, Ziad A. Memish From the Field Epidemiology Training Program (Al-Jasser, AlMazroa, Memish), Ministry of Health, Riyadh, Kingdom of Saudi Arabia and the Public Health and Community Medicine Department (Kabbash), Faculty of Medicine, Tanta University, Tanta, Egypt (iakabbash@gmail.com). This paper was first published in the Saudi Medical Journal, 2012, 33(8):879–886 and is reproduced here with kind permission of the Saudi Medical Journal. It is included in this supplement because the paper arose from one of the studies undertaken by the “Surveillance in Mass Gathering Workshops” for Field Epidemiology Training Program Residents and graduates under the mentorship of Centers for Disease Control and Prevention (CDC)/Eastern Mediterranean Public Health Network (EMPHNET) experts. HCÐçPUph[UÐpdCÐPL HnUÐ{dCÐ 2:nüÐØ{_UÐ S35 Introduction Hajj (pilgrimage) is a yearly event in which more than 2 million Muslims from around the world gather in Mecca, Saudi Arabia. It is the largest annual gathering of its kind in the world bringing millions of people in a small and geographically confined area. All adult Muslims who are physi- cally and financially able to do so have a religious obligation to make the pilgrimage once in their lifetime. The limited time and space in which this mass gathering takes place exposes these hajjis to several risk factors [1]. Overcrowding increases the chances of trauma and transmission of com- municable diseases. Transportation to the Hajj area is mainly through air for international hajjis. Domestic hajjis can reach the Hajj area either by air or surface transport, which is a cheaper mode of transport. Hajjis can use buses for transport within the Hajj area or can move around on foot. In this Hajj season, the services of train transporta- tion between key locations in the Hajj area were made available. A hamla is a company that is specialized in Hajj ser- vices. These hamlas are responsible for travel arrangements, accommodation and food arrangements for every hajji who paid for their services [2–5]. The changing of Hajj season from sum- mer to winter changes the pattern of diseases that are detected among hajjis. Since Hajj season has changed in the last few years from summer to winter, diseases that were seen in summer season (such as heat stroke, food poi- soning and exhaustion) are not seen anymore [6]. In Hajj season diseases are expected to be more common such as influenza, asthma and chronic obstructive pulmonary disease. Dur- ing Hajj rituals, hajjis are exposed to several health risks. Physical exertion is a health risk itself and it can aggravate pre-existing health conditions (such as diabetes mellitus, cardiovascular and renal disease) [2,4]. During animal slaughter, as part of Hajj rituals the risk of exposure to zoonotic diseases is in- creased [7]. Another Hajj ritual which poses a health risk is head shaving for men. Head shaving is performed with razors or blades which if used without changing for several hajjis can transmit blood borne infections ( HIV, hepatitis B and hepatitis C) [8]. Many Hajj stud- ies showed a change in the pattern of diseases detected among hajjis from infectious diseases to chronic diseases [9–11]. Mina is a key place in the Hajj area. It is where the hajji spends the most of the time in the Hajj season (at least 4 days). This relatively long dura- tion account for the burden on health services in this area. Many researchers studied pattern of diseases among haj- jis visiting Mina hospitals. Those cases that reach hospitals are usually the tip of the iceberg and they are mostly advanced stages of the disease, which can be less representative to the real Hajj population [5,12–14]. Currently there is no surveillance system for some hajj-related and post hajj illnesses. The primary objectives of this study were to assess the incidence of selected dis- eases and injuries among hajjis and to use this information by the Ministry of Health (MOH) for future surveillance of specified conditions at the Hajj, and to assess preventive measures practiced by hajjis. Specific conditions of inter- est included upper respiratory tract illnesses (URTI), diarrhoeal illnesses, and injuries. Methods Study setting This cohort study was conducted dur- ing November and December 2009 in Riyadh City, the capital of Saudi Arabia with a population of nearly 5 million. Since there is no common station to identify and recruit hajjis returning to Riyadh from Hajj, subjects were re- cruited as they sought their required pre-Hajj meningococcal vaccination. Riyadh City has 87 primary health care centres (PHCC) that give meningococ- cal vaccination as an obligatory require- ment for those who will perform the Hajj. These PHCC are distributed in 7 health sectors. The number of PHCCs in each health sector ranges from 7-20 centres. Therefore, the study population consisted of all adults older than 20 years of age living in Riyadh City with the intention to perform the Hajj in 2010, who sought their required menin- gococcal immunization at a PHCC. Vaccinations started on 16th October 2010 and continued on daily basis until 7 November 2010, which was the first day in the Hajj season. Case definition For the purpose of this study, URTI was defined as any person who reported having developed at least one of the con- stitutional symptoms (fever, headache, myalgia) and one of the local symptoms (running nose, sneezing, throat pain, cough with /or without sputum) after reaching Makkah for the Hajj or within 2 weeks from return to Riyadh [15]. Diarrhoea was defined as the passage of 3 or more loose or liquid stools per day after reaching Makkah for the Hajj or within 2 days from