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Table of Contents
Year : 2023  |  Volume : 6  |  Issue : 1  |  Page : 24-31

The factors affecting the response of 2019 pilgrims toward preventive measures against SARS and other Respiratory Infectious Diseases in Hajj

1 Department of Basic Science, Prince Sultan College for Emergency Medical Services, King Saud University, Riyadh, Saudi Arabia
2 Graduate Student, MPH Program, King Saud University, Ministry of Health, Riyadh, Saudi Arabia
3 Global Center for Mass Gatherings Medicine, College of Medicine, King Saud University, Ministry of Health, Riyadh, Saudi Arabia
4 Ministry of Health, Saudi Arabia

Date of Submission25-Aug-2021
Date of Decision06-Apr-2022
Date of Acceptance24-Jun-2022
Date of Web Publication3-Jan-2023

Correspondence Address:
Osama A Samarkandi
Department of Basic Science, Prince Sultan College for Emergency Medical Services, King Saud University, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jnsm.jnsm_110_21

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Purpose: This study aims to evaluate the response of pilgrims at Almadinah Almunawwarah Airport toward knowledge of preventive measures on respiratory infectious diseases, and to study the factors affecting the response of pilgrims to prevent infectious diseases such as SARS. Materials and Methods: This study was conducted at Almadinah Almunawwarah airport in the Kingdom of Saudi Arabia. Pilgrims who arrived at the city airport of Almadinah Almunawwarah (during the pilgrimage season in 2019) were invited to participate in this study. The tool used to collect data was a paper-based questionnaire. Results: The respondents' mean age was 39.8 years with a range of 18 to >50 years and a median age of 35–50 years. The findings indicated that 82.8% of the study participants reported overcrowding could increase the risk of infections. In addition, 67.4% of them agreed that cardiovascular and heat-related illnesses are major causes of death in travelers to the Hajj. With regards to attitudes about 70% agreed that visiting a physician before travel is essential whereas 73.7% of them agreed that personal hygiene protects them from many diseases. Conclusion: The current study shows that knowledge, attitudes, and practices toward preventive measures against respiratory infectious diseases, such as SARS, among pilgrims, are generally less acceptable if contrasted with their ways toward preventive procedures.

Keywords: Hajj, infectious diseases, pilgrims, preventive, respiratory, SARS, vaccine

How to cite this article:
Samarkandi OA, Alharbi YA, Khan AA, Alqarni HS. The factors affecting the response of 2019 pilgrims toward preventive measures against SARS and other Respiratory Infectious Diseases in Hajj. J Nat Sci Med 2023;6:24-31

How to cite this URL:
Samarkandi OA, Alharbi YA, Khan AA, Alqarni HS. The factors affecting the response of 2019 pilgrims toward preventive measures against SARS and other Respiratory Infectious Diseases in Hajj. J Nat Sci Med [serial online] 2023 [cited 2023 Jan 30];6:24-31. Available from: https://www.jnsmonline.org/text.asp?2023/6/1/24/366993

  Introduction Top

Every Hajj season, more than 2 million people coming from all over the world converge in the Kingdom of Saudi Arabia to partake in a religious event known as Hajj. The destination, Makkah and Almadinah Almunawwarah, Saudi Arabia, are the holiest cities in Islam, where around 2.4 million individuals reside during the Hajj period. Hajj is only one of many mass gatherings (MGs) events that take place in the world. These MG events carry a special public health concern due to the high density of people, accessibility and maintenance of lavatories, and food and water distribution.[1],[2],[3],[4]

In addition to a prepared infrastructure, one of the primary health concerns is that congested areas can create a focal point for spreading respiratory infectious diseases. Individuals from distant origins all meet, carrying the microorganisms to which they have already, perhaps unknowingly, developed resistance. Several MGs have produced outbreaks of infectious diseases: the 1992 and 1997 Glastonbury music festivals with Campylobacter from unpasteurized milk and Escherichia Coli, respectively,[5] the 2002 San Juan Festival with Salmonella enteric a,[6],[7],[8],[9] the 2008 Nagoya University Festival with Staphylococcus aureus,[10],[11] and the 2010 Winter Olympics with measles,[12] to name a few. Active infectious agents present in one or more individuals can be a super-spreader for the spreading of infectious diseases.[13]

