Hajj 2020 and Covid-19 risks: Should we decide to cancel it? Re: Covid-19 and Community Mitigation Strategies in a Pandemic. Shahul H Ebrahim, Qanta A Ahmed , Ernesto Gozzer , Patricia Schlagenhauf , et al. 368:m1066. doi: 10.1136/bmj.m1066.
Hajj 2020 and Covid-19 risks: Should we decide to cancel it? Re: Covid-19 and Community Mitigation Strategies in a Pandemic. Shahul H Ebrahim, Qanta A Ahmed , Ernesto Gozzer , Patricia Schlagenhauf , et al. 368:m1066. doi: 10.1136/bmj.m1066.
Dear Editor
Ebrahim and colleagues discuss the mass gatherings and events such as Hajj should be restricted during COVID-19.
Hajj is a major annual Muslim worship gathering of about 2.5 million people from over 180 nations and occurs at a specific time of the year. During Hajj, pilgrims visit two holy cities (Makkah and Madinah ) in Saudi Arabia; they remain there for about five days in small, crowded areas (Arafat, Mina, Muzdalifah), presenting a potential risk for multiple food-, water-, and air-borne communicable diseases such as COVID-19. Participation essentially amplifies their risk of acquiring and transmitting the disease. Once they completed all aspects of Hajj, pilgrims return to their countries with a 40–90% chance of contracting or transmitting a respiratory infection. 1
In 2009, the World Health Organization (WHO) consultation group established the Jeddah Recommendations to prevent and minimize the effects of the pandemic influenza A (H1N1) virus. In 2009, recommendations included voluntarily refraining from the Hajj for high-risk groups such as pregnant women, those with chronic diseases, and people under 12 or over 65 years of age, who accounted for at least 25% of the pilgrims.2 Hajj 2009 took place without any pandemic issue. Then, the same discussion emerged again in 2013- 2014, following the discovery of a new virus known as the Middle East Respiratory Syndrome Coronavirus (MERS- CoV), an outbreak with several cases and deaths in Saudi Arabia that year. There was no vaccine or treatment, so the WHO recommended that the same high-risk individuals postpone their plans to attend the Hajj. Again, there was no significant pandemic event. 2
Today, the situation is different. The first cases of pneumonia appeared in Wuhan, China, in early December 2019. This virus (now named SARS-CoV-2) increased rapidly all over the world in a few short months, and now almost everyone is aware of COVID-19. It has affected more than four millions people and killed over 290,000. These numbers continue to increase, and it remains unknown when the SARS-CoV-2 will over. 3 So far, it had a huge negative impact on all life aspects, including socio-economic and health, and the effect will persist for a while even if a successful vaccine or treatment was discovered.
As a consequence, mainland China was the first country hit by the virus, and subsequently banned all mass gatherings after the Chinese Lunar New Year holiday and encouraged people to stay at home, even from school. All activities were banned or closed, and this policy saved many lives. Japan ultimately postponed the Tokyo 2020 Summer Olympics until 2021. 3 The Olympics brings together hundreds of thousands of attendees as well as competing athletes and other visitors and typically requires about seven years of planning. It was likely a very difficult decision; however, protecting the health of the athletes, attendants, and the global community is critically important.
This year, Hajj will begin in late July and continue until the beginning of August, which coincidentally aligns with the original schedule of the World Olympics for 2020. Pilgrims who participate in Hajj could potentially serve as indexed cases once they return home, which could have dire consequences. The high risk of pilgrims interacting with others via person-to-person contact means likely transmission of SARS CoV-2 and new infections in their home countries. Transmissions could reach and affect entire cities and families who reside there; conversely, they could infect additional Saudi citizens, overwhelming health care workers, and increasing the risk of exposure. The spreading of the disease will increase simply because it will be difficult to control it.
The current situation in Saudi Arabia is fine, so far. The first case was detected on March 2 in a case brought in from a neighboring country. The total number of cases is about 3,000 after approximately 40 days, with a reported rate of mortality less than 1.5% .4 The Saudi government took several steps to minimize the disease spreading via the enforcement of remote education, suspension of domestic and international flights, the shutdown of public offices except for those that are health-related, closures of mosques, and lockdowns of specific cities. However, the number of cases continues to increase, and we do not know the point at which this disease will end, as numbers can change rapidly at any time.
