Epidemiological Pattern of Diseases and Risk Behaviors of Pilgrims
Transcription
Epidemiological Pattern of Diseases and Risk Behaviors of Pilgrims
Vol. 83 N°.l& 2,2008 / Egypt Public Health Assoc Epidemiological Pattern of Diseases and Risk Behaviors of Pilgrims Attending Mina Hospitals, Hajj 1427 H (2007 G) Nahla K. R. Ibrahim Epidemiology, Department of Epidemiology, High Institute of Public Health, Alexandria University ABSTRACT Hajj is a unique Islamic ritual where around 2.5 million Muslims gather annually in the Kingdom of Saudi Arabia. The objective of this work was to determine epidemiological pattern of diseases and risk behaviors of pilgrim patients during Hajj 1427 H. A cross sectional study was conducted at two randomly chosen Mina hospitals and a total of 248 patients were selected using systematic random sample method. Results show that about two-fifths (39.1%) of patients had chronic diseases and only 34.4 % received health education before Hajj. The commonest patients' complaints were cough, dyspnea and fever (28.2 %, 27.4% and 25 % respectively). Acute respiratory infections and gastrointestinal illnesses were the commonest diagnosed diseases. Analgesics and antibiotics were the most commonly prescribed drugs. Regarding risky behaviors, 24.6 % of pilgrims were unvaccinated against meningococcal meningitis, 87.9 % didn't wear protective masks and 43.1 % had their hair shaved or cut by re-used razors or scissors. Pilgrims who followed organized camps and who received health education before hajj conducted significantly lower risky behaviors compared to others. Recommendations: Intensified health education campaigns should be conducted for all pilgrims in their mother countries & KSA. Surveillance of behavioral risk factors, formulating intervention strategies and proposing new policies and regulations are urgently needed. Key words: Hajj, epidemiology, diseases, risk, behaviors. INTRODUCTION Every year around 2.5 million Muslims from more than 140 countries around the world gather annually in the Kingdom of Corresponding Author: Nahla Khamis Ragab Ibrahim Epidemiology, Department of Epidemiology High Institute of Public Health, Alexandria University Email:[email protected] / Egypt Public Health Assoc Vol. 83 N°. 1&2,2008 Saudi Arabia to perform the sacred ritual, the fifth pillar of Islam, Hajj. u-5> It is the largest annual gathering of its kind in the world. <® Pilgrims (Hajjes) vary considerably in their sociodemographic characteristics, health related behavior, underlying health status and medical needs. <5« 7> Pilgrims can be divided into two groups; the first which represents the majority, consists of those who join organized Hay groups (Hamla), and the second consists of those who do not join organized Hajj groups. This group resides on the street and is therefore given the name "Muftaresheen". It is expected that these Hajjes will face numerous difficulties. ® During HafJ, the extreme congestion of people and vehicles & poor behaviors increase the risk of spread of many epidemics & other health problems, w Non-communicable health risks associated with the Hajj are mainly related to heat exhaustion, heat stroke and physical injuries. In addition, the physical exertion, overcrowding and high prevalence of pre-existing health conditions favor the spread of communicable diseases. <6) Infection hazards at the Hajj have domestic and international ramifications as Muslim pilgrims return home.*10*11) Most of the infections likely to occur during the pilgrimage are preventable. Acute Respiratory Tract Infections (ARIs) have high secondary attack rates and thus there is great potential for its spread among the Hajjes. <10> In addition, epidemiological studies also showed that hajj pilgrimage plays an important role in meningococcal infections outbreaks.*1'12) Overcrowded conditions, high humidity and dense air pollution all contribute to occurrence of carrier rate as high as 80 %. When carrier rate become so abnormally high, outbreak become a real public health threat.