cord-007030-mewo9w43	2016	The purpose of this study is to determine the prevalence of respiratory illness and its associated factors among Malaysian hajj pilgrims in 2013 and to describe its preventive measures. Malaysian hajj pilgrims with previous experience of hajj (OR 0.24; 95% CI 0.10–0.56) or umrah (OR 0.19; 95% CI 0.07–0.52) and those who have practiced good hand hygiene (OR 0.35; 95% CI 0.16–0.79) were found to be significantly associated with lower risk of having respiratory illness. All preventive measures which include hand hygiene, wearing face masks and influenza vaccination must be practiced together as bundle of care to reduce respiratory illness effectively. Data based on the social demographic, co-morbid illness, smoking habits, symptoms of respiratory illness, history of contact with respiratory ill patients, previous experience of hajj or umrah, the practice of preventive measures, influenza and pneumococcal vaccination and supplement intake against respiratory illness were obtained by a self-administered proforma.
cord-255339-oudj079q	2019	The most important zoonotic viral diseases of which eight were diagnosed (in dead or diseased animals or through antibody detection) on the Arabian Peninsula over the last years include rabies, Middle East Respiratory Syndrome (MERS-CoV), influenza virus (IFV), Alkhurma hemorrhagic fever, Crimean-Congo hemorrhagic fever (CCHF), Rift Valley fever (RVF), West Nile fever (WNV), and dengue fever virus. The same WHO epidemiological data suggest that in these 22 countries including Saudi Arabia, in recent years, there has been report of steadily increasing number of sporadic human cases, incidence, and outbreaks of the virus [122] . Surprisingly, the current review showed that during an outbreak, each of these eight most zoonotic viruses (rabies, MERS-CoV, influenza, AHFV, CCHFV, RVFV, DHFV, and WNV) which occurred and/or cases confirmed in Saudi Arabia particularly from (Jeddah and/or Makkah) areas with at least one or all of these eight zoonotic viral pathogenic diseases [33, 44, 46, 78, [96] [97] [98] [99] 121, 130, 156, 171] .
cord-255901-nl9k8uwd	2016	Studies conducted in community or health care settings found facemasks to be generally effective against influenza-like illness (ILI) or even against severe acute respiratory syndrome (SARS) but its effectiveness against respiratory infections at MGs remains unknown. 15, 17 A review of non-pharmaceutical interventions against respiratory tract infections among Hajj pilgrims presented data on the uptake of facemask and acknowledged that compliance was generally poor, but did not evaluate its effectiveness during Hajj. A few studies showed that providing educational session on protective measures against respiratory infections (including facemask) before Hajj was associated with significantly higher uptake of facemasks among pilgrims. 68 Focused studies are required to investigate factors influencing facemask compliance among attendees of Hajj and other MGs. In this systematic review, pooled data of facemask effectiveness showed that participants who used facemask during Hajj are about 20% less likely to suffer from respiratory infections compared to those who do not use it.
cord-257200-q0vqlerz	2016	5 All previous experiences from different mass gathering show that vaccine preventable diseases is the most important infections like influenza, hepatitis A, polio and meningitis. 5 All previous experiences from different mass gathering show that vaccine preventable diseases is the most important infections like influenza, hepatitis A, polio and meningitis. The spread of severe acute respiratory syndrome coronavirus (SARS-CoV) from China to Hong Kong and further to Canada was not due to a mass gathering, but to infected individuals travelling late in the incubation period or just after the onset of symptoms. A review in this issue discusses the need for vaccines for mass gatherings and draws attention to immunization against pneumococcal infections in elderly pilgrims and highlights that polio may be a risk. Communicable diseases as health risks at mass gatherings other than Hajj: what is the evidence?
cord-258611-uzzs8w1j	2017	BACKGROUND: There is global health concern that the mass movement of pilgrims to and from Mecca annually could contribute to the international spread of Middle East Respiratory Syndrome Coronavirus (MERS-CoV). DISCUSSION AND CONCLUSION: The MERS-CoV and respiratory viruses detection results at points of entry in China from 2013 to 2015 indicated that there were no MERS-CoV infection but a 5.7% positive influenza viruses in returning Chinese pilgrims. As of November 2015, there had been 1618 laboratoryconfirmed cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection reported to the World Health Organization, and at least 579 cases had died [1, 2] . Two hypotheses were tested: (1) There is a significant difference in the positive and negative rates of influenza virus detection between Hajj pilgrims with symptoms and those without. In this study, we did not detect any cases of MERS-CoV infection but respiratory virus infections including influenza A and B, hMPV, hRSV, and human coronavirus were detected among Hajj pilgrims returning to China.