Many authors studied some of the communicable hazards at Hajj such as meningococcal meningitis, poliovirus, and food poisoning. Furthermore, noncommunicable hazards such as trauma and heat-related illnesses have been studied.[14],[15],[16],[17],[18] Kyu-Myoung conducted a research study that explored and examined the factors influencing the response to infectious diseases that encompass both communicable and noncommunicable diseases.[19]

The Saudi public health directorates, whether regional or central, receive routine reports from health facilities within the Kingdom that are produced by a regular indicator-based respiratory infectious disease surveillance system.[20] Moreover, to ensure timely reporting of event information for appropriate action, enhanced indicator-based notable disease surveillance systems are used to support the existing surveillance tool during Hajj.[21]

In the same line and to grab attention and educate society about the possible means of transmission of the SARS that causes respiratory syndrome in the Middle East, the Saudi Ministry of Health, for instance, started a large public educational project inside the Kingdom.[22],[23],[24] This project, or campaign, used television advertisements to present the potential dangers of the virus to the public and recommended different methods and strategies to avoid spreading and transmitting infectious diseases to others. Besides, the campaign involved messages that are sent through cell phones as well as various communication programs to inform the public about any updates in this regard. This study aims to evaluate the response of pilgrims at Almadinah Almunawwarah Airport toward knowledge of preventive measures on respiratory infectious diseases and to study the factors affecting the response of pilgrims to prevent infectious diseases such as SARS.

  Materials and Methods Top

The study examined the levels and factors affecting the responses of pilgrims toward preventive measures against respiratory infectious diseases in Hajj. For this purpose, a group of pilgrims arriving at Almadinah Almunawwarah Airport (during the pilgrimage season of 2019) were invited to answer questions about preventive measures that can be implemented to stop or control the spread of respiratory infectious diseases, including diseases caused by SARS.

A descriptive cross-sectional design was selected for this study, which was carried out at Almadinah Almunawwarah Airport in Saudi Arabia. The tool used for data collection was a sheet questionnaire, which was written in English and Arabic for ease of understanding for as many pilgrims as possible and to ensure that accurate information could be obtained. The researchers used the knowledge survey tool with the scoring guide that was validated at the design stage. The content was also validated by an experimental study where the responses provided were evaluated and the mysterious elements rephrased while the irrelevant ones were removed from the instrument. Internal validation has been verified by the management of search tools by the researchers.

Study variables

The questionnaires used for this study were prepared after the extensive literature review, published with similar objectives.[20],[21],[22],[23],[24] The study includes four set of questionnaires. The first set of the questionnaire contains demographic information such as age, gender, educational status, nationality, living arrangements, employment, and the number of times attended Hajj. The second set of the questionnaire deal with knowledge items with a total of 16 questionnaires. The third set of the questionnaires asked participants attitudes (10-item) and the last set of questionnaires deals with practice assessment toward travel health with a total of 10 items. All these questionnaires were measured on three-point scale ranging from agree/disagree, uncertain).

Target population and sampling technique

The needed sample size was computed using the Rao soft sample size calculator (http://www.raosoft.com/samplesize.html.)[25] with a 95% confidence level and a 5% margin of error. Because we were unaware of the possible results for each question, we assumed the response distribution for each question would equal 50%. The calculated sample size was 377 pilgrims. However, we opted to survey at least 385 pilgrims to increase the dependability of the results.

The total population was 384 pilgrims arriving at Almadinah Almunawwarah Airport in Saudi Arabia during the Hajj season in July and August 2019. They were from different countries and races. All the 384 respondents understood English or Arabic. Almost an equal number of males (57.8%) and females (42.2%) pilgrims participated in the study as respondents, with a median age of 35–50 years. Thus, the study population was not large and carried a degree of homogeneity between the vocabulary of the trait or characteristics being studied. The simple random sample exploited equal opportunities for the community vocabulary to enter the sample, but the vocabulary that came into the sample was by chance. Pilgrims were selected using the simple random sampling technique where self-administered questionnaires were distributed.

