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1. Introduction
Around 10 million pilgrims travel annually to the Kingdom of Saudi Arabia (KSA) for Umrah (a minor pilgrimage to Makkah) from more than 180 countries [1]. According to The Ministry of Hajj and Umrah, the government of KSA has issued 7,584,424 Umrah visas since 30 May 2019 (25 Ramadan 1440 H), with pilgrims coming via air, land, or sea to visit the holy cities of Makkah and Madinah [1,2].
Umrah is a spiritual practice that is not obligatory and has no fixed date or time to be performed so may be seasonally affected [3]. Similarly to the Hajj and other mass gatherings, the Umrah entails global movement of people, gathering of crowds, and therefore an increased health challenge, including the risk of spreading infection [4]. Respiratory tract infections, overcrowding accidents, pollution, and many other medical and health issues are encountered by the host country, which requires special attention and measurable responses to mitigate these risks [4,5]. Without proper planning and preventative measures, this religious activity can overwhelm the health system of the host country and impact global health preparedness, because the majority of Umrah pilgrims come from, and return to, their different countries [5,6].
The Umrah performer (pilgrim), called hajji in the Arabic language, must be received and accompanied by a company authorized by the Ministry of Hajj, called “Al Hamla”, which provides Hajj and Umrah services including catering, transportation, travel arrangements, accommodation, and first aid health services for every pilgrim who has paid for their services [1,6].
Before travelling to Saudi Arabia for Umrah, pilgrims are advised to seek medical advice about potential health risks and bring vaccination certificates to be inspected at the entry port by Saudi authorities [3]. Even before the COVID-19 pandemic, the Saudi Arabian Ministry of Health (MOH) published a guide for pilgrims on health issues and standard vaccination requirements, together with important control measures for the safety of the individuals and prevention of infectious disease outbreaks [7].
There is no doubt that providing health education to pilgrims on non-communicable and infectious diseases (including the preventative measures and modes of infection transmission) is of great interest for the Hajj and health authorities in Saudi Arabia [5]. It is also critical for global public health and disease control, which is considered good practice to minimize the risks and improve compliance with preventative control measures [8,9,10].
During Umrah, pilgrims have a vital role in sustaining public health through practicing preventative measures such as personal hygiene, catching coughs and sneezes, hand washing with water and soap or sanitizers, wearing face masks (and doing so properly), and subsequent waste disposal of materials in sanitary bins [5,7]. Face mask use was considered an affordable and effective method to control the exposure to pathogens in high-risk environments, to reduce the risk of transmittable infectious diseases including COVID-19 [11], and to protect from the inhalation of aerosols containing organic and inorganic particulates [12]. More recent studies cast doubt on the effectiveness of masks for preventing infection transmission, with some studies reporting over 90% of pilgrims experiencing respiratory tract infections (RTI), suggesting preventative measures are needed [13,14,15,16,17]. Hoang et al. (2019) conducted sequential systematic testing of 121 French pilgrims during Hajj 2018 [18]. Amongst their sample, 40.5% reported wearing a face mask, 55.4% washing hands more often, and 87.6% using disposable tissues. They found RTIs at the Hajj were as “a result of complex interactions between a number of respiratory viruses and bacteria” with 93.4% (n = 113/121) experiencing at least one respiratory infection despite preventative measures [18]. The same research team conducted a smaller study focused on COVID-19 at the 2020 Hajj, which had restricted attendance (n = 1000) with only Saudi nationals permitted [19]. The wearing of face masks was mandated with no public health emergency noted when the Hajj ended early August 2020 [19]. However, a recent systematic review of 21 studies by Liang et al. (2020) found “the risk of influenza, SARS, and COVID-19 infection were reduced by 45%, 74%, and 96% by wearing masks, respectively” [20]. The evidence is both contradictory and inconclusive [13,14,15,16,17,18,19,20].
On 27 February 2020, the KSA Foreign Ministry took a decisive and proactive preventative measure. To prevent the spread of COVID-19, it suspended Umrah visas, denying entry of pilgrims to the holy cities and the entire Kingdom [2].
The Saudi Arabian Vision 2030 aimed to build outstanding health and economic services for visitors to the country, including Umrah and Hajj pilgrims. In light of an initiative called “To care about Rahman Guests” introduced by the Ministry of Health Community Services in Jeddah, in collaboration with a voluntary group (Vision Team) and in view of the current global pandemic of COVID-19 that has affected millions of people worldwide, there is an imperative need for effective preventative measures to be adopted nationally to increase preparedness for future Umrah and Hajj.
Given the clear importance of controlling public health and infectious diseases at mass religious gatherings, underlined by the COVID-19 pandemic, this study aimed to assess the experiences of preventative measures practiced among Umrah pilgrims following their Hajj in Saudi Arabia.