*13) Following several outbreaks of meningococcal 16 / Egypt Public Health Assoc Vol.83 N°.l&2,2008 disease among pilgrims, the Saudi authorities now require medical certification of quadrivalent vaccine (A, C, W135, and Y) before obtaining Hajj Visa. & 6« i3> One of the rites of Hajj for men is to have their head shaved (although many also cut the hair, which is acceptable). Although the Saudi authorities provide licensed barbers with a new blade for each pilgrim, <4> other opportunistic barbers in makeshift centers may not conform to such standard and most of them use the same razor blade for many different people before discarding it. <4* 6> This practice puts pilgrims at risk of acquiring hepatitis B, C and HIV infections. <4- 6» 14*15> Pilgrims need to be made aware of this and should insist that a new razor blade is used. (15> During the Hajj days, too many Hajj pilgrims get medical problems ranging from minor flu to major illnesses.*5) Planning for health care requires knowledge of the pattern of diseases and risky behaviors of people during Hajj.f2) There is lack of comprehensive epidemiological studies on diseases and behaviors during Hajj. The objective of the work was to determine epidemiological pattern of diseases and risk behaviors of pilgrim patients during Hajj 1427 H. (2007 G). MATERIAL AND METHODS After obtaining approvals, a cross sectional study was conducted in Mina, a holy place where all pilgrims camp for 5 days from 8 to 13 Dull Hijjah. The study populations were patients attending two randomly selected Mina hospitals (Mina al Tawarri & Mina El- Jesser). Patients were chosen using systematic random sample technique, where every 10 to patient attended the selected hospitals, speaks Arabic or English, and accepted to participate in the study was included. The patients or their accompanying persons were interviewed using a pre- 17 1 Egypt Public Health Assoc Vol. 83 N°.l&2,2008 designed structured questionnaire for obtaining information about patient's personal & socio-demographic characteristics such as age, sex, nationality, level of education and occupation. Type of accommodation during Hajj either in organized camp (Hamla) or non-organized Hamla (Muftareesh) was inquired about. If the patient didn't follow an organized camp, cause of none-joining camp, place of accommodation and problems encountered during Hajj were also inquired about. Past history of chronic medical conditions was obtained. The main presenting patient's complaints were taken. In addition, Hajj health-related behaviors were inquired about. For example, receiving immunization with quadrivalent meningococcal vaccine, amount of drinking water per day, hours of sleeping, hand hygiene, wearing protective face mask or identified wrist bandage & method of hair shaving or cutting, Physicians were observed during examining and prescribing drugs for the patients. The diagnosis and the prescribed medications were recorded The data was checked, coded, and analyzed using the Statistical Package for Social Sciences (SPSS) version 13. Mean, standard deviation, x? and Fisher's Exact test were calculated. All values deemed statistically significant to p < 0.05. RESULTS The total number of pilgrims interviewed during the study amounted to 248 patients. About three-fourths (73.4 %) of them performed Hajj for the first time with mean age of 40.12 +17.6 years. Table (1) portrays that about one- third of Hayes aged less than 30 years or 50 years and above. The male to female ratio was 1:1.2. Concerning the nationality, 38.3% were Saudi while 18 / Egypt Public Health Assoc Vol. 83 N°.l&2,2008 34,3 % were from the other Arab countries. More than half (53.6 %) of patients had less than secondary education and 13.7 % of them were manual workers. It is also apparent from the table that more than one- fourth (26.6 %) of patients didn't join an organized Hamla. About two-fifths of Hajjes (39.1 %) suffered from chronic disease. Table (1): Characteristics of the Sample of Pilgrim Patients who Attended Mina Hospitals during Hajj 1427 H Characteristics Age: < 30 years 30- <40 40-<50 50 and more Sex: Male Female Nationality: Saudi Other Arab countries South East Asian& Indian Subcontinent Other African countries Iran, Turkey Europe Educational level: Less than secondary Secondary and above Occupation: Manual Clerical Technical Professional Housewife (Females) Not working or student Residence: Saudi Arabia International Chronic disease: Present Absent Residence during HaJJ: Organized Camp (Hamla) Non-organize camp (Muftarsheen) Total Number % 81 42 47 78 32.7 16.9 18.9 31.5 113 135 45.6 54.4 95 85 45 14 8 1 38.3 34.3 18.1 5.7 3.2 0.4 133 115 53.6 46.4 34 37 17 21 82 57 13.7 14.9 6.9 8.5 33.0 23.0 129 119 52.0 48.0 97 151 39.1 60.9 182 66 248 73.4 26.6 100 19 / Egypt Public Health Assoc Vol. S3 N". 