return to Riyadh to ensure that diarrhoea infection was acquired during hajj period not after return home. Sampling A 2 stage sampling technique was used. In the first stage, Riyadh City was stratified into 7 strata according to the number of health sectors. Simple random sampling of 1-2 PHCC from each stratum was carried out according to the number of PHCC in each health sector. From health sectors with 10 or fewer PHCC, one PHCC was selected. Two PHCC were randomly selected from health sectors with more than 10 PHCC, resulting in a total of 11 centres. In the second stage, study subjects were systematically selected from each of the 11 centres by selecting every third EMHJ • Vol. 19 Supplement 2 2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale S36 person seeking meningococcal vaccina- tion for their Hajj requirement. A sample size of 1499 was calculated using Epi-Info version 3.5.1 to estimate diseases with proportion of 1% or more in the study sample with a precision of 0.5% at 95% confidence level; and was then increased to 1804 to account for the anticipated non-responders. Recruits were asked to give their contact information and consent at the time of recruitment so that they could be contacted 48 hours upon re- turn from the Hajj up to a period of 4 weeks after return. A standardized phone-based questionnaire regarding selected illnesses (which include diabe- tes, hypertension, cardiac diseases, renal diseases and bronchial asthma), injuries, and preventive measures was developed and pilot-tested prior to administering it to returning hajjis. Three trained inter- viewers contacted participants during working hours, with follow-up calls at other times to improve the response. Those who were not contacted after 4 days of attempts were classified as non- responders and were excluded. Statistical analysis The collected data were organized, tabulated, and statistically analysed us- ing SPSS software statistical package version 19. The number and percent- age distribution for each variable was calculated. Observed differences were statistically analysed using Chi square test and risk estimation was carried out using relative risk and 95% confidence intervals. The level of significance was adopted at P<0.05. Results Out of 1804 initial enrolled, 1507 Hajj pilgrims responded and were included into the study. Males predominated the study population (61.7%). The mean age was 37.9 ± 12.1 years with a range of 21–83 years of age. The main nationalities were Saudi and Arabs (84.5%). Hajjis from South Asia com- prised 7.4%, South East Asia 4.9%, and Africa 3.2% of the study population. Half of the study population (49.5%) had a university education, includ- ing Master’s and Doctorate degrees. The occupational status of study participants was reported as 31.4% unemployed, 13.7% manual workers, 21.4% employee, 21.3% professional, 3.8% retired, 4.9% were students, and 3.5% self employed. All participants were vaccinated for meningococcal meningitis. Some hajjis received vac- cines upon their request other than meningococcal meningitis (n = 218); 5.9% were vaccinated against Hepa- titis A, 6.4% against Hepatitis B, and 94.4% were vaccinated for seasonal flu (categories not mutually exclusive). Different modes of travel to Mak- kah were available; 50.6% of hajjis travelled by bus, 20.2% by plane and 29.2% by car. The travel coordination services of a Hamla were utilized by nearly all Hajjis (95.7%). The average length of stay at the Hajj (Makkah and Mina) was 7.04 ± 1.78 days and all but 2 pilgrims were able to complete the Hajj. Illness symptoms were reported by 825 (54.7%) of the returning Hajjis. These symptoms were used to catego- rize participants into disease groups. Of the 825 reporting symptoms, 97% reported upper respiratory tract symp- toms (53% of total studied group), and 9.3% reported diarrhoeal symptoms (5.1% of total studied group) (not mutually exclusive). Of the 825 with symptoms, 51% reported contact with a person having similar symptoms and 43.2% sought medical care at a health care facility whether during hajj or upon return home. Traumatic injuries were reported by 2.9% (Table 1). Face masks were used by 851 (56.5%) of participants. Of those, 216 (25.4%) reported using it most of the time and 635 (74.6%) reported using it sometimes. Of the 577 females in the study population, 333 (57.7%) reported Table 1 Distribution of domestic hajjis in relation to health problems in Hajj Health problems in Hajj n % Having symptoms: n = 1507 Yes 825 54.7 No 682 45.3 Diseasesa n = 825 URTI 800 97.0 Diarrheal diseases 77 9.3 Othersb 16 1.9 Contact with similar case: n = 825 Yes 421 51.0 No 259 31.4 Do not know 145 17.6 Visited any health care facility: n = 825 356 43.2 Trauma: n = 1507 44 2.9 Type of trauma: n = 44 Fractures 1 2.3 Cut wounds 16 36.4 Contusions 13 29.5 Strain 14 31.8 aMore than one disease were sometimes reported. bAllergy, chest pain, hemorrhoids, joint pain, blocked nose, neck pain,sinusitis, sputum, URTI - upper respiratory tract illnesses. HCÐçPUph[UÐpdCÐPL HnUÐ{dCÐ 2:nüÐØ{_UÐ S37 wearing a face cover and 90.1% reported wearing it most of the time while 33 (9.9%) wore it sometimes. Food service was provided by a Hamla for 73.6%; the remainder reported consuming self cooked meals (8.4%) and food from street vendors (18.0%). Consumption of raw food or vegetables from any source was reported by 83.9% and most used bottled water for drinking dur- ing participation in the Hajj (88.9%). (Table 2). The services of a licensed barber were utilized by 392 (70.7%) of the 555 male participants who shaved their heads. Unlicensed barbers (10.1%) and other hajjis (19.3%) were also