cord-258711-3fqxr2yz	2019	Methods Two cohorts of HCWs, the first serving Hajj pilgrims in Mecca and the second serving patients in Al-Ahsa, were investigated for respiratory and gastrointestinal symptoms and pathogen carriage using multiplex polymerase chain reaction before and after the 2015 Hajj. 12 In a study conducted among 120 HCWs from the Saudi Ministry of Health (MOH) and other Hajj medical missions during the 2009 season, 10.6% reported respiratory symptoms during the Hajj, and 12.5% were found infected by at least 1 virus post-Hajj comparing to 7.5% pre-Hajj using a PCR assay. [13] [14] [15] Further studies are needed for a better understanding of the impact of Hajj-related illness among HCWs. Although no correlation was observed between clinical symptoms and detection of respiratory pathogens, we report that HCWs exposed to ill pilgrims carried and acquired a number of respiratory pathogens including acquisition of rhinovirus, enterovirus, respiratory syncytial virus, H influenzae, K pneumoniae, Moraxella catarrhalis, Staphylococcus aureus, and Streptococcus pneumoniae.
cord-258781-peppszqx	2011	The findings of the review may be able to help inform policy statements on the effectiveness of mass gathering restriction interventions that may be deployed to help reduce influenza virus spread during a pandemic. The other five observational studies were similarly designed, involving groups of intending Hajj pilgrims who were recruited in their home regions or countries prior to the event, and then re-assessed This was a well-organized systematic prospective influenza surveillance program, described by the authors as the first of its type at a large Games event Limitations include: A number of studies [18] [19] [20] [21] [22] have consistently demonstrated, over a number of years, that respiratory virus transmission occurs amongst pilgrims attending the annual Hajj in Saudi Arabia, and it is recognized as an issue of international public health significance [43] [44] [45] [46] that could be particularly important in a pandemic situation.
cord-259111-hffy6xtm	2014	This issue of Travel Medicine and Infectious Disease has a number of papers pertinent to infectious disease risks for pilgrims attending Hajj, one of the largest annual recurring mass gathering events that takes place in the Kingdom of Saudi Arabia (KSA). The number of Muslims and the average number of pilgrims from the four countries in West Africa involved in the current Ebola Virus Disease (EVD) outbreak are shown in Table 1 . And long before the WHO announcement about PHEIC, the Saudi MOH after careful review by its national infectious diseases committee had asked in April 2014 that the respective authorities to suspend issuing the Hajj and Umrah''s visas for the people of Guinea, Sierra Leone and Liberia [2, 7] . Based on risk assessment in 2012, the Saudi Ministry of Health excluded pilgrims from Uganda and the Democratic Republic of the Congo due to the occurrence of an Ebola outbreak at that time [8] .
cord-259966-szkiilb1	2019	METHODS: Investigators evaluated ill travelers returning from a mass gathering, and presenting to a GeoSentinel site between August 2015 and April 2019, and collected data on the nature of the event and the relation between final diagnoses and the mass gathering. CONCLUSIONS: Despite this surveillance being limited to patients presenting to GeoSentinel sites, our findings highlight the importance of respiratory diseases at mass gatherings, the need for pre-travel consultations before mass gatherings, and consideration of vaccination against influenza and pneumococcal disease. Diagnoses related to attendance at the three most common MGs -Umrah or Hajj, World Scout Jamboree, and Olympics -are presented in Table 1 . Ill MG attendees seen at a GeoSentinel site most frequently attended Umrah or Hajj, likely due to the large number of travelers to these pilgrimages.
cord-261303-xjbz9fw9	2018	Today Mass Gathering Medicine focuses on the public health challenges to hosting events attended by a large enough number of people, at a specific site, for a defined period of time, likely to strain both the planning and response to the mass gathering of a community, state, or nation. Today mass gathering medicine focuses on the public health challenges to hosting events attended by a large enough number of people at a specific site for a defined period of time to strain the planning and response of a community, state, or nation. But it is useful to consider the World Cup as a sporting event on a par with the Summer Olympics and the more recently developed Para-Olympics while the Hajj as a mass gathering centering on Islamic belief is better understood within the context of other mass gatherings centered on other theist belief systems including the Hindu Kumbh Mehla, World Youth Day and other pilgrimages [8] [9] [10] .
