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Background. Respiratory symptoms including cough, runny nose, sore throat, and fever are the most common clinical manifestations faced by hajj pilgrims in Mecca. The aim of the study was to determine the prevalence of respiratory symptoms among Malaysian hajj pilgrims and the effect of a few protective measures taken by hajj pilgrims to reduce respiratory symptoms.
Methods. A cross-sectional study was conducted by distributing survey forms to Malaysian hajj pilgrims at transit center before flying back to Malaysia. The recruitment of respondents to the survey was on a voluntary basis.
Results. A total of 387 survey forms were available for analysis. The mean age was 50.4 ± 11.0 years. The common respiratory symptoms among Malaysian hajj pilgrims were: cough 91.5%, runny nose 79.3%, fever 59.2%, and sore throat 57.1%. The prevalence of hajj pilgrims with triad of cough, subjective fever, and sore throat were 40.1%. The symptoms lasted less than 2 weeks in the majority of cases. Only 3.6% did not suffer from any of these symptoms. Seventy-two percent of hajj pilgrims received influenza vaccination before departure and 72.9% wore facemasks. Influenza vaccination was not associated with any of respiratory symptoms but it was significantly associated with longer duration of sore throat. Wearing masks was significantly associated with sore throat and longer duration of sore throat and fever.
Conclusions. The prevalence of respiratory symptoms was high among Malaysian hajj pilgrims and the current protective measures seemed inadequate to reduce it. Beside standardization of the term used in hajj studies, more collaborative effort should be taken to reduce respiratory symptoms. The hajj authority should prepare for the challenge of pandemic influenza by providing more healthcare facilities and implementation of more strict measures to reduce the transmission of pandemic influenza strain among hajj pilgrims.
Performing the hajj pilgrimage to Mecca is one of the five fundamental pillars of Islam. All physically and financially fit adult Muslims have an obligation to make the pilgrimage once in their lifetime. Approximately 3 million people from over 140 countries assemble annually a for 5-day period in a small specific geographically confined area. The pilgrimages move from one place to another in Mecca to complete the hajj ritual. This is one of the largest annual mass gathering events on earth.
About 25,000 Malaysian hajj pilgrims travel to Mecca every year. They are managed by Malaysian Hajj Fund (Tabung Haji Malaysia), ie, a government-linked company to take care of Malaysian hajj pilgrims. They stay in the holy land for about 40 days. Around two thirds of the hajj pilgrims go to Medina first for 8 days. Then they reside in Mecca for the rest of the hajj journey. After completing the hajj ritual, they go to Jeddah and stay at Medinatul-Hujjaj of Jeddah for two nights to wait for their flights to return home. Another one third of the hajj pilgrims go directly to Mecca and return to Malaysia via Medina.
Communicable diseases are known complications in a very congested and highly dense population. A large outbreak of meningococcal meningitis has been reported in the years 1987 and 2000.1,2 Tuberculosis has been reported as one of the most common causes of lung infection that requires hospitalization during hajj.3 The hajj pilgrims are also having high risk to contract hepatitis.4 Other reported communicable diseases include diarrheal disease, skin infection, and emerging infectious agents.5
Respiratory diseases are a common illness during hajj season and respiratory tract infections are the commonest cause of hospital admission during hajj.6 Pneumonia alone was the most common cause for hospital admission which accounted for 39.4% in 2002 and 19.7% in 2003 hajj season, respectively.7,8 In 2004 hajj season, pulmonary diseases like pneumonia, pulmonary edema, chronic obstructive pulmonary disease (COPD), and bronchial asthma were the next commonest admission to intensive care units after myocardial infarction. Pneumonia contributed to 22.1% of intensive care admission.9 The previous study among Malaysian hajj pilgrims was in 2000 hajj season on the effectiveness of influenza vaccination to reduce respiratory symptoms.10 However, this study was not about the prevalence of respiratory symptoms among Malaysian hajj pilgrims in general and the recruitment of the subjects was based on clinic attendance.
Therefore, the aim of this study was to determine the prevalence of specific acute respiratory symptoms among Malaysian hajj pilgrims. The effect of a few protective measures taken by hajj pilgrims to reduce respiratory symptoms was determined.