Hajj 2020 should be suspended in the interest of global safety; a further outbreak will jeopardize the health of pilgrims, workers, and national and international citizens. Hajj has been canceled several times in the past before the modern country of Saudi Arabia developed. On March 4, the Saudi government banned Saudi citizens and international visitors from Umrah, which is a minor worshipping event that can happen anytime during the year and with smaller crowd sizes.5 However, a large number of elderly and disabled individuals would participate during Hajj. Umrah visitors generally travel as singles or families in small groups and are not exposed to didactic health education programs like Hajj. International visitors spend on average 10 days, and between 43% -50% of them are over the age of 55 and have pre-existing chronic diseases; two-thirds of them are from countries with insufficient disease surveillance systems or travel health-counseling services. 6
Yes, participants can take numerous precautions during Hajj, such as handwashing, using sanitizer, gloves, and facemasks, equipping hospitals, and providing educational materials. However, such precautions will not prevent the disease from spreading if an epidemic occurs during Hajj. Consider facemasks, for example; while they can alleviate aerosolized transmission, they cannot prevent it in densely populated areas. Few people used them during the last two outbreaks (8.4% during the 2009 H1N1 influenza A pandemic and 0.02% during Middle East Respiratory Syndrome coronavirus (MERS-CoV)). 7 Moreover, there are no definitive treatments or a vaccine available yet. It will take time to have it ready to use and be available to all people. Even if it is ready by the time of Hajj, it could minimize the number of new cases, but there is always a risk of transmission and spreading the disease further.
The decision to cancel Hajj will have a significant and negative impact on the Saudi economy due to airline rescheduling and cancellations, transport and hospitality vacancies, and a reduced workforce. It will also be emotionally and mentally challenging for the many pilgrims who consider Hajj to be a cornerstone of the Muslim faith; for many, it is a lifelong dream to participate. However, this decision will have immeasurable benefits beyond Saudi Arabia to family members and cities of many people in Asia, Africa, Europe, and other Middle Eastern countries. Cancelling Hajj will prevent the numerous challenges associated with a massive volume of pilgrims during this critical time. Hajj is approaching quickly; we should not wait until the last minute to cancel it because the decision will be even more devastating to the many people who have prepared themselves for this religious experience.
References
1. Memish ZA, Steffen R, White P, et al. Mass gatherings medicine: public health issues arising from mass gathering religious and sporting events. Lancet 2019; 393:2073-84. doi: 10.1016/s0140-6736(19)30501-x pmid: 31106753.
2. Ebrahim SH, Memish ZA, Uyeki TM, et al. Public health. Pandemic H1N1 and the 2009 Hajj. Science 2009; 326:938-40. doi: 10.1126/science.1183210 pmid: 19933105.
3. Gautret P, Al-Tawfiq JA, Hoang VT. COVID 19: Will the 2020 Hajj pilgrimage and Tokyo Olympic Games be cancelled? Travel Med Infect Dis 2020; 101622. doi: 10.1016/j.tmaid.2020.101622 pmid: 32171882.
4. Worldometers. Coronavirus Cases:Saudi Arabia [April 8 , 2020]. Available from: https://www.worldometers.info/coronavirus/country/saudi-arabia/.
5. Ebrahim SH, Memish ZA. Saudi Arabia`s measures to curb the COVID-19 outbreak: temporary suspension of the Umrah pilgrimage. J Travel Med 2020; doi: 10.1093/jtm/taaa029. pmid: 32109274
6. Ebrahim SH, Memish ZA. COVID-19: preparing for superspreader potential among Umrah pilgrims to Saudi Arabia. Lancet 2020; 395:e48. doi: 10.1016/s0140-6736(20)30466-9 pmid: 32113506.
7. Elachola H, Assiri AM, Memish ZA. Mass gathering-related mask use during 2009 pandemic influenza A (H1N1) and Middle East respiratory syndrome coronavirus. Int J Infect Dis 2014; 20:77-8. doi: 10.1016/j.ijid.2013.12.001 pmid: 24355682.