cord-265363-xw56intn	2014	A prospective epidemiological study was conducted to evaluate the incidence of febrile cough episodes among adult Muslims travelling from Marseille to Saudi Arabia during the Hajj pilgrimage and to assess if use of statin had an influence on this incidence. This result suggests that while treatment with a statin has been demonstrated to reduce the mortality from severe sepsis associated with respiratory tract infections, it probably does not play a role in the outcome of regular febrile cough episodes as observed in the cohort studied here. The pre-travel questionnaire included demographic factors (age, gender, location of residence), indicators of immigration status (country of birth and duration of stay in France), socio-economic indicators (level of education, employment, type of housing, rooms per person and household, complementary health insurance modalities), health status indicators (diabetes, hypertension, chronic respiratory diseases, statin use, vaccination coverage against influenza) and number of previous travels to Saudi Arabia.
cord-267427-kg84j802	2020	We revisited our data by investigating the prevalence of common HCoVs in the Hajj and Grand Magal pilgrims and studying the potential risk factors for HCoV acquisition in a large number of individuals. Symptoms were more frequent in Hajj pilgrims as compared to Grand Magal pilgrims (Supplementary Table 1) . In univariate analysis, acquisition of HCoVs was higher in Hajj pilgrims than in Grand Magal pilgrims. In addition, HCoVs acquisition was more frequent in pilgrims reporting respiratory symptoms, although this was not significant in univariate analysis. This report reveals the role of participation in a large gathering in common HCoVs acquisition and related infections. Significant acquisition of HCoVs following participation in the Hajj pilgrimage has been reported by several authors due to overcrowded conditions encouraging the person-to-person spread of respiratory viruses including HCoVs [3] .
cord-268105-617qcgpe	2016	title: Cross‐sectional survey and surveillance for influenza viruses and MERS‐CoV among Egyptian pilgrims returning from Hajj during 2012‐2015 The purpose of this study was to estimate influenza virus and MERS‐CoV prevalence among Egyptian pilgrims returning from Hajj. The MOHP has additionally conducted an annual survey among pilgrims returning from Hajj to explore the risk of influenza virus transmission to the broader community. T A B L E 1 The distribution of Egyptian pilgrims surveyed by season according to gender, age group, presence of influenza-like illness (ILI), vaccination status and influenza laboratory test result Middle East respiratory syndrome coronavirus (MERS-CoV) -Saudi Arabia Risk factors for primary middle east respiratory syndrome coronavirus illness in humans, Saudi Arabia High prevalence of common respiratory viruses and no evidence of Middle East respiratory syndrome coronavirus in Hajj pilgrims returning to Ghana Cross-sectional survey and surveillance for influenza viruses and MERS-CoV among Egyptian pilgrims returning from Hajj during 2012-2015
cord-270408-4qqyb8sd	2013	title: Causes of Mortality for Indonesian Hajj Pilgrims: Comparison between Routine Death Certificate and Verbal Autopsy Findings This study presents the patterns and causes of death for Indonesian pilgrims, and compares routine death certificates to verbal autopsy findings. In the last two decades, the mortality rate of Indonesian pilgrims, excluding years in which disasters such as stampedes occurred, fluctuated between 200-380 deaths per 100,000 persons during the ten-week Hajj period [5] . The cause of death based on this verbal autopsy method was then recorded in the database and compared to that reported by the hospital or flight doctor death certificate. A greater proportion of deaths were attributed to cardiovascular disease by the flight doctor or hospital death certificate (66%) compared to the cause of death ascertained using the verbal autopsy method (49%, p<0.001). Based on both the death certificates and verbal autopsy categories, cardiovascular disease was the leading cause of Indonesian pilgrim mortality in 2008.
cord-275605-mbiojk39	2018	METHOD: The MEDLINE/PubMed and Scopus databases were searched for all relevant papers published prior to February 2018 that evaluated the prevalence of clinical symptoms of respiratory infections, including pneumonia, among Hajj pilgrims, as well as their influenza and pneumococcal vaccination status. We carried out a systematic review of cohort and hospital studies that reported the prevalence of clinical symptoms of respiratory infections and pneumonia among pilgrims during the Hajj, and both their influenza and pneumococcal vaccination status, with the aim to provide data allowing the investigation of the impact of this large mass-gathering event on public health policies and services and to identify potential targets for preventive measures. For inclusion, the article had to meet the following criteria: (1) Original study involving Hajj pilgrims; (2) detailed description of the study population, including influenza and pneumococcal vaccination status when available; (3) clinical or self-reported respiratory symptoms and diseases.