1 & 2, 200S Regarding t h e type of chronic diseases, it was found that 11.7 %, 6 %, 5.6, % and 10.1 % of pilgrims suffered from bronchial a s t h m a , diabetes mellitus, hypertension and multiple chronic diseases respectively while 5.7 % suffered from other diseases. Concerning pilgrims who didn't join organized camps (Muftasheen), 89.4% of t h e m mentioned that the reason for non joining Hamla w a s financial. About two-fifths of t h e m (39.4%) stayed on t h e streets, 36.4 % resided on a tent for more t h a n one person, 15.1 % o n mountain a n d 9.1 % on a tent for one person. Figure (1) shows t h a t the main problems encountered by Muflasheen were overcrowding, offensive odors, overcrowded WC's a n d lack of hygienic food (26.1%, 16.9% , 9.2% and 3 . 1 % respectively). On the other h a n d , 4 4 . 6 % mentioned thai Ihey suffered from more than one problem. 44.6 50 40 30 20 10 0 26.1 —_ 16.9 9.2 —, A Jt& ,<? cf & ■••• •■"•■• • • - » ^ *PV > ^ c? 3.2 i ^ <X x> <? ^ v»* ^ c Problem Figure (1): Problems Encountered among Pilgrims Who didn't Join Organized Camp (Muftasheen) 20 / Egypt Public Health Assoc Vol.83 N°.l&2,2008 Table (2) shows patients' complaints, physicians' diagnosis and prescribed drugs for Hajjes. Cardiorespiratory symptoms as cough, dyspnea and chest pain were presented by 28.2%, 27.4%, and 15.3/ of patients respectively. Table (2): Pilgrims' Complaints, Diagnoses and Prescribed Drug of Patients who Attended Mina Hospitals during Hajj 1427 H Symptoms Cough Dyspnea Fever Abdominal pain Headache Running nose Chest pain Diarrhea Vomiting Pain, swelling of feet Coma Itching of the skin Constipation Physicians' diagnoses: Respiratory tract infection Gastrointestinal illnesses Cardiovascular disease Injury, trauma Musclo-skeletal Fracture Abscess Chronic disease Skin disease Urinary tract infections Neurological disease Suspected meningitis Heat related problems Prescribed drugs: Analgesics Antibiotics Anti-tussives Ventilator (Nebulizer) I.V. fluid Anti- histaminic Anti-spasmodic Anti-hypertensive Hypoglycemic No. 70 68 62 53 48 41 38 34 34 20 9 6 5 Prevalence (%) 28.2 27.4 25.0 21.4 19.4 16.5 15.3 13.7 13.7 8.1 3.6 2.4 2.0 74 28 25 22 18 16 10 7 6 4 4 3 1 29.8 11.3 10.0 8.9 7.3 6.5 4.0 2.8 2.4 1.6 1.6 1.2 0.4 147 70 48 37 33 31 26 15 8 59.3 28.2 19.4 14.9 13.3 12.5 10.5 6.0 3.2 N.B. Bach inquiry is separately taken 21 / Egypt Public Health Assoc Vol. 83 AK 1 & 2,2008 Gastrointestinal complaints as abdominal pain was encountered among 21.4%, while both vomiting and diarrhea were found among 13.7 % of patients. On the other hand, coma occurred among 3.6 % of Hajjes. Regarding physicians' diagnosis, it was found that ARIs, gastrointestinal illnesses, and cardiovascular diseases were the commonest diagnosed conditions among pilgrim patients (29.8%, 11.3 % and 10.0 % respectively). On the other hand, the least diagnosed cases were cases with urinary tract infections (UTIs), neurological diseases, suspected meningitis and heat related problems. The number of prescribed drugs ranged from 0-5 drugs and the average number of drug per encounter was 1.5 drugs. Analgesics were the commonest prescribed drugs (59.3%), followed by antibiotics (28.2%) and anti-tussives (19.4%). Table (3) shows the relationship between the type of accommodation in Mina and health-related behaviors done by hajjes. It is apparent from the table that risky behaviors were much lower among pilgrims who joined organized Hamla compared to Muftarsheen. Meningococcal vaccine coverage rate was 75.4 % (88.5 % for those who joined Hamla compared to only 39.4 % among Muftasheen). A highly statistical significant difference is found (x2= 62.87, p <0.000). Similarly, 74.2 % of Hajjes who followed Hamla had their hair shaving or cut by unused or own blades or scissors compared to only 9.1 % among Muftasheen. A highly statistical significance difference is present (x2= 83.64, p <0.000). The same was also seen regarding wearing face mask, wrist bandage, and other health related behaviors. 