4. Discussion
One thousand and twelve pilgrim of 41 nationalities who performed Umrah in the Saudi Arabia in 2019 had completed the survey, almost a quarter of whom had not received any vaccination prior to travel to the holy city, including meningitis vaccine and poliomyelitis vaccine, which are mandatory by Saudi Arabian health authorities. Another issue is that a considerable percentage of pilgrims (30.1%) never wore a face mask in crowded areas during Umrah, which merits further investigations for the causes and improvement polices, particularly amid the COVID-19 pandemic.
Notably, all pilgrims arriving Saudi Arabia must have received a single dose of quadrivalent meningococcal vaccine and provide proof of a valid vaccination or prophylaxis in the five years before arrival to allow the issue of a Hajj or Umrah visa by the Saudi Arabian Authorities [7]. However, this study reported less than half of the pilgrims (n = 418, 41.3%) surveyed actually had this vaccination, an issue that has been raised before by Ahmed et al. (2006) [5] and Shibl et al. (2017) [13], which should be examined again to avoid the spread of contagious disease. This is especially important during the COVID-19 pandemic, as recent studies have noted [16,17,18,19,20]. The Center for Disease Control and Prevention (CDC) goes further in strongly recommending that hajjis receive a seasonal influenza vaccine, which is recommended for high risk pilgrims to reduce their own morbidity and mortality, but also to reduce transmission of the disease [3,18]. As raised by Barasheed et al. (2014) [14], Benkouiten et al. (2013) [15], and others more recently [16,17,18,19,20], the crowded conditions during Hajj and Umrah increase the risk of respiratory disease transmission including influenzas, tuberculosis, and Middle East Respiratory Syndrome (MERS) coronavirus, which was first identified in Saudi Arabia in 2012 [3,18,21,22]. In this study, 50.8% of pilgrims had reported that they were vaccinated against seasonal influenzas, which is higher than recently reported among Malaysian pilgrims (24.9%) [23], French pilgrims (31.8%), and Saudi Arabian, Qatari, and Australian pilgrims (31.0%) [14,15]. It should be considered whether the CDC recommendation should be added to the Umrah and Hajj visa requirements, although the evidence is still inconclusive and at times contradictory [16,17,18,19,20]. Whether greater enforcement of the regulations would help promote public health remains to be seen, but dramatically reducing the size of mass religious gatherings and adopting preventative measures has been shown to work at Hajj 2020 [19]. Following the COVID-19 pandemic these restrictions, and greater adoption of preventative measures such as the wearing of face masks may also be more acceptable to pilgrims.
Yet again, few pilgrims (n = 285, 28.1%) were vaccinated against poliomyelitis. The Saudi Arabian health authorities require proof of poliomyelitis vaccination from at least four weeks before arrival from pilgrims who are traveling from poliomyelitis reporting countries. This is an issue returned to again and again over the years by research teams including Memish et al. (2012a,2012b,2014, 2016, 2019), considering infectious disease prevention during Umrah and Hajj pilgrimages [8,22,24,25,26]. Of note, free polio vaccination is administered to pilgrims by Saudi Arabian MOH at the entry ports to promote the aim of world eradication of polio [7]. Perhaps there are more opportunities to offer further vaccinations at ports of entry.
The majority of respondents believed that the health education they had received was helpful (n = 661, 65.3%); however, some (n = 135, 13.3%) disagreed. Promoting health education and awareness programs prior to and during this spiritual journey is essential to improve their practices and to ensure lower risk of acquiring and spreading infections or existing medical conditions deteriorating, thus helping pilgrims to complete their rites safely and properly. The Saudi Arabian MOH has created an easy read guide to Hajj for Umrah pilgrims that comprises important information about vaccinations required and other preventative and precautionary measures [1,7]. These measures are founded in research following year on year Umrah pilgrimages [4,5,6,8,9,10,13,14,15,22,23,24,25,26,27,28].