cord-286654-sox98pp3	2015	To better characterize the "Hajj cough" symptoms and its outcome, this study provides a clinical description of respiratory symptoms experienced by a cohort of French Hajj pilgrims during three consecutive Hajj seasons. The "Hajj cough" affected all individuals independently on their age, comorbidities, vaccination status and use of individual non-pharmaceutical preventive measures against respiratory tract infections. At the moment, none of the usual preventive measures against respiratory tract infection have been proven effective, including vaccination against influenza which is recommended for all Hajj pilgrims by French authorities and vaccination against pneumococcal infections which is recommended for at risk pilgrims suffering chronic conditions and or for those aged 60 years and over [27] . Nevertheless, prescription of antibiotics to Hajj pilgrims suffering mild respiratory symptoms is frequent in local health care structures: 95-99% patients consulting at the Ear, Nose and Throat clinic of a Hospital in Mecca were prescribed antibiotics while 85-92% presented with upper tract respiratory infection including pharyngitis and tonsillitis [28, 29] .
cord-287159-bjccnp7u	2017	The aim of this study was to determine and compare the prevalence of Middle East respiratory syndrome coronavirus (MERS-CoV) and influenza virus infections among Iranian general population and pilgrims with severe acute respiratory infections (SARI) returning from Mecca and Karbala during 2013–2016. METHODS: During 2013–2016, a total of 42351 throat swabs were examined for presence of influenza viruses and MERS-CoV in Iranian general population and pilgrims returning from Mecca and Karbala with SARI by using one step RT-PCR kit. CONCLUSION: This study showed the prevalence of influenza infections among Iranian pilgrims and general population and suggests continuing surveillance, infection control and appropriate vaccination especially nowadays that the risk of influenza pandemic threatens the world, meanwhile accurate screening for MERS-CoV is also recommended. The National Influenza Center (NIC) in Iran, located at Virology Department, School of Public Health, Tehran University of Medical Sciences, examines clinical samples from patients with severe acute respiratory infections (SARI) for influenza virus surveillance throughout the year in general population and/or pilgrims.
cord-291821-ovfqfurf	2011	Among all MGs, the public health issues, associated with the Hajj (an annual pilgrimage to Mecca, Saudi Arabia) is clearly the best reported—probably because of its international or even intercontinental implications in terms of the spread of infectious disease. Imperial organisations linked cholera morbus, a non-epidemic diarrhoea, to Hajj, allowing a public health industry to develop that used health concerns to control immigration, pilgrim passports, proof of suffi cient funds to allow return travel, maritime regulation, and vessel quarantine procedures. Effi cient reorganization of the pilgrimage in every direction is needed and should be facilitated by the governments of the large number of the countries involved." 34 By the early 20th century, non-Muslim European powers were heavily engaged in the management of the Hajj and would remain so until modern Saudi Arabia came into existence and acquired fi nancial independence through petrochemical wealth.
cord-293247-ltxt2dfv	2015	title: Advancing the global health security agenda in light of the 2015 annual Hajj pilgrimage and other mass gatherings Although current GHSA is yet to specifically highlight mass gathering preparedness as a strategic priority even in countries with high participant contribution to mass gatherings, the 12 Global Health Security Agenda action packages and the strategies to minimize the implications of mass gathering on public health are similar. Given that two-thirds of the emerging diseases are zoonotic, human-animal interaction during some mass gatherings such as the Hajj further increases the risk, and Saudi Arabia imports sacrifice animals from 6 countries. Mass gatherings offer opportunities to implement, test, and assess GHSA objectives in its entirety and can contribute significantly to health security of individuals, nations, and the world. Mass gatherings medicine and global health security
cord-299440-y6o5e2k5	2016	Although winter temperatures mean that mosquito density is expected to be low in Brazil at the time of the Olympics, given the summer time mosquito density in the northern hemisphere, including in Saudi Arabia, the introduction of a few infections to the mosquito population might be suffi cient to cause outbreaks of Zika virus in other countries. 11 Although both countries may have robust vector control eff orts, no single approach is adequate to prevent mosquito bites and non-vector modes of Zika virus transmission; a combination of measures is needed at personal, community, and policy levels. Given that pilgrim fl ow to Saudi Arabia is continuous, these eff orts will help minimise current transmission of Zika virus as well. 4, 13 Lessons from Saudi Arabia''s success with hosting Hajj during declared pandemics can be helpful to Brazil and the Olympics organisers. Liraglutide safety and effi cacy in patients with non-alcoholic steatohepatitis (LEAN): a multicentre, double-blind, randomised, placebo-controlled phase 2 study
cord-302784-jkjdglns	2019	title: Management of hospitalized drug sensitive pulmonary tuberculosis patients during the Hajj mass gathering: A cross sectional study This study documents the management of drug-sensitive TB patients during Hajj and explores the compliance of healthcare providers with the KSA TB management guidelines in the Ministry of Health (MOH) hospitals in Makkah during the mass gathering. The management of TB patients was documented using a specifically designed data collection form which included patients'' demographics data, underlying health conditions and TB risk factors as well as clinical data including various aspects of TB management such as patients'' screening, infection prevention and control (IPC), TB diagnosis and treatment and case notification and outcome. The result showed high level of compliance with the assessed TB management guidelines indices for systematic screening of TB suspects as well as IPC and surveillance, but low compliance scores were obtained for prompt TB diagnosis and use of standardized treatment regimen for drug-susceptible TB.