utilized; 40.3% did not shave. Requests for a new shav- ing blade were made by 95.9%. Scalp wounds from shaving were reported by 13.5%. Few of the hajjis reported being involved in animal slaughter (1.2%). A majority of hajjis washed their hands more than 5 times per day (90.3%). Nearly half of the hajjis used hand sani- tizer during Hajj (45.5%). None of the females reported smoking, and among males, 307 (33.3%) were smokers (Table 2). Selected chronic diseases were re- ported by 278 (18.4%) of study partici- pants. Of those, diabetes was reported in 55.7%, hypertension in 60.7%, other cardiac disease (7.5%), and bronchial asthma (11.5%) (not mutually exclu- sive). Hajjis who had a chronic disease were using their medications regularly (82.0%); of those with a chronic disease, 89.2% reported that they had enough supply of their medications (Table 3). Gender was found to be significantly associated with the occurrence of diar- rhoea were males reported an incidence of 6.3% compared to 3.1% for females (RR=2.03, P=0.006). On the other hand, nationality (whether Saudi or non-Saudi) did not affect the risk of diarrhoea. The incidence of diarrhoea was highest among hajjis who stayed 4 days or less (11.5%). Longer durations of stay were found to have lower risk for diarrhoea, which was lowest for those 7 days of stay where the incidence was re- ported to be 2.9% (RR= 0.25, P=0.021). Source of food, eating raw vegetables, frequency of hand washing and use of hand sanitizers did not significantly af- fect the incidence of diarrhoea among studied hajjis (Table 4). Gender, na- tionality whether Saudi or non-Saudi did not show significant effect on risk of occurrence of URTI. The incidence of UTRIs significantly increased with increased level of education where it was highest among those with primary education (RR= 1.65, P=0.002). Con- cerning duration of stay in hajj areas, those who stayed 8 days or more were significantly suffering from lower risk of infection (RR=0.78, P=0.006) com- pared to other hajjis spending shorter periods. Never or sometimes using face mask was found to significantly in- crease the risk for URTI (RR= 1.17 and RR=1.21) compared to those who used it most of times. On the other hand, Table 2 Use of preventive measures among domestic hajjis from Riyadh Preventive measures n % Face mask (n = 1507) Most of the time 216 14.3 Sometimes 368 24.4 Occasionally 267 17.7 Never 656 43.5 Face cover (n = 577) Most of the time 300 52.0 Sometimes 25 4.3 Occasionally 8 1.4 Never 244 42.3 Eat usually (n = 1507) Street vendor 272 18.0 Hamla 1109 73.6 Self cooked food 126 8.4 Eat raw food/vegetables: (n = 1507) 1265 83.9 Shaved head (n = 930) Did not shave 375 40.3 Shaved: 555 59.7 By licensed barber 392 70.6 By unlicensed barber 56 10.1 By another hajji 107 19.3 Ask for new blade 532 95.9 Scalp wounds 126 13.5 Animal slaughter: (n = 930) 11 1.2 Hand washing (n = 1507) Less than 5 times/day 146 9.7 More than 5 times/day 1361 90.3 Using hand sanitizer: (n = 1507) 686 45.5 Source of drinking water (n = 1507) Bottled water 1340 88.9 Shared water 41 2.7 Public water 334 22.2 Smoking (n = 1507) 307 20.4 More than one source of drinking water were reported. EMHJ • Vol. 19 Supplement 2 2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale S38 the use of face cover was not found to significantly decrease the risk of infec- tion (Table 5). Discussion Acute respiratory tract infections, diarrhoeal diseases and injuries occur worldwide throughout the year and are not limited to any specific age, gender, or nationality. For example, several factors contribute to the wide spread of URTIs including direct contact with affected person, change in climate, and crowded places; all of these contributing factors are present in the Hajj environment [16]. Significant proportion (53%) of hajjis from Riyadh reported experienc- ing an URTI during or immediately after the Hajj. This high incidence of an illness reveals a high burden of disease. While outside the scope of this study, potential secondary spread among the susceptible population in the home- town of returning hajjis can occur. The disease is uniformly distributed between both genders both old age and diabetes mellitus is known to reduce the immunity and increase the risk for URTIs and other viral infections. The reduced risk between these 2 groups can be due to the reduced mobility of these groups making them less exposed to URTI cases [11]. The present study showed that those who stayed more than 8 days suffered less URTIs. This could be explained by the fact that hajjis who tend to spend shorter periods were in hurry to perform all rituals during the rush time, which increases the physi- cal burden and possibility of getting infected. On the other hand those spending a relatively longer duration had more opportunity to avoid periods of overcrowdings and perform rituals relatively more comfortably. As in many mass gatherings, it is important to understand how to prevent the occurrence of a heavy burden of URTI. Given the circum- stances of Hajj,it is almost impossible to adequately control the spread of illnesses, facilitated by crowding. The use of personal protective measures such as vaccination,chemoprophylaxis, frequent hand washing/sanitizing,and the use of a face mask provide some protection [15]. Use of a face mask in our study population, was the most important practical protective factor against de- velopment of an URTI, although the research evidence regarding the effec- tiveness of face masks does not include consensus agreement. The use of face masks has been advocated to protect from inhalation of aerosols containing organic and inorganic