Despite evidence to the contrary on information provided by the MOH in KSA [1,7], almost one quarter of the participants reported not receiving any health education and orientation around preventative measures (n = 213, 21.1%). This adds to the challenges in the management of the Hajj and Umrah and may have an impact on the services that are offered by the Saudi Hajj and Health authorities [7,10]. Clearly, despite all attempts to date to include advance provision of health education to pilgrims, there is more to be done in reaching the wider population. With hindsight, this study was an opportunity to establish which types of content and delivery of health education are seen as most helpful to pilgrims. This is an area for future research.
Of note, less than half of the pilgrims (n = 485, 47.9%) had reported using face masks “always or often”, and less than a third of participants (n = 305, 30.1%) had reported never using face masks in crowded areas; however, 63.2% reported lack of availability of these masks. This study showed an almost equal divide in those who do and do not use face masks in crowded places. This finding is in accordance with other studies in Saudi Arabia (56%) and the USA (42%) [19,24,25]. Since the outbreak of COVID-19 [27,28], the use of face masks has become universal in China and the rest of the world. However, the evidence of their protection against respiratory infections in the community is still controversial [16,17,18,20,28,29,30]. In Saudi Arabia, a study to estimate the incidence of Hajj-related acute respiratory tract infections (ARI) among pilgrims travelling from Riyadh revealed that the use of a facemask by men was a significant protective factor against ARI in Hajj, and fewer pilgrims (15.0%) had ARI compared with hajjis who used it sometimes (31.4%) or never (61.2%) [29].
It was reported in other studies that the use of face masks for more than eight hours can lead to a substantial decrease in the incidence of influenza-like illness (ILI) among pilgrims [14,29]. However, the effectiveness depended largely on adherence to mask use [30]. Hoang et al. (2019 and 2020) noted the complexity of the bacterial and viral RTIs [18] and high transmission rates despite preventative measures [19]. Adaptations to accommodation should be considered as the current use of large, single space dormitory style tents has been noted to encourage the spread of viral infections [16,18,19,20].
In the chain of transmission, regularly washing hands and the use of hand sanitizers resulted in significantly less ILI symptoms. A large proportion of the respondents (n = 840, 83%) always performed proper hand hygiene after coughing and sneezing. This percentage is higher than the French pilgrims in 2012 (46.3%) and USA pilgrims in 2009 (45.5%) [14,15]. Recent studies again emphasize the need for good hygiene practices and the ready provision of personal protective equipment [16,17,18,19,20].
In the present study, 852 pilgrims (84.1%) always used razor blades for shaving their heads, a practice which, if not done hygienically, poses a risk of transmission of blood-borne diseases such as HIV and Hepatitis B and C [5,18]. Some studies have identified issues with unlicensed barbers and sharing of razor blades amongst pilgrims [20].
The majority of pilgrims rated their experience with the Saudi Arabia Ministry of Health Services as “very satisfied” (n = 734, 72.9%). Of note is that health services including primary, secondary, and intensive care medical services are offered to millions of Umrah and Hajj pilgrims free of charge. Whether pilgrims felt open to express their opinions during completion of the survey is open to debate.

Limitations of the Study
There are a number of biases that are present in this study, including the self-reporting and recall biases of participants. There may also be recruitment bias from the researchers at the airport in whom they approach and participation bias in those who decided to take part in this study and the responses (the number of refusals to participate was not recorded).
Although the sample size is reasonable, when compared with the cited literature, and considering the millions of Umrah pilgrims arriving at the holy cities in Saudi Arabia yearly, the findings may not be generalizable. Time constraints and language barriers were also limiting factors, since the recruitment was conducted at the airport.
The definition of health education was left open to the participant’s interpretation. This is an area that would benefit from closer attention in future studies to establish the content and type of information to include targeting the perhaps varying needs of different groups of pilgrims (language, literacy, economic aspects).
Despite these limitations, this study has currency and has provided several insights that were consistent with other studies, and some further insights on the behaviors and practices of pilgrims attending Hajj and Umrah in Saudi Arabia.