cord-305460-wln758og	2020	This study assessed Australian Hajj pilgrims'' knowledge, attitude and practices throughout their Hajj journey to understand their health behaviors, use of preventative measures and development of illness symptoms. Similarly, hand hygiene and other preventative practices also vary among pilgrims, making it more difficult for researchers to ascertain whether vaccine uptake and health behaviors overall have improved in comparison to previous years or studies [5] [6] [7] . To address these research gaps, we conducted a cohort study to explore Australian Hajj pilgrims'' knowledge about the risk of diseases during Hajj, assess their preparedness and use of preventive measures at three times points (before, during and after Hajj) , investigate the factors affecting their preventive health behavior, and determine the number of reported infections during and after Hajj. This cohort study captured and compared the health behavior, knowledge, attitudes and practices of Australian Hajj pilgrims regarding preventative measures against communicable diseases throughout the course of Hajj travel (before, during and after the journey).
cord-310557-d33ll0ka	2017	Method: We reviewed documents, including guidelines and reports from the Saudi Ministry of Health''s database, to describe the characteristics of the infectious diseases surveillance systems that were operational during the 2015 Hajj, highlighting best practices and gaps and proposing strategies for strengthening and improvement. During Hajj, enhanced indicator-based notifiable diseases surveillance systems complement the existing surveillance tool to ensure timely reporting of event information for appropriate action by public health officials. 10 The use of appropriate surveillance systems during mass gatherings ensures the timely collection, analysis and interpretation of health data for effective planning and response to infectious diseases threats. 14 Furthermore, there is need to sustain the enhanced surveillance system and other public health interventions at key locations in the Kingdom, including the points of entry, after the Hajj, as a prevention and control strategy for the international spread of diseases during other mass gatherings with international dimensions, principally the Umrah pilgrimage.
cord-311654-ixn65hxb	2020	Apart from generic prevention and control issues of public health and lockdown measures to limit epidemic spread, specific issues of Mass Gathering (MG) sporting and religious events came under specific spotlight (Alzahrani et al, 2020; Baloch et al, 2020; McCloskey et al, 2020; . WHO with global MG partners, developed comprehensive key recommendations for COVID-19, and since end of February, 2020, there was a stepwise increase in cancellation, temporary suspension or postponement of international and national religious, sporting, musical, and other MGs, as countries worldwide took public health and other measures (WHO, 2020b; McCloskey et al, 2020; Petersen, McCloskey et al, 2020) . The successful completion of the 2020 Hajj is a major tribute to the leadership and commitment of the Saudi authorities, and it reflects their extensive experience of organising the annual Hajj pilgrimage, and continued commitment to improvement public health issues related to mass gatherings events.
cord-314421-j5psma9i	2020	While health care workers (HCWs) will be familiar with these measures, and Hajj pilgrims are always escorted by Hajj tour agencies who also provide basic education in infection control, the Umrah pilgrim (the traveler making the mini-pilgrimage to Mecca sometimes on the spur of the moment and at any time of the year) and the general public will not have experience in hand hygiene education. Similarly when KSA has faced the extremely delicate balance of welcoming religious pilgrims for both Hajj and Umrah this year many of whom have waited a life time to enact their religious rites, and weighing the impact of propagating outbreaks, difficult and unpopular decisions have to be made to safeguard not only the mass gathering but also the wider global community.
cord-314607-bcocsjij	2011	The prevalance of respiratory viruses among healthcare workers serving pilgrims in Makkah during the 2009 influenza A (H1N1) pandemic KEYWORDS Hajj; Viral; Respiratory; Healthcare workers; H1N1 Summary Despite the high risk of acquiring respiratory infections, healthcare workers who treat pilgrims at Hajj have not been studied in previous research on respiratory diseases during Hajj. The objective of this study was to determine the prevalence of different respiratory viruses among healthcare workers who treated pilgrims during Hajj 2009, the year of the influenza A H1N1 pandemic. The objective of this study was to determine the prevalence of different respiratory viruses among healthcare workers who treated pilgrims during Hajj 2009, the year of the influenza A H1N1 pandemic. Among the 18 circulating respiratory virus types and subtypes, only two were detected in the healthcare workers in the pre-and post-Hajj period: rhinovirus (N Z 21, 12.6%) and coronavirus 229E (N Z 1, 0.6%) .