particulates [17]. Therefore, as a preventive measure,the recommendations for the prevention of influenza include wearing face mask [18].Although wearing mask may not provide complete protection from infection; it may reduce exposure to droplet nuclei, considered one of the main modes of transmission of most URTIs [18] The use of face cover (Hijab/Niqab) by women can also be treated as use of face mask. As most of the female hajjis were Saudis, who practices face cover more often during Hajj as compared to other nationalities,the usage of face mask was quite frequent. But there was no evidence of significant decrease in the incidence of URTI, among women in the present study related to using face mask or face cover. This difference from males can be explained on the basis of other customary practices. Women when alone in their tents with other females do not cover their face (as the use is meant mainly for Hijab and not for personal hygiene) thus having the same high risk of disease transmission in a closed environment with exposure to droplet infection. Thus, the use of face cover as proxy of face mask in status. This change of practice within tents may not be so prominent in men, who are using face mask as personal hygiene measure, independent of the place where they were. In this study, 9.3% of hajjis from Riyadh who reported symptoms had an attack of diarrhoeal disease during or immediately after the Hajj. The high risk of diarrhoea among males could be explained by the liability of males to get food from different sources due to their wide range of movement compared to females who are usually in the tents most of the time. The Hajj season this year was in the month of November, which means that the weather was cool and that was not in favour of food born diseases. Also, most of the study par- ticipants ate food prepared by a Hamla Table 3 Distribution of chronic diseases among domestic hajjis from Riyadh Chronic diseases n % Any chronic disease (n = 1507) 278 18.4 Type of chronic diseases (n = 278) Diabetes 155 55.7 Hypertension 169 60.7 Cardiac diseases 21 7.5 Bronchial asthma 32 11.5 Renal diseases 1 0.3 Having exacerbations of current disease (n = 278) 79 28.4 Diabetics (n = 155) 50 32.2 Hypertensive’s (n = 169) 57 33.7 Using medications regularly during Hajj (n = 278) 228 82.0 Have enough supply of medications during Hajj (n = 278) 248 89.2 Types of chronic diseases were not mutually exclusive. HCÐçPUph[UÐpdCÐPL HnUÐ{dCÐ 2:nüÐØ{_UÐ S39 and drank bottled water. Nearly half of the studied hajjis were using hand sanitizers and mostly was washing their hands more than 5 times per day. The high percentage of diarrhoea among those with high educational level may be contributed to their chance to live in better housing conditions and neigh- bourhood compared to those with low educational level and low income. At hajj, and due to overcrowdings, the environment suffers much from pollu- tion which can be relatively tolerated better by the low educated who may be exposed to similar conditions at their homes while the highly educated can- not leading to their more suffering from diarrhoea In the present study, more than half of the hajjis had used the razor blades to shave their head during hajj. Head shaving exposes hajjis to scalp wounds especially in case of unexperienced barbers, hastiness due to rush or the hajjis shaving for each other. Due to inability to find barber shops and their crowdedness, hajjis were forced to rely on other hajjis for head shaving or hair cutting, which gave a good chance for the unlicensed mobile barbers to be active or hajjis learning head shaving on their fellow hajjis with increased risks of cuts. Less than 15% of hajjis who get their head shaved were aware of having at least one cut wound in their scalps. Excessive scalp wounds with the added risk of poor personal hygiene create ideal environment for skin infections and wound contaminations. It is good Table 4 Factors affecting incidence of diarrhoea among Hajjis from Riyadh (1431 Hijra [2009 Gregorian]) Source of food Total hajjis (n = 1507) Cases of diarrhoea (n = 77) Incidence (%) Relative risk 95% confidence interval P-value Gender Male 930 59 6.3 2.03 1.21-3.41 0.006 Female 577 18 3.1 1 Nationality Saudi 610 31 5.1 1 Non-Saudi 897 46 5.1 1.01 0.65-1.57 0.968 Educational level Illiterate 53 2 3.8 1 Primary school 159 4 2.5 0.67 0.13-3.54 0.632 Intermediate school 188 8 4.3 1.13 0.25-5.15 0.876 High school 362 12 3.3 0.88 0.20-3.82 0.863 University 745 51 6.8 1.81 0.45-7325 0.385 Duration of stay in Hajj area in days <4 26 3 11.5 1 5 144 8 5.6 0.48 0.14-1.70 0.254 6 520 28 5.4 0.47 0.15-1.44 0.186 7 344 10 2.9 0.25 0.07-0.86 0.021 >8 473 28 5.9 0.51 0.17-1.58 0.248 Source of food Street vendor 272 13 4.8 1 Hamla 1109 58 5.2 1.09 0.61-1.97 0.763 Self cooked food 126 6 4.8 1.00 0.39-2.56 0.994 Eat raw vegetable 0.59-1.90 0.840 Yes 1265 64 5.1 1 No 242 13 5.4 1.06 Hand washing <5 times/day 146 8 5.5 1 >5 times/day 1361 69 5.1 0.93 0.45-1.89 0.831 Use of hand sanitizer Yes 686 42 6.1 1 No 821 35 4.3 0.70 0.45-1.08 0.103 The reference group is the one with relative risk = 1. EMHJ • Vol. 19 Supplement 2 2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale S40 to find that 95.5% of hajjis asked for a new blade before shaving which was similarly found by other studies where the hajjis who got their head shaved with the used razor were only 6% (Choudhry et al. Behavioural risk factors for diseases during the pilgrimage to Makkah, [un- published]). This reflects an increase in awareness about the danger of us- ing used blades for head shaving and reduces transmission of blood-borne disease such as HIV, Hepatitis