22 / Egypt Public Health Assoc Vol. 83 N°.l&2,2008 Table (3): Relationship Between Type of Accommodation and Healthrelated Behaviors of Pilgrim Patients Attending Mina Hospitals p ^ ^ ~ Accommodation Following organized camp No 1 Yes II Behavior ^"^--^^ % % No. No. II Received Meningococcal Vaccine— Yes 161 88.5 26 39.5 No 22 40 64.5 11.5 || Wear face mask 15.4 Yes 28 2 3.0 No 154 70.6 64 97.0 Wear wrist bandage Yes i4t 79.1 8 12.1 No 20.9 38 58 87.9 II Hair Shaving or cut 135 74.2 6 9.1 I Unused or own blades / scissors || Reused or other's blades / scissors 47 25.8 90.9 60 || Hand Hygiene: || Frequent washing 75 41.2 3 4.5 || Infrequent or no 107 58.8 63 95.5 || Sleeping hours / day || > 6 hours 76 41.8 5 7.6 1 ^ 6 hours 61 92.4 106 63.5 B| Amount of water/day < 1 Liter 129 70.9 25 37.9 || < 1 Liter 53 29.1 41 62.1 || Carry luggage during hajj 22.7 171 94.0 15 No 11 51 77.3 6.0 II Yes || Go to Manasek: || By Bus or car 172 94.5 6 9.1 10 5.5 | On back of buses and on foot 60 90.9 182 100 66 100 I Total ! I I I Total X2 (P) No. % 187 62 75.4 24.6 (0.000) 1 30 218 12.1 87.9 (0.004) 1 152 96 61.3 38.7 (0.000) 1 141 107 56.9 43.1 (0.000) 1 78 170 31.5 68.5 (0.000)* 81 167 32.7 67.3 25.73 154 94 62.1 37.9 (0.000) 1 186 62 75.0 25.0 131.1 (0.000) 1 178 70 248 71.8 28.2 100 (0.000) 1 62.87 6.92* 91.64 83.64 (0.000) 1 22.41 174.4 mtSSSSSSSSSSmi • Fishefs Exact test It is apparent from table (4) that receiving health education before Hajj resulted in lowering the rate of risky behaviors. The rate of meningococcal vaccine coverage was 87.5 % among those 23 / Egypt Public Health Assoc Vol. 83 N°.l&2,2008 who received health education compared to only 66.7 % among those who didn't take the educational advice. About one-fourth of those who received education were protective mask during doing Haft rituals compared to only 3.5 % of those who didn't receive educational advice. On the other hand, only 7.7 % of those received health education carried their luggage during Manasek compared to 37.5 % of those who didn't receive education (x2= 28.61, p <0.000). Table (4): Relationship Between Receiving Health Education before Hajj and Health-related Behaviors of Pilgrim Patients Attending Mina Hospitals ||^--^. Received H.E Health Education X2 Total No II Behavior ^^""^^^^^ (P) No. % No. % No. % II Yes No 91 13 87.5 22.6 96 48 66.7 77.4 187 62 75.4 24.6 (0.000)* | jl Yes H No 25 79 24.0 36.2 5 139 3.5 63.8 30 218 12.1 87.9 24.02 || (0.000)* || 82 22 78.8 21.2 70 74 48.6 51.4 152 96 61.3 38.7 23.26 11 || Un-used or own instrument | Used or non-own instrument || Hand Hygiene: I Frequent washing 1 Infrequent or no I Sleeping hours / day I > 6 hours 1 < 6 hours || Amount of water/day 82 22 78.8 21.2 59 85 41.0 59.0 141 107 56.9 43.1 (0.000) 11 61 43 58.7 41.3 17 127 11.8 88.2 78 170 31.5 68.5 61.47 || (0.000)* || 48 56 46.2 53.8 33 111 22.9 77.1 81 167 32.7 67.3 (0.000)* 1 II < 1 Liter I < 1 Liter 87 17 83.7 16.3 67 77 46.5 53.5 154 94 62.1 37.9 35.36 || (0.000)* || 11 Received Meningococcal Vaftciael II11 Wear face mask 14.13 II II Wear wrist bandage Yes II No II11 Hair Shaving or cut (p.000)* || 35.31 || 14.82 || 24 II / Egypt Public Health Assoc Vol. 83 N: 1&2, 2008 Table(4):Cont. |P^Z~^ Accommodation BSiaesaassassssasssBsssssBS Following organized camp Yes No II Behavior ^**"^^^^ No. % % No. II Carry luggage during hajj No 96 92.3 90 62.5 | Yes 7.7 8 54 37.5 || Go to Manasek: || By Bus or car 94 84 58.3 90.4 10 41.7 II On back of buses and on foot 6.9 60 1 Total 1 ——— * Significant 104 100 144 100 Total (P) No. % 186 62 75.6 25.0 28.61 (0.000)* 178 70 71.8 28.2 30.62 (0.000)* 1 248 100 sagsag DISCUSSION In modern health care system continuous measurement and monitoring of clinical data comprise the basis of documentation for the quality of care. <1G) The present study revealed that the leading causes of morbidity among Hajjes were respiratory arid gastrointestinal illnesses. These findings coincide with results of study conducted by reviewing records of Hajjes attended Mina Primary Health Care Centers, w Similar results are also reported from other studies.*16^) On the other hand, Khan et al. (2006) found that cardiovascular diseases were the commonest morbidity that necessitated admission to a tertiary care hospital in Mecca. <18> The discrepancy between the current study and previous one may be attributed to differences in the type of patients or health care settings, as Khan's study was conducted among patients admitted in a tertiary care hospital and twothirds of them were referred from other facilities (severer cases). (18) Hajj represents a major c&Ilmge to the Saudi Ministry of Health in addressing infection control at this big gathering, uo) 25 / Egypt Public Health Assoc Vol. 83 N°. 