key: cord-0836961-jkbfu23m authors: Sridhar, Shruti; Belhouchat, Khadidja; Drali, Tassadit; Benkouiten, Samir; Parola, Philippe; Brouqui, Philippe; Gautret, Philippe title: French Hajj pilgrims' experience with pneumococcal infection and vaccination: A knowledge, attitudes and practice (KAP) evaluation date: 2015-02-18 journal: Travel Med Infect Dis DOI: 10.1016/j.tmaid.2015.02.002 sha: 08a1b1757d3252fc3037c8b72028095dae895b7a doc_id: 836961 cord_uid: jkbfu23m BACKGROUND: Transmission of respiratory infections poses a major public health challenge during the Hajj and Umrah in the Kingdom of Saudi Arabia. Acquisition of Streptococcus pneumoniae during Hajj has been studied in the past and recommendations for vaccination against S. pneumoniae have been made for high risk groups. METHODS: The purpose of this study was to assess the knowledge and attitudes of French Hajj pilgrims towards pneumococcal vaccination. Adult pilgrims departing from Marseille, France to Mecca for the 2014 Hajj season were administered a face-to-face questionnaire to ascertain their knowledge and attitudes towards pneumococcal vaccination before departing for Hajj. RESULTS: A total of 300 participants took part. Their overall knowledge about the severity of pneumonia and the existence of the vaccine was very low. Out of 101 participants who had an indication for pneumococcal vaccination, irrespective of their travel status, only 7% were advised to have the vaccine by their general practitioner. CONCLUSIONS: These results reinforce the need for better dissemination of information either before or during the pre-travel counselling. The visit to the travel clinic for receiving the mandatory meningococcal vaccination for Hajj is a good opportunity to update routine immunizations, including pneumococcal vaccination. Each year, more than 10 million pilgrims from over 180 countries arrive in Mecca, Kingdom of Saudi Arabia (KSA), for the Hajj or Umrah, presenting a major public health challenge in terms of transmission of infectious diseases, notably respiratory infections [1] . Pneumonia is the leading cause of hospitalization and intensive care unit admissions during the Hajj [2] . Streptococcus pneumoniae was isolated in 37% of patients with severe community-acquired pneumonia during the Hajj in Saudi hospitals [3] . Attack rates of respiratory symptoms among French Hajj pilgrims have been shown to be as high as 90% [4] . Nasal carriage of S. pneumoniae among French Hajj pilgrims, as reported in 2012, was 20% before leaving the KSA as opposed to 7% before departing from France [5] . In 2013, 62% of the French Hajj pilgrims tested positive for S. pneumoniae in throat samples following participation to the Hajj and 36.3% of them had acquired the infection during their stay in KSA [4] . Evidence for the importance of pneumococcal disease at the Hajj is summarized in Table 1 . Currently, the French Ministry of Health recommends pneumococcal vaccination to high risk patients such as individuals with immunocompromised conditions, chronic respiratory diseases, chronic cardiac diseases, chronic renal diseases, diabetes, chronic liver diseases and cochlear implants [6] . In addition, it recommends that Hajj pilgrims aged 60 and over be vaccinated independently of their medical status [7] in line with the recommendations of some experts [8] . This study aimed to evaluate the knowledge and attitudes and practices (KAP) of French Hajj pilgrims with regard to pneumococcal vaccination. Travellers who were participating in the Hajj 2014 season were recruited from two different settings. Most of them were recruited over a period of 5 weeks, from 11th August 2014 to 12th September 2014, during their visit to a travel clinic at Hospital Nord, Marseille for their pre-travel counsel and vaccination. In addition, some participants were recruited during a pre-travel preparation session arranged by a specialized travel agency in Marseille, which organizes travel to Mecca. This meeting was spread over 2 Sundays, on 7th September and 14th September 2014 respectively. The questionnaire was administered during a face-to-face interview by a French-speaking or Arabic-speaking medical intern, as required. The first part of the questionnaire contained all demographic details including age, sex, Two hundred and twenty nine people, participating in Hajj, attended the travel clinic at Hospital Nord and agreed to participate in the study. In addition, 98 people were approached during the pre-travel preparation session. Among them, 71 were included in the study and 27 either refused to participate or were already recruited in the study at the hospital. In total, 300 individuals were thus included in the study, with a male-to-female sex ratio of 1:1 and a mean age of 58.5 years (SD: 14.09; range, 22e85 years) ( Table 2) . About 13% were born in France and the others were immigrants, mainly from North Africa. The average duration of stay for immigrants in France was 37 years (Range: 1e65 years). One hundred and thirty-three (44%) of the participants had at least one