B and C. Study limitations Limitations of this study included the self-reported nature of information collection, and possibly recall bias since some of our recruits were contacted a week post Hajj while others were contacted 4 weeks post Hajj. Also demographic data of nonrespondents were not available to determine if they differed from respondent or not. The strengths of this study included the use of trained interviewers, use of standard- ized questionnaire and collecting infor- mation regarding symptoms rather than disease names, which should reduce variation in participant description. A substantial study size (n=1507) pro- vided for ample statistical power. While comparing the results of the present study with previous behavioural risk fac- tors studies conducted in 1998, 2002, and 2066 [19,20] improvements were noticed in some of the variables, such as increase in proportion of hajjis for whom Hamla was the main source of cooked food, for whom sealed plastic bottles/ bags were the main source of drinking water, who get their hair cut by professional barber, who used face mask during hajj, who had both influenza and Hepatitis A vaccination coverage; and decrease in proportion of hajjis who suffered from injuries. In conclusion, URTI is a com- mon health problem among studied Table 5 Factors affecting incidence of upper respiratory tract illnesses (URTI) among Hajjis from Riyadh (431 Hijra [2009 Gregorian]) Source of food Total hajjis (n = 1507) Cases of URTI (n = 800) Incidence (%) Relative risk 95% confidence interval P-value Gender Male 930 483 51.9 1 Female 577 317 54.9 1.06 0.96-1.16 0.256 Nationality Saudi 610 326 53.44 1 Non-Saudi 897 474 52.84 0.99 0.90-1.09 0.819 Educational level Illiterate 53 20 37.73 1 Primary school 159 99 62.26 1.65 1.14-2.38 0.002 Intermediate school 188 99 52.65 1.40 0.96-2.02 0.055 High school 362 190 52.48 1.39 0.97-1.99 0.045 University 745 392 52.61 1.39 0.98-1.98 0.036 Duration of stay in Hajj area in days <4 26 14 53.84 1 5 144 84 58.33 1.08 0.74-1.59 0.670 6 520 296 56.92 0.98 0.83-1.14 0.762 7 344 192 55.81 0.96 0.81-1.13 0.609 >8 473 214 45.24 0.78 0.65-0.92 0.006 Used face mask Most of the time 216 98 45.37 1 Sometimes 635 341 53.70 1.17 1.00-1.38 0.045 Never 656 361 55.03 1.21 1.03-1.43 0.014 Used face cover (Hijab/Niqab)* Most of the time 300 164 54.66 1 Sometimes 33 22 66.66 1.22 0.94-1.59 0.188 Never 244 131 53.68 0.98 0.84-1.15 0.820 The reference group is the one with relative risk = 1. *total number was 577 as the question was for females only. HCÐçPUph[UÐpdCÐPL HnUÐ{dCÐ 2:nüÐØ{_UÐ S41 domestic hajjis. Generally, there is im- provement in the adoption of preven- tive measures by hajjis, however still face mask use is limited in spite of the fact that using it significantly decreases the risk for URTI. 1. Gatrad AR, Sheikh A. Hajj: journey of a lifetime. BMJ 2005; 330: 133-137. 2. Ahmed QA, Arabi YM, Memish ZA. Health risks at the Hajj. Lancet 2006; 367:1008-1015. 3. Shafi S, Memish ZA, Gatrad AR, Sheikh A. Hajj 2006: com- municable disease and other health risks and current official guidance for pilgrims. Euro Surveill2005; 10: E051215. 4. Al-Harthi AS, Al-Harbi M. Accidental injuries during Muslim pilgrimage. Saudi Med J 2001; 22:523-525. 5. Madani TA, Ghabrah TM, Albarrak AM, Alhazmi MA, Alazraqi TA, Althaqafi AO, et al. Causes of admission to intensive care units in the Hajj period of the Islamic year 1424 (2004). Ann Saudi Med 2007; 27:101-105. 6. Khan NA, Ishag AM, Ahmad MS, El-Sayed FM, Bachal ZA, Ab- bas TG. Pattern of medical diseases and determinants of prog- nosis of hospitalization during 2005 Muslim pilgrimage Hajj in a tertiary care hospital. A prospective cohort study. Saudi Med J 2006; 27:1373-1380. 7. Rahman MM, Al-Zahrani S, Al-Qattan MM. Outbreak of hand injuries during Hajj festivities in Saudi Arabia. Ann Plast- Surg1999; 43: 154-155. 8. Gatrad AR, Sheikh A. Hajj and risk of blood borne infections. Arch Dis Child 2001; 84:375. 9. Yousuf M, Nadeem A. Meningococcal infection among pil- grims visiting Madinah Al-Munawarah despite prior A-C vac- cination. J Pak Med Assoc 2000; 50: 184-186. 10. Khan MA. Outbreaks of meningococcal meningitis during Hajj: changing face of an old enemy. J Pak Med Assoc 2003; 53:1-3. 11. Ahmed AM. Care of diabetic patients on the Haj. Diabetes International 2002; 12: 8-9. References 12. Yousuf M, Al-Saudi DA, Sheikh RA, Lone MS. Pattern of medi- cal problems among Haj pilgrims admitted to King Abdul Aziz Hospital, Madinah Al-Munawarah. Ann Saudi Med 1995; 15:619-621. 13. Madani TA, Ghabrah TM, Al-Hedaithy MA, Alhazmi MA, Alazraqi TA, Albarrak AM, et al. Causes of hospitalization of pilgrims in the Hajj season of the Islamic year 1423 (2003). Ann Saudi Med 2006; 26:346-351. 14. Al-Ghamdi SM, Akbar HO, Qari YA, Fathaldin OA, Al-Rashed RS. Pattern of admission to hospitals during Muslim pilgrimage (Hajj). Saudi Med J 2003; 24:1073-1076. 15. Choudhry AJ, Al-Mudaimegh KS, TurkistaniAM, Al-Hamdan NA. Hajj-associated acute respiratory infection among hajjis from Riyadh. East Mediterr Health J 2006; 12:300-309. 16. Chin J. Control of communicable diseases manual. 17th ed. Washington (DC): American Public Health Association; 2000.p. 425-425. 17. Pippin DJ, Verderame RA, Weber KK. Efficacy of face masksin preventing inhalation of airborne contaminants. J OralMaxil- lofacSurg1987; 45:319-323. 18. CDC. Recommendations for the Prevention of Influenza. MMWR 2008; 57:1-60. 19. Al-Fefy S, EI-Bushra H, Al-Wehebi S, Al-Salman S, Ba Omer A,Khawaja A, et al. Behavioral risk factors for pilgrims to Mak- kah,1997. Saudi Epidemiology Bulletin 1998; 5:1-4. 