Competing interests:
No competing interests
17 May 2020
Zuhair S Natto
Assistant Professor
Department of Dental Public health, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia
P.O.Box 40311 Jeddah 21499 Saudi Arabia. Department of Dental Public health, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia
Rapid Response:
Hajj 2020 and Covid-19 risks: Should we decide to cancel it? Re: Covid-19 and Community Mitigation Strategies in a Pandemic. Shahul H Ebrahim, Qanta A Ahmed , Ernesto Gozzer , Patricia Schlagenhauf , et al. 368:m1066. doi: 10.1136/bmj.m1066.
Dear Editor
Ebrahim and colleagues discuss the mass gatherings and events such as Hajj should be restricted during COVID-19.
Hajj is a major annual Muslim worship gathering of about 2.5 million people from over 180 nations and occurs at a specific time of the year. During Hajj, pilgrims visit two holy cities (Makkah and Madinah ) in Saudi Arabia; they remain there for about five days in small, crowded areas (Arafat, Mina, Muzdalifah), presenting a potential risk for multiple food-, water-, and air-borne communicable diseases such as COVID-19. Participation essentially amplifies their risk of acquiring and transmitting the disease. Once they completed all aspects of Hajj, pilgrims return to their countries with a 40–90% chance of contracting or transmitting a respiratory infection. 1
In 2009, the World Health Organization (WHO) consultation group established the Jeddah Recommendations to prevent and minimize the effects of the pandemic influenza A (H1N1) virus. In 2009, recommendations included voluntarily refraining from the Hajj for high-risk groups such as pregnant women, those with chronic diseases, and people under 12 or over 65 years of age, who accounted for at least 25% of the pilgrims.2 Hajj 2009 took place without any pandemic issue. Then, the same discussion emerged again in 2013- 2014, following the discovery of a new virus known as the Middle East Respiratory Syndrome Coronavirus (MERS- CoV), an outbreak with several cases and deaths in Saudi Arabia that year. There was no vaccine or treatment, so the WHO recommended that the same high-risk individuals postpone their plans to attend the Hajj. Again, there was no significant pandemic event. 2
Today, the situation is different. The first cases of pneumonia appeared in Wuhan, China, in early December 2019. This virus (now named SARS-CoV-2) increased rapidly all over the world in a few short months, and now almost everyone is aware of COVID-19. It has affected more than four millions people and killed over 290,000. These numbers continue to increase, and it remains unknown when the SARS-CoV-2 will over. 3 So far, it had a huge negative impact on all life aspects, including socio-economic and health, and the effect will persist for a while even if a successful vaccine or treatment was discovered.
As a consequence, mainland China was the first country hit by the virus, and subsequently banned all mass gatherings after the Chinese Lunar New Year holiday and encouraged people to stay at home, even from school. All activities were banned or closed, and this policy saved many lives. Japan ultimately postponed the Tokyo 2020 Summer Olympics until 2021. 3 The Olympics brings together hundreds of thousands of attendees as well as competing athletes and other visitors and typically requires about seven years of planning. It was likely a very difficult decision; however, protecting the health of the athletes, attendants, and the global community is critically important.
This year, Hajj will begin in late July and continue until the beginning of August, which coincidentally aligns with the original schedule of the World Olympics for 2020. Pilgrims who participate in Hajj could potentially serve as indexed cases once they return home, which could have dire consequences. The high risk of pilgrims interacting with others via person-to-person contact means likely transmission of SARS CoV-2 and new infections in their home countries. Transmissions could reach and affect entire cities and families who reside there; conversely, they could infect additional Saudi citizens, overwhelming health care workers, and increasing the risk of exposure. The spreading of the disease will increase simply because it will be difficult to control it.
The current situation in Saudi Arabia is fine, so far. The first case was detected on March 2 in a case brought in from a neighboring country. The total number of cases is about 3,000 after approximately 40 days, with a reported rate of mortality less than 1.5% .4 The Saudi government took several steps to minimize the disease spreading via the enforcement of remote education, suspension of domestic and international flights, the shutdown of public offices except for those that are health-related, closures of mosques, and lockdowns of specific cities. However, the number of cases continues to increase, and we do not know the point at which this disease will end, as numbers can change rapidly at any time.