1& 2, 2008 The present study demonstrated that the prevalence of ARIs among pilgrim patients was 29.8%. This may be attributed to overcrowding, congestion and also because this Hajj occurred during winter months when respiratory diseases are more frequent. This result agrees with that of a study conducted among 250 personnel serving Hajj medical mission at Al-Hada and Taif Armed Forces Hospitals (the rate of ARIs was 25.6%) <19) ARIs were also found among 26 % of patients in a study during Hajj 1420 H.(20> The most common diseases among Iranian pilgrims during the 2 recent Hajj journeys were also ARIs. <21) Another cross-sectional study found that pneumonia was responsible for 22% of admission to ICU of Mina and Arafat hospitals during Hajj 1424H. & On the other hand, a higher ARIs cumulative incidence rate (39.8%) was reported from a cohort study done among hajjes from Riyadh governorate.*10* This higher rate may be attributed to differences in the study designs; as pilgrims from Riyadh's study were followed up during the period from 8 Dhu al-Hijja to 27 Dhu al-Hijja. <10> Cough, dyspnea and fever were the commonest complaints of patients in the present study. On the other hand, Khan et al. (2006) reported that dyspnea, chest pain, cough and fever were the most common symptoms.<18) These disagreements may be also due to differences in type of patients and study settings. Travelers commonly face diarrhea, being the most commonly reported medical problem when visiting developing nations.f13> Results of the current study showed that 13.7 % of pilgrims complained from diarrhea which goes on line with results reported among patients from different Gulf countries who attended clinics of Gulf Cooperation Council States' Hajj Medical Mission (GCCSHM). UT> 26 / Egypt Public Health Assoc Vol. 83 N°.l&2,2008 In the present study urinary problems and heat disorders constituted only 1.6 % and 0.4 %, which coincide with results of GCCSHM study. (17> These low rates may be because Hajj in these two studies didn't occur during summer months. In the present study trauma was found among 8.9 % of patients. Madani et al. (2004) found that trauma accounted for 6.4% of causes of admissions to ICU. ® As regards chronic diseases, results of the current study showed that diabetes mellitus and hypertension were reported by 6 % and 5.6 % of pilgrims respectively. Khan et al. (2006) reported higher rates (31.9% and 37.2 % respectively).(18> Th^se discrepancies may be attributed also to differences in type of patients and health care facility. Regarding drugs, results of the present study revealed that analgesics, antibiotics and anti-tussives were the most commonly prescribed drugs which coincide with results of a study conducted among patients attending GCCSHM Clinics. (17> Analysis of results of the present study showed that 26.6 % patients didn't join organized camp (Muftarsheen). The majority of them explained that the most common reason for not joining Hamla was financial. This goes on line with result of Fatani et al. (2001) <8> Muftarsheen in the present study faced many problems (overcrowding, offensive odors, overcrowded WC's, and lack of hygienic food) which also coincide with results of Fatani et al. (2001) In addition, the majority of them mentioned that their sleeping hours during Hajj were less than 6 hours/ day which coincide with results of the previous study. Muftarsheen in the two studies also conducted significantly higher rates of risky Hajj health related behaviors compared to other hajjes. In the current study, only 75.4 % of hajjes received meningococcal vaccine 27 / Egypt Public Health Assoc Vol. 83 N°. 1&2,2008 (87.5 % among those joined organized Hamla versus 66.7 % among Muftrasheen). On the other hand, higher vaccination coverage rate (89.8%) was reported from a study conducted during Hajj 1422H. The cause of lower vaccination coverage in the present study may be attributed to lower percentage of pilgrims who joined Hamla in the present study (73.4%) compared to the study of 1422 H study (94.4 %).») Organized Hamla usually require a valid meningococcal vaccine certificate for obtaining Hajj permission and joining the camp. The CDC recommendations for the prevention of influenza include wearing a facemask. Although this may not provide complete protection from infection, it will reduce the incidence of infection by preventing droplet inhalation, which is considered one of the main modes of transmission of most upper respiratory tract infections (URTIs). 