20. Al-Maghderi Y, Al-Joudi A, Chaudhry A, Al-Rabeah A, Ibra- himM, Turkistani AM. Behavioral Risk Factors for Diseases duringHajj 1422 H, (2002 G). Saudi Epidemiology Bulletin 2001; 9:19-20. In recommendations, the surveil- lance system for URTI need to be en- hanced by the Ministry of Health due to its high incidence and the burden it has on health system both in Hajj area and the city of residence of the hajjis Health education programs should be organized to all those who intended to perform hajj to increase the aware- ness about protective measures against URTI, diarrhoeal diseases, injuries and exacerbations of chronic diseases. EMHJ r 7PM 4VQQMFNFOU &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF S42 ABSTRACT This review describes major mass gatherings in the MENA region and the public health implications of these events, and provides recommendations for public health officials of the host country. Through our search of the literature for peer-reviewed publications, we identified relevant 77 papers; all were related to the annual Hajj. Using the information obtained from the literature review, the Eastern Mediterranean Public Health Network (EMPHNET) and the Centers for Disease Control and Prevention (CDC) developed and conducted 2 workshops on Public Health Surveillance during Mass Gatherings for field epidemiology training programmes and ministry of health focal points from 10 countries. The main potential public health concerns associated with mass gatherings include: infectious diseases (e.g. respiratory disease, gastro-intestinal tract disease, foodborne disease), injuries, traffic accidents, heat-related illnesses, insect stings, non-communicable diseases and terrorism. Review Public health considerations for mass gatherings in the Middle East and North Africa (MENA) region M. AlNsour 1 and A. Fleischauer 2 1Eastern Mediterranean Public Health Network, Amman, Jordan (Correspondence to M. AlNsour: mohannadnsour973@yahoo.com). 2Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America. Considérations de santé publique pour les rassemblements de masse dans la région du Moyen-Orient et de l'Afrique du Nord RÉSUMÉ Le présent article porte sur les principaux rassemblements de masse dans la région du Moyen-Orient et de l'Afrique du Nord ainsi que sur leurs conséquences pour la santé publique. Il fournit des recommandations à l’intention des responsables de la santé publique dans le pays d’accueil. À l’issue d’une recherche de publications parues dans des revues à comité de lecture, nous avons identifié 77 articles pertinents, relatifs au pèlerinage annuel de la Mecque (Hajj). À partir des informations tirées de cet examen de la documentation, le Réseau de la Méditerranée orientale pour la santé publique (EMPHNET) et les Centers for Disease Control and Prevention (CDC) ont préparé et organisé deux séminaires-ateliers sur la surveillance de la santé publique lors des rassemblements de masse, à l’intention des programmes de formation à l’épidémiologie de terrain et des points focaux au ministère de la Santé de dix pays. Les principaux problèmes de santé publique lors de tels rassemblements sont notamment : les maladies infectieuses (maladies respiratoires, de l'appareil gastro- intestinal, d'origine alimentaire, etc.), les traumatismes, les accidents de la circulation, les maladies liées à la chaleur, les piqûres d’insectes, les maladies non transmissibles et les actes terroristes mgaw|QÌé5HíGíúÐçOTÐoa\eX9ØYcTogXd^TÐogZTÐÓÐÚmKøÐ ÚZhdRëíÚnwºÚfUÐ{fgY ê ¬{bô>íºÓnHnfCÐì|wDLp>GCÐphYe_UÐp[UÐÓn_>íºnhbx}RÌé5IíHíúÐçPUÐpb]fY:phhý}UÐØZ"Ðp_@Ð}CÐì|w[>oåÉ°#Ð ç}]xðn=77DLëAnUÐ}Lºpe côCÐÓÐÚÐ{ÉüÐíÓnh=ØúÐ:rUÐéĆBí h\CÐ{dUn=phYe_UÐp[UÐén6:NdYn_UÐOÎÓnhÉ> ngfYpxnSUÐíßÐ}YúÐpRncY~TÐ}YíphYe_UÐp[dUHCÐç pcIÓØnaHÐí s"ÐHe=ng_h+Ôn=úÐì|wqbd_>íºpUjCÐì|4 sYÐFUØZ"ÐÊnf?ÌphYe_UÐp[UÐén6:{É´GUÐéANhdeLNbdA|haf>íØÐ{LÎ:nghUÎÚnZCÐÓnh=ØúÐp_@Ð}YYÒnbóôCÐÓnYd_CÐY p]>}CÐípdeCÐphhý}UÐphYe_UÐp[UÐæín8pdYÌYí ëÐ{d=ÒPL:p[UÐÓÐÚÐÛ=én[>øÐàníÓnhýn=UÐén6:©Ð{hCÐoxÚ{UÐ ºpxÚí}CÐ ÔØÐ"ÐíºÓn=nÉüÐíºÊÐ|`Un= pUbfCÐ ßÐ}YúÐíºe\4ÐÛng!ÐßÐ}YÌíº¢afUÐ Ûng!ÐßÐ}YÌYpx{_ôCÐ ßÐ}YúÐØZ"n= ÑnwÚüÐíºpxÚnUÐEQßÐ}YúÐíºÓÐP"ÐÓnQ{Uíº ¬}"n=pböd_CÐßÐ}YúÐí HCÐçPUph[UÐpdCÐPL HnUÐ{dCÐ 2:nüÐØ{_UÐ S43 Introduction Mass gatherings, defined as planned or spontaneous events for a specific purpose, in a specific location, and for a specific period of time and typically with attendance exceeding 25 000 persons, may increase the likelihood of acute public health threats and strain the response resources of the hosting site [1]. Due to potential risk factors such as overcrowding, exposure to unsafe food and water, improper sanitation, and adverse weather, these threats may manifest in an increased risk for communicable disease transmission, acute injuries, and opportunities for terrorism. In- creasingly, international mass gather- ings, such as the 2010 FIFA World Cup in South Africa, are being held in developing countries and provide an economic boon to the host country. Public health preparedness is nec- essary to support public safety and minimize potential health risks to resi- dents and travellers. Although many areas of public health preparedness are needed, efforts for international and high profile mass gatherings should include, at a minimum, a thorough risk assessment coupled with some form of enhanced epidemiologic sur- veillance and response [1]. While there have been publica- tions that have addressed the public health threats associated with mass gatherings in the Middle East and North Africa (MENA) region, those available have described acute out- comes associated with The Hajj. Dur- ing The Hajj, communicable disease outbreaks have been reported repeat- edly [2].However, no publication to date has addressed the scope and