key: cord-0757535-k6ijng66
authors: Memish, Ziad A.; Ahmed, Yusuf; Alqahtani, Saleh A.; Ebrahim, Shahul H.
title: Pausing super spreader events for COVID-19 mitigation: International Hajj pilgrimage cancellation
date: 2020-07-13
journal: Travel Med Infect Dis
DOI: 10.1016/j.tmaid.2020.101817
sha: b30dee6bc325fb80ce9f852b4d1b0593f4cbe685
doc_id: 757535
cord_uid: k6ijng66

nan

In view of the ongoing COVID-19 pandemic and for avoiding super-spreader events, Saudi Arabia on June 22, 2020 announced restriction of international visitors for the 2020 annual Hajj pilgrimage to Mecca and for the domestic population with chronic diseases and aged 65 years and older [1] . Although the holy sites will remain open, limiting access to no more than 1,000 people (who already reside in Saudi Arabia) to the holy sites that would normally be crowded by 3 to 5 million pilgrims will enable the health authorities assure adequate physical distancing and implement disinfection measures. The new restrictions add to the existing restrictions on the less well-known year-around pilgrimage called Umra that was suspended on March 3, 2020 [2, 3] .

[ Figure] The first such decision for suspension of Hajj to international pilgrims since over 200 years and ever in the history of the current nation known as Saudi Arabia is a protection strategy not just to the Muslim pilgrims and their home countries, but to global health security and from a whole world consideration of pandemic mitigation. This action is highly relevant to COVID-19 due to three reasons; 50% of the routine pilgrims are elderly and with comorbid conditions; two-thirds originate from countries with sub-optimal public health capabilities or are in conflict situations, where additional sources of seeding of SARS-CoV-2 infections should be avoided at all cost; and respiratory infections are most common during the Hajj, usually affecting 80% [4, 5] .

Cancellation of Hajj is uncommon. The last restriction of international pilgrims for the Hajj was between the years 1798 and 1801, during the incursions of Napoleon's military aimed at checking British colonial influence in the region. Hajj, unlike any other mass gatherings, is an event of huge religious, geopolitical, and economic significance to multiple stakeholders including the 24% of the world population that are Muslims, governments with high population of Muslims, and numerous religious, travel and service sectors that support the movement of close to 3 million pilgrims from over 180 countries along with 1-2 million domestic pilgrims participating in the mandatory 5-day event and others who wish to perform additional days of rituals in the holy sites. For financially able believers performing the Hajj is a once a lifetime religious obligation but the perceived benefits of compliance are unquantifiable to the extent that some would consider death during the pilgrimage as God's divine blessing. The Hajj related financial planning may span a lifetime for some persons, and some governments have developed a savings schemes that enable its citizens to perform the Hajj. Hajj is a significant source of revenue for pilgrim air and surface travel providers, preparatory, and hospitality services both in home countries and in Saudi Arabia. Saudi Arabia's COVID-19 status is also highly relevant to the health of Hajj and pilgrimage.

Saudi Arabia, despite its success with mitigating huge super spreader events through international seeding, the returning Saudi pilgrims who visited pilgrimage sites in Iran and Iraq were early source of community seeding of SARS-CoV-2, making it contribute 150,000 cases to global total. By extending restrictions on international pilgrimage, Saudi Arabia's proactive decision would contribute significantly to COVID-19 mitigation globally [3] .

In addition to significant contribution to global COVID-19 mitigation, the restriction of international visitors to Hajj will also usefully help reduce transmission of other diseases. Of relevance is the ongoing Ebola outbreak in DRC, and other diseases such as measles which is now widespread globally [8, 9] .

The legacy of Hajj-related scientific contribution to public health can be enriched by advancing public health research on COVID-19 mitigation tools that would be implemented at the restricted holy sites. The proposed pre-and post-testing of the 10,000 domestic pilgrims that will be permitted to perform rituals at the hajj at summertime temperatures above 40 degree Celsius coupled with follow up for 14 days offers the most scientifically sound prospective mass gathering research infrastructure to study the natural history of COVID-19. The opportunities include assessment of spatial, temporal and environmental determinants of disease acquisition, survival of the virus on innate surfaces, the frequency and types of disinfectants required to achieve maximum viral elimination, and the role of stress and meditation on disease acquisition.

Taken together, the earlier decision by the International Olympic Committee to cancel the summer Olympics in Japan and the Saudi decision to restrict international Hajj pilgrimage, two events with super spreader potential, offers impetus and precedence for other stakeholders and countries faced with similar challenges amidst the reports of worsening COVID -19 global pandemic. As a global community, in the absence of a vaccine, the political commitment of nations and compliance of communities to effectively use known mitigation tools will help us overcome the current pandemic. Our decisions today will also offer important lessons for future generations.

Declaration of competing interest: All authors have no conflicts of interest. 

Saudi Arabia's drastic measures to curb the COVID-19 outbreak: temporary suspension of the Umrah pilgrimage

COVID-19: preparing for superspreader potential among Umrah pilgrims to Saudi Arabia

Mass Gatherings Medicine: Public Health Issues Arising From Mass Gathering Religious and Sporting Events

From Hajj Services to Mass Gathering Medicine: Saudi Arabia Formalizes a Novel Discipline

From the "Madding Crowd" to mass gatherings-religion, sport, culture and public health

All Hands on Deck: A Synchronized Whole-of-World Approach for COVID-19 Mitigation

Modelling the importation risk of measles during the Hajj