cord-316727-ktrlohm9	2014	title: Treatment and prevention of acute respiratory infections among Iranian hajj pilgrims: a 5-year follow up study and review of the literature Background Respiratory diseases/syndromes are the most common causes of referring to physicians among pilgrims in Hajj. The main aim of our study was to determine types, frequencies, etiologies, and epidemiologic factors of respiratory diseases among Iranian Hajj pilgrims and to suggest some preventive and treatment strategies. The aim of our study was to determine types, frequencies, etiologies, and some of other epidemiologic factors of respiratory diseases among Iranian Hajj pilgrims and to suggest some preventive and treatment strategies based on our 10 years of experience and literature review. We used the results of above mentioned studies and reviewed the literature, and offered a guideline for the treatment and prevention of acute respiratory infections (ARIs) in Hajj.  Significant difference values of NBT test before and after travel showed that respiratory diseases of pilgrims might have infectious origins.
cord-318315-r6wqywwe	2014	We aimed to screen Hajj pilgrims admitted to healthcare facilities in 2013 with severe community-acquired pneumonia (CAP) for MERS-CoV and to determine other etiologies. METHODS: Sputum samples were collected from all pilgrims admitted to 15 healthcare facilities in the cities of Makkah and Medina, Saudi Arabia, who were diagnosed with severe CAP on admission, presenting with bilateral pneumonia. 7, 10 In recent years, the Middle East respiratory syndrome coronavirus (MERS-CoV) has also emerged as a cause of serious illness including severe pneumonia. Respiratory tract infections are common illnesses during the Hajj, 15 and pneumonia is the leading cause of hospital admission, including admission to the ICU, during the pilgrimage. 16 In the current study, as part of the Saudi MoH MERS-CoV surveillance, we investigated the etiology of severe CAP in pilgrims attending the 2013 Hajj requiring hospitalization. 7,10 Studies performed during previous Hajj seasons have reported the organism as a cause of respiratory tract infections including penumonia.
cord-319784-lpmsalux	2015	title: Pilot use of a novel smartphone application to track traveller health behaviour and collect infectious disease data during a mass gathering: Hajj pilgrimage 2014 Pilot use of a novel smartphone application to track traveller health behaviour and collect infectious disease data during a mass gathering: Hajj pilgrimage 2014 1 Therefore, we conducted a pilot study using a smartphone app to examine its feasibility to track not only Hajj pilgrim KAP regarding preventive measures, but also symptom onset and participation in high-risk activities before, during, and after Hajj 2014. The first screen (first phase) is the pre-Hajj questionnaire, including data on participant demographics, pre-existing chronic diseases, vaccinations received before travel, factors influencing vaccination decision and uptake, perception of the risk of respiratory infection during Hajj, willingness to participate in highrisk activities, such as drinking unpasteurised milk, and awareness of official health recommendations provided by Saudi Arabian authorities.
cord-323455-26xi2lqf	2018	This study was performed to evaluate the proportion of adult community-acquired pneumonia (CAP) cases attributable to Streptococcus pneumoniae among Hajj pilgrims in 2016. METHODS: Adult subjects hospitalized with X-ray-confirmed CAP were enrolled prospectively from all general hospitals designated to treat Hajj pilgrims in the holy cities of Mecca and Medina. RESULTS: From August 23 to September 23, 2016, a total of 266 patients with CAP were enrolled in the study, 70.6% of whom were admitted to hospitals in Mecca; 53% of the cases were admitted after the peak of Hajj. pneumoniae among adult Hajj pilgrims in 2016, using the urine antigen test as well as standard culture-based tests, in order to determine the clinical burden of disease associated with Hajj and inform vaccination policy-making. General pattern of community-acquired pneumonia (CAP) case admissions to hospitals during the study period. It was aimed to systematically enroll all hospitalized X-ray-confirmed CAP cases among Hajj pilgrims during the study period.
cord-324215-1tzbvgyr	2019	This report uses data extracted from the Indonesian Hajj surveillance to provide a descriptive overview of mortality patterns in each cohort of pilgrims from 2004 to 2011 (winter Hajj season) to identify health issues of pilgrims for further research planning. Demographic variables collected include name, age, sex, home address, employment, flight group, travel route, date of arrival into Saudi Arabia, and cause of death (if any), according to the hospital medical record or flight doctor death certificate. Public health surveillance was conducted as the morbidity and mortality surveillance in Hajj by the Indonesian public health authorities accompanying pilgrims to Saudi Arabia with daily reporting of hospitalizations and deaths. Database variables included name, age, sex, home address, employment, flight group, travel route, date of arrival into Saudi Arabia, and cause of death as obtained from the hospital medical record or flight doctor''s death certificate.