scale of mass gatherings in the MENA region and the public health implica- tions of these events for countries in the region. This review describes major mass gatherings in the MENA region and provides recommendations for public health officials of the host country. It also includes a description of the mass gathering training workshop that took place as a part of this project Methods We conducted a literature search for peer-reviewed publications regarding mass gatherings in the MENA region by using the following search terms in PubMed: “Hajj”, “mass gatherings”, “sporting events”, “social events”, “festival” and “pilgrimage”. Our search focused only on planned mass gather- ings. Manuscripts were excluded if the focus of the mass gathering event was outside the MENA region. We consulted with ministries of health across the MENA region and used internet search engines to de- scribe the purpose, scale and frequency of major mass gatherings in the region. Using the information obtained from the literature review, The Eastern Mediterranean Public Health Net- work (EMPHNET) and the Centers for Disease Control and Prevention (CDC) designed, developed and con- ducted the first workshop on Public Health Surveillance During Mass Gatherings for field epidemiology training programmes and ministries of health focal points in the MENA re- gion in Amman, Jordan during 25–29 September 2010. The workshop was aimed at enhancing preparedness, sur- veillance and response during mass gathering events in the MENA region. The workshop was supported by Training Programs in Epidemiology and Public Health Interventions Net- work (TEPHINET), and the Council of State and Territorial Epidemiolo- gists (CSTE). Results Our search identified 77 peer- reviewed manuscripts with a research or public health focus on planned mass gatherings in the MENA region [3–79]: All 77 were related to the Hajj. Specifically, 71 were research papers and 6 were reviews. Most (50, 65%) focused on communicable diseases such as an investigation of an outbreak; 7 assessed all potential risks associ- ated with attendance at a planned mass gathering; 5 examined noncommu- nicable diseases and 10 investigated heat stroke-related issues; 5 focused on other issues specific to Hajj such as skin-related disease and vaccination requirements. Although our research addressed only the Hajj as a major mass gathering event, there are many other planned mass gatherings in the MENA region still not addressed in the literature. Table 1 shows various examples of planned mass gatherings in the region. Some of these events attract only a few thousand participants, but many attract millions. The main potential public health concerns associated with such gatherings include: infectious diseases (e.g. respiratory disease, gastrointesti- nal tract disease, foodborne disease), injuries, traffic accidents, heat-related illnesses, insect stings, noncommuni- cable diseases and terrorism. Residents on field epidemiology training programmes and Ministry of Health focal points from 9 coun- tries (Afghanistan, Egypt, Iraq, Jordan, Morocco, Pakistan, Saudi Arabia, Syria, and Yemen) attended the Pub- lic Health Surveillance during Mass Gatherings workshop. Attendees dis- cussed the existing strategies and ex- periences of their countries with mass gatherings. They worked with external CDC and EMPHNET experts to identify ways in which those strategies might be strengthened. The workshop provided the participants with com- prehensive training on dealing with public health risks pre-, during, and post-event. Training focused on risk EMHJ r 7PM 4VQQMFNFOU &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF S44 assessment, surveillance, training, risk communication, response, and post event activities. By the end of the workshop, residents had developed the mass gathering plan for their countries. Participants then implemented their country projects within the follow- ing 6 months under the guidance of experts from CDC, CSTE, and EM- PHNET. In February 2011, the field epidemiology training programme residents attended a second mass gathering workshop which gave them the opportunity to present their country’s mass gathering plan and the findings of their surveillance evalua- tion. They also received training on scientific communication skills, es- pecially manuscript writing, and then worked closely with CDC, CSTE, and EMPHNET experts to translate their surveillance evaluation results into scientific manuscripts for publi- cation in peer- reviewed public health journals. Discussion In working closely with the workshop participants and Ministry of Health focal points from 9 countries in the MENA region, it was clear that many routine and sporadic mass gatherings events are held in the MENA Region, including cultural, religious and sporting events. While the literature review shows that prior research in the region has concentrated solely on the Hajj, one of the largest mass gath- erings in the world, it is evident there Table 1 Attendance at major mass gatherings in the Middle East and North Africa region Event Type Estimated attendance Afghanistan Nawroz Cultural 150 000–300 000 Egypt International Egyptian marathon Sport >1500 Mohammed’s (BPUH) birthday (Nile Delta) Religious 3 million Iraq Anniversary ofdeath of Imam Alhussain Religious 3–4 million 40th day of Imam Alhussain Religious 5–6 million Anniversary of birth of Imam Almahdi Religious 5–6 million Jordan Dead Sea Ultra Marathon Sport >4000 Jerash Festival of Culture and Arts Cultural 100 000 Eid event in Aqaba city Religious 70 000–100 000 Morocco Moussems Religious 30 000–100 000 Marrakech international marathon Sport >5000 Pakistan Basant Festival Cultural 100 000 Tablighi Ijtema Religious >500 000 Dawat-e-Islamie Religious 200 000 Urs events of famous saints Religious 300 000–400 000 Saudi Arabia Hajj Religious 3 million Riyadh Motor Show Trade 96 000 during 5 days Saudi International Motor Show Trade >100 000 during 5 days Al Janadriyah Heritage and Cultural Festival Cultural > 1 million during 2 weeks Syrian Arab Republic Bosra festival Cultural 1.2–2.5 million over 10 days Anniversary of death of Imam Alkadhem Religious 5–6 million Yemen Al-Hamdi mass gathering Religious 12 000–45 000 20th Gulf Cup (football) sport 60 000 HCÐçPUph[UÐpdCÐPL HnUÐ{dCÐ 2:nüÐØ{_UÐ S45 is a gap in research focusing on other significant mass gatherings that occur in the region. Public health practice and research must address other mass gathering events to determine risks and identify adverse health outcomes to improve the safety of these events for the region. Absence or weak surveillance sys- tems at mass gathering events, lack of information for decision-makers, poor advocacy supporting the estab- lishment and/or strengthening of surveillance systems at mass gather- ings, a shortage of skilled public health personnel, lack of specific training programmes, and the absence of, or poor, comprehensive plans for mass gathering events, are major challenges that face the countries in the MENA 1. Memish ZA. The Hajj: communicable disease alert and response for mass gatherings: key considerations. Geneva, World Health Organization, 2008 (http://www.who.int/csr/mass_gathering/ en/index.html, accessed 11 September 2013). 2. Memish ZA. The Hajj: communicable and non-communica- ble health hazards and current guidance for pilgrims. Euro Surveillance: European Communicable Disease Bulletin, 2010, 15(39):19671 (http://www.eurosurveillance.org/ViewArticle. aspx?ArticleId=19671, accessed 11 September 2013). 3. Aguilera JF et al. Outbreak of serogroup W135 meningococcal disease after the Hajj pilgrimage, Europe, 2000. Emerging Infec- tious Diseases, 2002, 8:761–767. 4. Ahmed QA, Arabi YM, Memish ZA. Health risks at the Hajj. Lan- cet, 2006, 367:1008–1015. 5. Ahmed QA, Barbeschi M, Memish ZA. The quest for public health security at Hajj: the WHO guidelines on communicable disease alert and response during mass gatherings. Travel Medi- cine and Infectious Disease, 2009, 7:226–2300. 6. Ahmed QA, Barbeschi M, Memish ZA. The quest for public health security at Hajj: the WHO guidelines on communicable disease alert and response during mass gatherings. Travel Medi- cine and Infectious Disease, 2009, 7:226–230. 7. Alborzi A et al. Meningococcal carrier rate before and after hajj pilgrimage: effect of single dose ciprofloxacin on carriage. Eastern Mediterranean Health Journal, 2008, 14(2):277–282. 8. Al-Ghamdi SM et al. Pattern of admission to hospitals during Mus- lim pilgrimage (Hajj). Saudi Medical Journal, 2003, 24:1073–1076. 9. Al-Harthi AS, Al-Harbi M. Accidental injuries during Muslim pil- grimage. Saudi Medical Journal, 2001, 22:523–525. 10. Al-Harthi SS et al. Metabolite and hormonal profiles in heat stroke patients at Mecca pilgrimage. Journal of Internal Medicine, 1990, 228:343–346. 11. Alherabi AZ. Impact of pH1N1 influenza A infections on the Otolaryngology, Head and Neck Clinic during Hajj, 2009. Saudi Medical Journal, 2011, 32:933–938. References 12. Al-Joudi AS. An outbreak of foodborne diarrheal illness among soldiers in mina during hajj: the role of consumer food handling behaviors. Journal of Family & Community Medicine, 2007, 14:29–33. 13. Al-Mashhadani SA et al. The coagulopathy of heat stroke: alterations in coagulation and fibrinolysis in heat stroke pa- tients during the pilgrimage (Haj) to Makkah. Blood Coagula- tion & Fibrinolysis, 1994, 5:731–7366. 14. Al-Mashhadani SA, Gader AM, Al Harthi S. The role of plate- lets in the coagulopathy of heatstroke- a study of platelet aggregation in heatstroke patients during the Makkah pil- grimage (Haj) to Makkah. Platelets, 1997, 8:37–42. 15. Alzeer A et al. Tuberculosis is the commonest cause of pneumonia requiring hospitalization during Hajj (pilgrim- age to Makkah). Journal of Infection, 1998, 36:303–306. 16. Alzeer AH. Respiratory tract infection during Hajj. Annals of Thoracic Medicine, 2009, 4:50–53. 17. Balkhy HH et al. Influenza a common viral infection among Hajj pilgrims: time for routine surveillance and vaccination. Journal of Travel Medicine, 2004, 11:82–86. 18. Balkhy HH et al. Neisseria meningitidis W-135 carriage dur- ing the Hajj season 2003. Scandinavian Journal of Infectious Diseases, 2004, 36:264–26. 19. Balkhy HH, Memish ZA, Osoba AO. Meningococcal car- riage among local inhabitants during the pilgrimage 2000- 2001. International Journal of Antimicrobial Agents, 2003, 21:107–111. 20. Baomer AA, El Bushra HE. Profile of diabetic Omani pilgrims to Mecca. East African Medical Journal, 1998, 75:211–2144. 21. Borrow R. Meningococcal disease and prevention at the Hajj. Travel Medicine and Infectious Disease, 2009, 7:219–225. 22. Chiffoleau S. Les pèlerins de La Mecque, les germes et la communauté internationale [Pilgrims to Mecca, germs and the international community]. Medecine Sciences, 2011, 27 (12):1121–1125. region. These challenges are can vary between different countries. The World Health Organization developed guidance for “communica- ble disease alert and response for mass gatherings” [1]. This guidance assesses the operations and methods required to strengthen health systems for alerts and response to communicable dis- eases. It is recommended to develop mass gathering guidance specific to the MENA region. 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