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A cross-sectional study was conducted among Malaysian hajj pilgrims in the 2007 hajj season. Survey forms were distributed at Madinatul-Hujjaj, Jeddah, and Tabung Haji Clinic, Medina where pilgrims stay on transit before returning to Malaysia. The survey form was in Malay language and designed to be self administered. The response was on a voluntary basis. The respondents returned the completed survey forms to the collection box located at the clinic in Madinatul-Hujjaj, Jeddah, or Tabung Haji Clinic, Medina. Ethical approval was obtained from USM Research and Ethics Committee prior to the conduct of this study.
The calculated sample size was 276 respondents. After including 20% expected dropout, total required minimal sample size was 331. In view of possible low response rate in a voluntary self-administered survey and a very busy situation, 2,000 survey forms were distributed at the transit center.
The specific respiratory symptoms, namely cough, sore throat, runny nose, and fever were analyzed in detail to determine the effect of protective measures taken by Malaysian hajj pilgrims. Influenza-like illness (ILI) was defined as the triad of cough, subjective fever, and sore throat as suggested by Rashid et al.11
Data were entered and analyzed using spss software (SPSS, Chicago) version 12.0. Results were expressed in terms of the number and percentage for the mean ± standard deviation. The statistical parameters were presented based on missing data of each variable. For categorical variables, the differences in patient characteristics and risk factors were tested using chi-square or Fisher's exact test. Comparison of means between groups was analyzed by independent t-test. Mann–Whitney test was used for nonparametric analysis. Some continuous variables were grouped together and analyzed as categorical variables. p Value of < 0.05 was considered to be statistically significant.
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Of 394 pilgrims who returned the questionnaires, 219 were males and 173 were females. Two persons did not state their gender and were excluded from the analysis. Five other forms were grossly incomplete and were also dropped from the analysis. The mean age was 50.4 ± 11.0 years. Seventy-three (19.7%) hajj pilgrims went for hajj using private travel package.
In descending order the prevalence of symptoms among Malaysian hajj pilgrims were: cough 91.5% (95% CI 88.7–94.3); runny nose 79.3% (95% CI 75.3–83.4); fever 59.2% (95% CI 54.3–64.1); and sore throat 57.1% (95% CI 52.2–62.1). The symptoms lasted less than 2 weeks in the majority of cases (Table 1). Only 3.6% (95% CI 1.8–5.5) of Malaysian pilgrims did not suffer from any of these symptoms throughout their stay in the holy land. About 87.1% (95% CI 83.7–90.4) of Malaysian hajj pilgrims had more than one respiratory symptom and 58.9% (95% CI 54.0–63.8) had fever with other symptoms.
Table 1. Prevalence of upper respiratory tract symptoms among Malaysian pilgrims in 2007
|Symptoms||N||n (%)||95% CI||Duration||n (%)|
| || || || ||≤ 2 weeks||193 (54.5)|
|Cough||387||354 (91.5)||(88.7–94.3)||> 2 weeks||148 (41.8)|
| || || || ||No duration||13 (3.7)|
| || || || ||≤ 2 weeks||206 (67.1)|
|Runny nose||387||307 (79.3)||(75.3–83.4)||> 2 weeks||91 (29.6)|
| || || || ||No duration||10 (3.3)|
| || || || ||≤ 2 weeks||167 (75.6)|
|Sore throat||387||221 (57.1)||(52.2–62.1)||> 2 weeks||47 (21.3)|
| || || || ||No duration||7 (3.2)|
| || || || ||≤ 2 weeks||212 (92.6)|
|Fever||387||229 (59.2)||(54.3–64.1)||> 2 weeks||10 (4.4)|
| || || || ||No duration||7 (3.1)|
Besides cough that occurred significantly more common in older age, there was no other influence of age and gender to the respiratory symptoms among Malaysian pilgrims in 2007 (Table 2).
