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Lessons learned from the management of the Hajj pilgrimage could help strengthen global health security

Lancet

This week The Lancet Infectious Diseases launches a Series of six papers on mass gatherings (MGs) health. The first paper suggests that lessons learnt from decades of managing the safety and wellbeing of millions of pilgrims at the annual Hajj to Mecca in Saudi Arabia could help prevent global disease outbreaks and tackle other complex public health challenges at MGs, like the Olympic Games and G20 summits.

In this paper, Ziad Memish from the Ministry of Health in Saudi Arabia and colleagues, outline the history and diversity of MGs and describe the emergence of the new science-based discipline of MG health.

The increasing scale and frequency of international large-scale events for reasons such as religious pilgrimage, sports events, state funerals, and music concerts pose substantial risks to global health security including the rapid spread of infectious diseases, and complex public health challenges such as terrorist attacks, violence, and stampedes that require specialist expertise outside the realm of traditional medicine and event planning.

The authors note that after decades of hosting the Hajj--the world's largest annual MG attracting more than 2.5 million pilgrims from almost every country in the world--Saudi Arabia is at the forefront of expertise in the management of MGs that could help other communities and countries better prepare for, and respond to, such challenges.

They explain: "The public health implications of the Hajj are huge--nearly 200 000 pilgrims arrive from low-income countries, many will have had little, if any, pre-Hajj health care, added to which are the extremes of climate and crowding, rugged terrain, mingling of populations from around the world, and migration to the country of livestock, butchers, and abattoir workers."

In response to these health hazards, Saudi Arabia has made considerable progress to ensure the wellbeing of pilgrims including improved disease surveillance, regularly updated immunisation recommendations, regulations about food and water security, regulation of barbers, and the building of a separate terminal at Jeddah's International Airport for pilgrims with its own health-screening systems, medical clinics, customs, and immigration security.

The success of enhanced screening and surveillance measures implemented by WHO and the Saudi authorities in response to the SARS outbreak in 2003 and the H1N1 influenza pandemic in 2009, including travel restrictions on visitors from SARS-hit countries, rapid testing, and quarantine, prevented large outbreaks arising from the Hajj.

Memish and colleagues say: "MGs pose complex challenges that require a broad expertise and Saudi Arabia has the experience and infrastructure to provide unique expertise with respect to MGs." For example, the preparations for Barack Obama's Presidential Inauguration and crowd management were based on experience gained from the Hajj.

Moreover, they add, collaborative work on this scale makes the Muslim world an important contributor to global health diplomacy: "Saudi Arabia's experience of Hajj medicine contains rapidly developing public health solutions to several global challenges. Multiagency and multinational approaches to public health challenges are likely to become major factors in the specialty of global health diplomacy, engaging societies globally, and drawing the west a little closer to the east."

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Professor Ziad Memish, Ministry of Health, Riyadh, Saudi Arabia. T) +96 6505 483 515 (mobile) E) zmemish@yahoo.com

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