chronic comorbidity; with hypertension and diabetes being the most frequent. In addition, 79% of the participants were either obese or over-weight. Out of 300 study participants, 194 (64.7%) had at least one risk factor warranting pneumococcal vaccination in the context of the Hajj; of whom 13 (6.7%) reported receiving a pneumococcal vaccination in the past 5 years. Sex was evenly distributed between those having risk factors and those not having risk factors for pneumococcal diseases (p > 0.05). Age was unevenly distributed between the two groups (p < 10 À3 ) with the risk group having a higher mean age of 65.7 years (95% CI 64.5e67.1) than the not-at-risk group of 45.2 (95% CI 43.0e47.4). The overall knowledge of participants about the severity of pneumonia and the existence of a vaccine was low. Even though one-third of them (33.7%) had an indication for pneumococcal vaccination according to the French guidelines, independent of their participation in the Hajj, only 7% were offered the vaccination by their general practitioner ( Table 3) . Three of the questions had significantly different responses between the risk and the not-at-risk group. However, when multinomial logistic regression was performed with age group below and above 65 years as one of the covariates, the differences became insignificant for two of those questions. After adjusting for covariates, response to the question "Did your general practitioner ever recommend vaccination for pneumococcus?" was significantly different in both groups (p Z 0.039). Those in the risk group had the vaccination recommended to them more often than those in the not-at-risk group. The overall lack of knowledge about pneumococcal infection at Hajj in French pilgrims corroborates results obtained from a survey of Australian pilgrims in 2013 [9] . We [10] that was also comparable to the Australian data [9] . These results reinforce the need for better dissemination of information either during the pre-travel counselling or at the entry point of KSA [11] . Tour leaders may also play a significant role in promoting vaccination [12] . In our survey, the low rate of vaccination against pneumococcus among pilgrims prior to consultation at our specialized clinic is similar to that observed here in 2010 [13] , 2011 and 2013 (unpublished data). Pneumococcal pathogens play a significant role in the infections reported among Hajj patients hospitalized in KSA and S. pneumoniae carriage is frequently acquired by pilgrims following participation to the Hajj (Table 1 ). An estimated one third of Hajj pilgrims are at risk of pneumococcal disease either by virtue of age or pre-existing medical conditions and consideration should be given to vaccinating high risk pilgrims against pneumococcal disease [2] . The new generation of conjugate vaccine has proven effective in the prevention of severe pneumococcal disease. It is well tolerated. Local reactions tend to be mild and short lived [2] . Data on the preventive effect of pneumococcal vaccination in the context of Hajj is lacking, and further epidemiological research is needed to assess the likely benefit of vaccinating Hajj pilgrims against pneumococcal disease and to allow Saudi Arabian Ministry of Health to issue appropriate recommendations regarding health interventions for Hajj pilgrims [8] . The consultation in the travel clinic for mandatory meningococcal vaccination for Hajj provides a good opportunity to update routine vaccination including pneumococcal vaccination in this specific population comprising a high proportion of individuals at-risk of pneumococcal disease. Global perspectives for prevention of infectious diseases associated with mass gatherings Pneumococcal infections at Hajj: current knowledge gaps Etiology of severe community-acquired pneumonia during the 2013 Hajj-part of the MERS-CoV surveillance program Respiratory viruses and bacteria among pilgrims during the Acquisition of Streptococcus pneumoniae carriage in pilgrims during the 2012 Hajj Calendrier des vaccinations et recommandations vaccinales Health recommendations for travellers The potential for pneumococcal vaccination in Hajj pilgrims: expert opinion Australian Hajj pilgrims' knowledge about MERS-CoV and other respiratory infections Hajj pilgrims knowledge about Middle East respiratory syndrome coronavirus Using health educators to improve knowledge of healthy behaviour among Hajj 1432 Influenza vaccination among Australian Hajj pilgrims: uptake, attitudes, and barriers Pneumococcal vaccination and Hajj Pattern of admission to hospitals during muslim pilgrimage (Hajj) Causes of hospitalization of pilgrims in the Hajj season of the Islamic year Saudi Med Causes of admission to intensive care units in the Hajj period of the Islamic year 1424 Pattern of medical diseases and determinants of prognosis of hospitalization during 2005 Muslim pilgrimage Hajj in a tertiary care hospital. A prospective cohort study Clinical and temporal patterns of severe pneumonia causing critical illness during Hajj All authors declare no conflict of interest.