cord-326768-uo6482ah	2019	The aim here was to screen symptomatic pilgrims for Middle East respiratory syndrome coronavirus (MERS‐CoV) and other viral etiologies. 2, [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] The emergence of the novel Middle East respiratory syndrome coronavirus (MERS-CoV) in Saudi Arabia, its endemicity, and high mortality rates (35%-40%) clearly represent another major public health concern, especially during Hajj. High prevalence of common respiratory viruses and no evidence of Middle East respiratory syndrome coronavirus in Hajj pilgrims returning to Ghana Detection of respiratory viruses among pilgrims in Saudi Arabia during the time of a declared influenza A(H1N1) pandemic MERS-CoV but positive influenza viruses in returning Hajj pilgrims, China Cross-sectional survey and surveillance for influenza viruses and MERS-CoV among Egyptian pilgrims returning from Hajj during 2012-2015. Middle east respiratory syndrome coronavirus (MERS-CoV) infections in two returning travellers in the Netherlands MERS-CoV, influenza and other respiratory viruses among symptomatic pilgrims during 2014 Hajj season
cord-329275-cd71wttk	2014	Nasal swab samples were independently tested as described (5) for influenza virus A/H3N2 (16), influenza B virus (16), influenza C virus (17) , and A(H1N1)pdm09 virus (18) ; human adenovirus (19) ; human bocavirus (20) , human cytomegalovirus (21) ; human coronaviruses (HCoVs); human enterovirus (22) ; human metapneumovirus (23); human parainfluenza viruses (HPIVs); human parechovirus (24); human respiratory syncytial virus (25) ; and human rhinovirus (HRV) (26) by using real-time reverse transcription PCRs. HCoVs and human HPIVs were detected by using an HCoV/HPIV R-Gene Kit (Argene/bioMérieux, Marcy l''Etoile, France) (27) . Of 19 participants whose post-Hajj specimens were positive for HRV, 17 (89.5%) had acquired the infection during their stay in Saudi Arabia (Figure 1 ). Of 50 participants whose post-Hajj specimens were positive for ≥1 respiratory virus, 43 (86.0%) reported ≥1 respiratory symptom during their stay in Saudi Arabia, of whom 37 (86.0%) still had respiratory symptoms at the time of sampling. Also, of 79 participants whose post-Hajj specimens were negative for respiratory viruses, 74 (93.7%) reported ≥1 respiratory symptom during their stay Saudi Arabia, of whom 53 (71.6%) still had respiratory symptoms at the time of sampling.
cord-331980-m6dflwmm	2016	title: Association between Australian Hajj Pilgrims'' awareness of MERS-CoV, and their compliance with preventive measures and exposure to camels Through a prospective cohort study the relationship between travellers'' awareness of MERS-CoV, and compliance with preventive measures and exposure to camels was evaluated among Australian Hajj pilgrims who attended Hajj in 2015. [7] [8] [9] However, no study has attempted to investigate the association between Hajj pilgrims'' awareness of MERS-CoV, and their compliance with preventive measures and exposure to camels. This study shows that only 28% of Australian pilgrims were aware of MERS-CoV before attending the Hajj 2015, with some engaging in high risk behaviours such as exposure to camels (2%), and non-compliance with preventive measures. 8, 9 Importantly, this study showed that pilgrims who were aware of MERS-CoV were twice more likely to intend to avoid contact with camels and consume their raw products during Hajj than those who were unaware.
cord-339124-m7choyr6	2020	In order to avoid a COVID-19 outbreak with potential spreading to many countries through returning pilgrims, Saudi Arabia suspended the Umrah, and access to the 2020 Hajj was very limited. The KSA Ministry of Health recommends individual preventive measures such as use of face mask and disposable handkerchiefs and hand hygiene to mitigate the risk of RTIs. However, the efficacy of these measures against RTIs is debated [35] , and there have been no reliable controlled studies investigating their efficacy on the incidence of Hajj-related RTIs. The use of face masks may not provide optimal protection from infection, but that may reduce the spread of smallsized saliva droplets around when coughing or sneezing which is the main mode of transmission of most RTIs. Mandatory use of face mask in public places is considered one of the effective measures in controlling the COVID-19 pandemic [54] [55] [56] , but no investigation has been conducted in the context of MGs so far.