Table 2. Influence of age and gender to the respiratory symptoms among Malaysian pilgrims in 2007
|Mean (SD)||p Value*||Male n (%)||Female n (%)||p Value*|
|Cough|| || || || || |
| Yes||50.9 (10.4)||0.001†||195 (90.3)||159 (93.0)||0.344‡|
| No||44.2 (14.9)|| ||21 (9.7)||12 (7.0)|| |
|Duration of cough§|| || || || || |
| Less than 2 weeks||49.6 (11.6)||0.200†||121 (58.2)||105 (63.3)||0.318‡|
| More than 2 weeks||51.1 (9.9)|| ||87 (41.8)||61 (36.7)|| |
|Runny nose|| || || || || |
| Yes||50.4 (10.7)||0.874†||167 (77.3)||140 (81.9)||0.272‡|
| No||50.2 (12.0)|| ||49 (22.7)||31 (18.1)|| |
|Duration of runny nose§|| || || || || |
| Less than 2 weeks||49.6 (11.1)||0.083†||161 (75.9)||125 (75.8)||0.967‡|
| More than 2 weeks||51.9 (10.6)|| ||51 (24.1)||40 (24.2)|| |
|Sore throat|| || || || || |
| Yes||49.4 (10.7)||0.057†||122 (56.5)||99 (57.9)||0.780‡|
| No||51.5 (11.2)|| ||94 (43.5)||72 (42.1)|| |
|Duration of sore throat§|| || || || || |
| Less than 2 weeks||50.4 (11.1)||0.670†||183 (85.9)||150 (89.8)||0.251‡|
| More than 2 weeks||49.7 (10.4)|| ||30 (14.1)||17 (10.2)|| |
|Fever|| || || || || |
| Yes||50.6 (11.0)||0.591†||129 (59.7)||100 (58.5)||0.805‡|
| No||50.0 (11.0)|| ||87 (40.3)||71 (41.5)|| |
|Duration of fever§|| || || || || |
| Less than 2 weeks||50.3 (10.9)||0.783†||211 (8.6)||159 (95.8)||0.089‡|
| More than 2 weeks||49.3 (14.5)|| ||3 (1.4)||7 (4.2)|| |
As protective measures, 72.8% of hajj pilgrims received influenza vaccination before departure and 72.9% wore facemasks. In terms of specific respiratory symptoms, influenza vaccination did not have a significant increase in any of the respiratory symptoms but it was significantly associated with longer duration of sore throat (Table 3). Wearing a mask was significantly associated with sore throat (OR 1.89; 95% CI 1.20–2.97) and longer duration of sore throat and fever (Table 4).
Table 3. Association between respiratory symptoms and influenza vaccination among Malaysian pilgrims in 2007
|Symptom||N||Influenza vaccine||p Value*||OR (95% CI)|
|Vaccinated n (%)/ mean (SD)||Not Vaccinated n (%)/ mean (SD)|
|Cough||378||252 (91.6)||94 (91.3)||0.907†||1.05 (0.47–2.35)|
|Duration of cough (days)‡||370||15.3 (12.3)||14.0 (12.3)||0.390§|| |
|Runny nose||378||219 (79.6)||81 (78.6)||0.831†||1.06 (0.61–1.85)|
|Duration of runny nose (days)‡||374||7.0 (13.0)||||5.0 (12.3)||||0.414¶|| |
|Sore throat||378||166 (60.4)||51 (49.5)||0.058†||1.55 (0.99–2.45)|
|Duration of sore throat (days)‡||374||2.0 (8.5)||||0.5 (5.0)||||0.027¶|| |
|Fever||378||158 (57.5)||66 (64.1)||0.243†||0.76 (0.47–1.21)|
|Duration of fever (days)‡||375||2.0 (3.0)||||2.0 (4.0)||||0.275¶|| |
Table 4. Association between respiratory symptoms and usage of masks among Malaysian pilgrims in 2007
|Symptom||N||Wearing facemasks||Not wearing facemasks||p Value*||OR (95% CI)|
|n (%)/ mean (SD)||n (%)/ mean (SD)|
|Cough||387||259 (91.8)||95 (90.5)||0.668†||1.19 (0.54–2.58)|
|Duration of cough (days)‡||374||15.6 (12.5)||13.0 (11.9)||0.073¶|| |
|Runny nose||387||225 (79.8)||82 (78.1)||0.715†||1.11 (0.64–1.91)|
|Duration of runny nose (days)‡||377||7.0 (13.0)||||6.0 (8.0)||||0.152§|| |
|Sore throat||387||173 (61.3)||48 (45.7)||0.006†||1.89 (1.20–2.97)|
|Duration of sore throat (days)‡||380||2.0 (7.0)||||0.0 (5.0)||||0.008§|| |
|Fever||387||175 (62.1)||54 (51.4)||0.059†||1.55 (0.98–2.43)|
|Duration of fever (days)‡||380||2.0 (4.0)||||1.0 (3.0)||||0.039§|| |
The prevalence of hajj pilgrims with triad of cough, subjective fever, and sore throat were 40.1% (95% CI 35.2–45.0). ILI cases were not influenced by age, as the age of ILI cases was 49.8 ± 10.6-year-old and non-ILI cases was 50.7 ± 11.2-year-old (p = 0.422). It was also not influenced by gender as male gender was 54.8% in ILI versus 56.5% in non-ILI (p = 0.752). There was no significant association between ILI with influenza vaccination and those wearing a facemask (Table 5).