Hajj 2020 should be suspended in the interest of global safety; a further outbreak will jeopardize the health of pilgrims, workers, and national and international citizens. Hajj has been canceled several times in the past before the modern country of Saudi Arabia developed. On March 4, the Saudi government banned Saudi citizens and international visitors from Umrah, which is a minor worshipping event that can happen anytime during the year and with smaller crowd sizes.5 However, a large number of elderly and disabled individuals would participate during Hajj. Umrah visitors generally travel as singles or families in small groups and are not exposed to didactic health education programs like Hajj. International visitors spend on average 10 days, and between 43% -50% of them are over the age of 55 and have pre-existing chronic diseases; two-thirds of them are from countries with insufficient disease surveillance systems or travel health-counseling services. 6
Yes, participants can take numerous precautions during Hajj, such as handwashing, using sanitizer, gloves, and facemasks, equipping hospitals, and providing educational materials. However, such precautions will not prevent the disease from spreading if an epidemic occurs during Hajj. Consider facemasks, for example; while they can alleviate aerosolized transmission, they cannot prevent it in densely populated areas. Few people used them during the last two outbreaks (8.4% during the 2009 H1N1 influenza A pandemic and 0.02% during Middle East Respiratory Syndrome coronavirus (MERS-CoV)). 7 Moreover, there are no definitive treatments or a vaccine available yet. It will take time to have it ready to use and be available to all people. Even if it is ready by the time of Hajj, it could minimize the number of new cases, but there is always a risk of transmission and spreading the disease further.
The decision to cancel Hajj will have a significant and negative impact on the Saudi economy due to airline rescheduling and cancellations, transport and hospitality vacancies, and a reduced workforce. It will also be emotionally and mentally challenging for the many pilgrims who consider Hajj to be a cornerstone of the Muslim faith; for many, it is a lifelong dream to participate. However, this decision will have immeasurable benefits beyond Saudi Arabia to family members and cities of many people in Asia, Africa, Europe, and other Middle Eastern countries. Cancelling Hajj will prevent the numerous challenges associated with a massive volume of pilgrims during this critical time. Hajj is approaching quickly; we should not wait until the last minute to cancel it because the decision will be even more devastating to the many people who have prepared themselves for this religious experience.
References
1. Memish ZA, Steffen R, White P, et al. Mass gatherings medicine: public health issues arising from mass gathering religious and sporting events. Lancet 2019; 393:2073-84. doi: 10.1016/s0140-6736(19)30501-x pmid: 31106753.
2. Ebrahim SH, Memish ZA, Uyeki TM, et al. Public health. Pandemic H1N1 and the 2009 Hajj. Science 2009; 326:938-40. doi: 10.1126/science.1183210 pmid: 19933105.
3. Gautret P, Al-Tawfiq JA, Hoang VT. COVID 19: Will the 2020 Hajj pilgrimage and Tokyo Olympic Games be cancelled? Travel Med Infect Dis 2020; 101622. doi: 10.1016/j.tmaid.2020.101622 pmid: 32171882.
4. Worldometers. Coronavirus Cases:Saudi Arabia [April 8 , 2020]. Available from: https://www.worldometers.info/coronavirus/country/saudi-arabia/.
5. Ebrahim SH, Memish ZA. Saudi Arabia`s measures to curb the COVID-19 outbreak: temporary suspension of the Umrah pilgrimage. J Travel Med 2020; doi: 10.1093/jtm/taaa029. pmid: 32109274
6. Ebrahim SH, Memish ZA. COVID-19: preparing for superspreader potential among Umrah pilgrims to Saudi Arabia. Lancet 2020; 395:e48. doi: 10.1016/s0140-6736(20)30466-9 pmid: 32113506.
7. Elachola H, Assiri AM, Memish ZA. Mass gathering-related mask use during 2009 pandemic influenza A (H1N1) and Middle East respiratory syndrome coronavirus. Int J Infect Dis 2014; 20:77-8. doi: 10.1016/j.ijid.2013.12.001 pmid: 24355682.
Competing interests: No competing interests