02) i n the present study 87.9 % of hajjis didn't use the mask. In a study in Riyadh's it was reported that 46.4% of hajjes never used a facemask while 20.4 % used it sometimes. (1(» The present work revealed that 61.3 % of pilgrims wore identified wrist band which is similar to results of previous study conducted for identifying behavioral risk factors for diseases during Hajj 1418 and 1419. <23> On the other hand, a higher rate (73 %) was reported by Turkistani et al.(1995) ^ The hygienic behavior of Hajjes and the practice of barbers could make head shaving during Hajj an optimum focus of spread of blood borne diseases. (l5> Results of the present study showed that 43.1 % of Hajjes had their hair shaved or cut by reused (used by other Hajjis) razor blades or scissors. Another study found that 25 % of Hajjes reused razor blades used by 28 I Egypt Public Health Assoc Vol. 83 N°. 1&2,2008 others (23> while a third one reported that 21 % of barbers used the same blade for more than one head shave. (15> Health education remains the backbone for preventing most of Hajj associated diseases. ® During Hajj season Saudi Ministry of Health in collaboration of Islamic countries and the WHO carries out the health education. (25> In the present study, strong associations were found between practicing sound Hajj healthrelated behaviors and receiving health education advice before Hajj. This coincides with results ?.:other studies. <25-27> Hand washing is recommended for protection of many diseases, including influenza, during Hajj. <28) Results of the present study showed that 58.7 % of hajjes who received health education advice frequently washed their hands, and this rate was much lower among those who didn't take the educational advice. Similar findings were obtained among Hajjes from different nationalities who received educational advice in Hajj 1999. v® CONCLUSION ARIs and gastrointestinal illnesses were the most prevalent diseases among pilgrims in the current study. Poor Hajj healthrelated behaviors (un-vaccination against meningococcal vaccine, re-using of hair shaving and cutting tools, and not wearing protective face masks or identified wrist bandage) were prevailed among high percentage of pilgrims. Those who didn't join an organized camp (Muftasheen) or who didn't receive health educational advice before Hajj were significantly more susceptible to practice poor Hajj health-related behaviors. 29 / Egypt Public Health Assoc Vol. 83 N°.l&2,2008 RECOMMENDATIONS • Surveillance of behavioral risk factors can provide the basis for evaluating programs designed to reduce the prevalence of unhealthy risk behavior during Hajj and for formulating intervention strategies with proposing new policies and regulations. • Strong efforts should be exerted to stop the problem of "Eftrash" by intensifying health education on the hazards of staying on street, application of strong regulations regarding joining organized Hajj group and decreasing the cost of camps. • Exerting continuous efforts to raise the immunization coverage of meningococcal vaccine to almost 100 % to prevent outbreaks. • Hepatitis B vaccination is recommended by CDC for those who didn't receive vaccine in the Expanded Program on Immunization (EPI) and who stay for a period of more than 1 month in SA. • Increasing the availability of safe razors blades and sterile head shaving services is needed. In addition, establishing official shaving areas at each camp is recommended. In these areas head shaving should to be done by trained, screened barbers (free from blood borne diseases), who received health education on sterile hair shaving and who are licensed and supervised by Saudi government. Used blades should be placed in punctureresistance containers, • Increasing the availability of free face masks and identified wrist bandages in each camp. • Intensifying health education activities before Hajj to raise awareness of pilgrims about Hajj health related behaviors and how to avoid conduction of poor behaviors. 30 J Egypt Public Health Assoc Vol. 83 N°.l&2,2008 Acknowledgements The author would like to thank the entire group of C3 of the fourth year medical students during the educational year 2006 2007 for their active participation in the study. Special thanks to students Mona Al-Khotani and Dania Monagel for their active contribution to this work. 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