Table 5. The association of influenza-like illness with influenza vaccination and wearing facemask
|Protective measure||Influenza-like illness||p Value*||OR (95% CI)|
|Yes n (%)||No n (%)|
|Influenza vaccination||111 (73.0)||164 (72.6)||0.922†||1.02 (0.65–1.63)|
|Wearing facemask||121 (78.1)||161 (69.4)||0.060†||1.57 (0.98–2.52)|
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Respiratory symptoms are one of the most common problems faced by pilgrims in Mecca.12 Besides low returned survey form, the major limitation of the study was the definition of acute respiratory infection. The definition of acute respiratory infection in previous studies was mainly based on clinical symptoms and not microbiological detection of the causative agents.13–15 In reality, it is very difficult to differentiate between infectious and non-infectious respiratory symptoms on clinical basis. Only 49.4% of the patients with suspected respiratory tract infections had identifiable causative agents.16 Some of the previous studies were designed to evaluate the causative pathogens responsible for respiratory infections, eg, viruses or bacteria.3,16–18
Symptom wise, respiratory tract infection was defined as presence of at least one constitutional symptom (fever, headache, and myalgia) plus at least one of the local symptoms.13,15,19 It was very difficult to ask the hajj pilgrims retrospectively regarding headache, fatigue, and myalgia especially during hajj season whereby the hajj pilgrims needed to complete hajj ritual in a very close and dense environment. Whereas the CDC (Centers for Disease Control) definition of ILI (“temperature of ≥ 37.8°C and either cough and/or sore throat in the absence of a known cause other than influenza”) has been shown to have low sensitivity in clinical practice20 especially for hajj pilgrims.11 Some studies among hajj pilgrims used “sore throat in combination with either temperature 38.0°C or cough” as ILI.10,21 A few other studies suggest that ILI to be defined as “cough, subjective fever, and fatigue.”22,23 However, since pilgrims were expected to feel fatigue as a result of strenuous hajj rituals or as a travel-associated symptom, fatigue is not suitable for the criteria. The variation in defining respiratory tract symptoms showed the need of standard definition in future research among hajj pilgrims especially in the era of pandemic influenza. The suggestion by Rashid et al. (2008) is very practical for hajj pilgrims or any mass gathering, hence being used in our study.11 The term “acute respiratory infection” is suggested to be used only in hajj pilgrims that were admitted to hospital or whenever the causative pathogen is identified.
We found 40.1% of hajj pilgrims met the ILI criteria as defined by Rashid et al. (2008). We were unable to compare our findings with other studies as no other study used such definition yet. In this study, we found combination of fever and other respiratory symptoms (defined as acute respiratory infection by other studies) among Malaysian hajj pilgrims were 58.9%, which was higher when compared to Saudi medical personnel (25.6%),13 hajj pilgrims from Riyadh (39.8%),14,15 hajj pilgrims from Iran for year 2004 (35.2%),24 hajj pilgrims from France (fever and cough, 15.6%),25 and hajj pilgrims from Egypt (fever, 25% and cough, 28.2%).26 On the other hand, the incidence of respiratory symptoms among Malaysian hajj pilgrims were lower than hajj pilgrims from Iran in year 2005 (70.0%) because there was a possible outbreak of noninfluenza in that year.24 There were many other factors involved in the large variation in the prevalence of these study populations. Malaysians are used to wet and hot environment in the country as opposed to dry and dusky environment in Mecca. Furthermore, the hajj season in 2007 fell in winter, which resulted in a more severe climatic change for Malaysians.