cord-341775-mucatzaa	2016	Mass gathering sporting and religious events pose important public health challenges, including the transmission of infectious diseases, exacerbation of non-communicable diseases, and disorders related to climate change. [1] [2] [3] [4] [5] Every year, the Kingdom of Saudi Arabia (KSA) hosts the Hajj pilgrimage, which is the largest mass gathering in the world held on a recurrent annual basis. Mass gatherings at religious events can pose major public health challenges, particularly the transmission of infectious diseases. Lethal infectious disease outbreaks were common during Hajj in the 19th and 20th centuries although they have now been controlled to a great extent by the huge investments made by the KSA into public health prevention and surveillance programs. Lethal infectious disease outbreaks were common during Hajj in the 19th and 20th centuries although they have now been controlled to a great extent by the huge investments made by the KSA into public health prevention and surveillance programs.
cord-347907-0nrejsgr	2016	1, 2 Hajj presents a public health challenge for Saudi Arabia, as the authorities need to cater for an increasing number of pilgrims and respond to emerging infections such as the Middle East respiratory syndrome coronavirus (MERS-CoV). In an effort to reduce the risk of infectious diseases at Hajj, an array of preventive measures have been recommended by the Saudi Arabian Ministry of Health (MoH), which include vaccination and hygiene measures (Table 1) . 8 A French study demonstrated that less than half of pilgrims were aware of social distancing and facemask use as precautions against respiratory infections, 9 but no study has explored the barriers to and facilitators of the uptake of preventive measures. To address these questions, two cross-sectional surveys were conducted among Australian pilgrims, one before and one after the Hajj 2014, to identify what preventive advice and interventions pilgrims received before travel, and what factors influenced their compliance with these measures while they were there.
cord-349956-h4i2t2cr	2019	We conducted this study to describe the dynamics of the acquisition of respiratory pathogens, their potential interactions and risk factors for possible lower respiratory tract infection symptoms (LRTI) among French pilgrims during the 2018 Hajj. showed that human rhinovirus (HRV) and influenza viruses were the most common viral respiratory pathogens isolated from ill Hajj pilgrims [6] . Unadjusted associations between respiratory pathogen carriage with multiples factors: sociodemographic characteristics (gender, ≥60 years), chronic respiratory disease, BMI classification, smoking status; individual preventive measures (vaccination against influenza, vaccination against IPD, use of a face mask, hand washing, disinfectant gel and disposable handkerchiefs); antibiotic intake 10 days before each sample; respiratory virus or bacteria and dual carriage were analysed by univariable analysis. aureus carriage increase and the initial wave of respiratory symptoms, suggests that this pathogen association was responsible for the RTIs that affected most pilgrims soon after arriving in Mecca.
cord-354011-v9t2b2ca	2013	We performed a prospective survey among a cohort of pilgrims departing from Marseille, France, to Mecca in the Kingdom of Saudi Arabia (KSA) for the 2012 Hajj season. This study suggests a rapid acquisition of respiratory viruses among pilgrims during their stay in the KSA, most notably rhinovirus, and highlights the potential of spreading these infections in the pilgrims'' home countries upon their return. This study, including sample collection and laboratory methods, was conducted among a cohort of pilgrims departing from Marseille, France, to Mecca in the KSA for the 2012 Hajj season. Each sample was tested for the following viruses by real-time reverse transcription polymerase chain reaction (rRT-PCR): influenza A (FLUA) [11] , influenza B (FLUB) [11] , influenza C (FLUC), and A/2009/H1N1 [12] viruses; human respiratory syncytial virus A and B (RSVB) [13] ; human metapneumovirus (HMPV) [14] ; human rhinovirus (HRV) [15] ; MS2 bacteriophage; human adenovirus (HAdV) [16] ; and human enterovirus (HEV) [17] .
cord-356048-nku844kt	2018	RECENT FINDINGS: In the context of Hajj, one of the largest religious MGs at Mecca, Saudi Arabia, respiratory tract infections are the leading cause of infectious diseases in pilgrims with a prevalence of 50–93%. In this review, we summarize recent findings in the field of infectious diseases associated with international MGs. The Hajj (Table 1) The Hajj, an annual Muslim pilgrimage to Mecca, Saudi Arabia, is one of the largest religious MGs in the world with about two million pilgrims from 185 countries [4] . The predominance of bacterial pathogens in Hajj-related gastrointestinal infections poses a major risk to public health through the potential emergence and transmission of antimicrobial-resistant bacteria [53] . (Table 1) Although numerous gastrointestinal and respiratory outbreaks have been documented at large-scale open-air festivals, particularly music festivals, with thousands of participants, these events are probably neglected, in terms of public health attention, as well as surveillance and prevention of infectious disease strategies, compared to other categories of MGs [78] .