In terms of specific symptoms, this study found that cough (91.3%), runny nose (79.2%), fever (59.1%), and sore throat (57.1%) were common respiratory symptoms among Malaysian hajj pilgrims. We found cough occurred significantly in older hajj pilgrims. Malaysian hajj pilgrims are more susceptible to cough, runny nose, and fever compared to UK or Saudi hajj pilgrims. In UK pilgrims, sore throat (72%) was the most common respiratory symptoms followed by cough (68%), rhinorrhea (52%), and fever (41%); similarly, in Saudi pilgrims sore throat (86%) was the commonest followed by rhinorrhea (72%), cough (66%), myalgia (46%), and fever (43%).17
This study showed that wearing facemasks was associated with more ILI cases but statistically it was not significant. This finding was in agreement with Al-Asmary et al. (2007) who found that using facemasks offered no significant protection against acute respiratory infections. Intermittent usage of facemasks carried more risk than using facemasks all the time.13 Our findings showed that wearing facemasks was significantly associated with specific respiratory symptoms, ie, sore throat. It also showed that wearing facemask was associated with prolonged duration of sore throat and fever. This was against the findings of study by AlMudmeigh et al. (2003) which stated the facemasks were the most important practical protective factor.15 Usual paper and surgical facemasks were not known to provide complete protection from influenza infection. Facemasks are not designed to protect against breath in very small particles and should be used only once.27 The hajj pilgrims tend to reuse the facemasks or not follow the proper guidelines using facemasks for optimum protection.
The influenza vaccine coverage of Malaysian hajj pilgrims was more than 70%. This is not different from the previous study that found vaccination between 63 and 90%.10 The vaccine coverage was low in developed countries such as only 33% of hajj pilgrims from Marseille, France,28 and 27.7% from Britain.29 This study showed that influenza vaccination was not helpful to reduce ILI and respiratory tract symptoms. There were no significant differences of respiratory symptoms between vaccinated and unvaccinated group.
The previous study among Malaysian hajj pilgrims found that influenza vaccination was effective in preventing clinic visits for ILI. Their subjects solely were hajj pilgrims who attended the clinic with respiratory symptoms. The controls were those who were in the room on the same day that the subjects went to clinics and no question regarding respiratory symptoms to the controls.10 We had reported that 25.9% of hajj pilgrims with respiratory symptoms did not attend the clinic and 16.5% of hajj pilgrims with respiratory symptoms recovered without seeking any kind of medication.30 Mustafa et al. (2003) used sore throat as a must in the definition10 but we found influenza vaccination significantly associated with longer duration of sore throat in this study. We presumed other causes or etiological agents responsible for respiratory symptoms in this cohort. The previous study had shown that influenza A virus was only detected in 0.6%,31 8.1%,32 8.6%,17 and 10.2%,29 respectively, of the hajj pilgrims.
Other earlier studies also showed that the crude ILI attack rate among vaccinated persons was significantly lower than control group.21,33 But later, another study showed that influenza vaccine appeared to provide some protection against influenza in immunosuppressive conditions and those hajj pilgrims over the age of 65 but not in the others.34 In the previous study by Meysamie et al. (2006), the rate of respiratory diseases significantly increased from 35% in year 2004 to 70% in 2005 with the increment of influenza vaccination coverage.24
In the era of H1N1 pandemic influenza, the ILI cases increased five times more than baseline rate and the pandemic influenza strain took over the seasonal vaccine strain.35 There was no epidemiological evidence of significant protection by seasonal vaccine against pandemic influenza virus infection.36 Although some cross protection of H3N2 was documented when the subjects are injected by H2N2 vaccine, the protection of H1N1 pandemic influenza 2009 is not expected after vaccination with H1N1 2008 strain because of major different in antigenic site.37
H1N1 pandemic strain vaccination is expected to be the best solution for ILI prevention at the moment. While waiting for the vaccine to appear in the market, infective control measures were implemented, including to hajj pilgrims. Restricting high-risk Muslims from performing hajj this year was one of the options.38 Regular reminders on personal hygiene, avoiding mass crowds as much as possible, reducing unnecessary exertions and taking a lot of water are very important to minimize the problem with respiratory symptoms.
In conclusion, respiratory symptoms were very common among Malaysian hajj pilgrims. The current protective measures are inadequate to give protection. Future research should be aimed at finding other possible interventions which could reduce respiratory infections. As the number of hajj pilgrims increases each year, these measures ought to be instituted soon. Future studies should also aim at standardization of the terms used and be done in collaboration with researchers from the host nation.