Data collection

The simple random sampling technique was used. The researchers personally distributed the questionnaire to the respondents during the pilgrims' presence at Almadinah Almunawwarah Airport in July and August 2019. That enabled the researchers to explain the contents of the tool and clarify any ambiguity raised by the participants. The responses were collected and analyzed.

Data management and statistical analysis

The quantitative data were collected and examined for completeness and clarity, and the data were edited, coded, and tabulated according to the study objectives to facilitate the analysis. Data analysis was conducted using the IBM Corp. Released 2017. IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp. Encrypted responses were entered into computer programs and analyzed using the SPSS. Results were obtained in the form of frequency tables, means, and percentages, and, where appropriate, statistical conclusions were made.

  Results Top

Socio-demographic characteristics of the respondents

A total of 384 pilgrims participated in this study. The respondents' mean age was 39.8 years with a range of 18 to >50 years and a median age of 35–50 years. In addition, 22.1% of the participants held a higher university degree certificate.

The respondents were asked to indicate their nationality, gender, age, occupational group, and level of education in the survey questionnaire, as shown in For example, the study included questionnaires submitted for pilgrims coming from Asia (e.g., Indonesia, Pakistan, and India) as well as from Africa (e.g., Algeria and Nigeria), as shown in [Figure 1] which shows the percentages of participants based on their nationalities. [Figure 1] shows that most of the participating pilgrims were Pakistanis (46.6%) while the smallest percentage was (2.6%) Nigerian pilgrims.
Figure 1: The nationalities percentage of the participating pilgrims

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Knowledge of preventive measures among hajj pilgrims

The results of this knowledge assessment among the participating Hajj pilgrims are shown in [Table 1] in Appendix A. This knowledge assessment showed that most participants were aware of the standard precautions. Most respondents answered correctly all questions on the components of the concept of standard precautions. The findings also indicated that the majority (82.8%) of the study participants reported that overcrowding could increase the risk of infections, while 14.3% reported the opposite and 2.9% were uncertain in their answers. About (64.3%) of the respondents reported that diarrheal disease is common during Hajj, compared to (27.9%) who disagreed. The majority (67.4%) of the respondents indicated that cardiovascular and heat-related illnesses are major causes of death in travelers to the Hajj, while (27.3%) disagreed with that statement and about (10%) were uncertain.
Table 1: Knowledge assessment among the participated Hajj pilgrims (n=384)

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When the participating pilgrims were asked if people with comorbidity were more likely to be infected, most of them (69.5%) agreed, (9.1%) were uncertain, while (21.4%) did not know that people with morbidity were more susceptible to infection. About (65.4%) of the respondents agreed that SARS spreads through close contact with an infected person and the same percentage agreed that SARS could be fatal, and around (74%) supported the view that isolating patients with SARS is essential to ensure effective implementation of infection control measures. The participating pilgrims confirmed the importance of pretravel advice: avoiding health problems and taking vaccination percentage of (74%) and (76.6%), respectively.

The majority (79.4%) of the respondents agreed that the vaccine is effective against diseases. Antibiotics could be used to relieve pain, and fever-like aspirin and paracetamol were the points of view of about (71.1%). Two hundred and twenty-two pilgrims (57%) agreed that antibiotics are effective against the common cold and flu, while (31.3%) disagreed. When they were asked about antibiotics as the first-line treatment, (57.3%) agreed while (32.6%) disagreed, and around (10%) were uncertain. However, some misconceptions about the correct medical procedure were shared, as reflected in the (33%) of the subjects who realized that antibiotics could not reduce the infection, and in the (58%) who knew that physicians had no antiviral drug for SARS.

About (69.5%) of the participants agreed that humans could become resistant to antibiotics, but (70.1%) and (69.5%) supported the view of antibiotics as being effective against bacteria and viruses, respectively. Two hundred and sixty-five pilgrims (69%) agreed that they should see a health care provider at least 4–6 weeks before traveling.

In general, most of the participants provided satisfactory answers about precautions against infectious diseases caused by SARS. However, their responses revealed misconceptions about preventive measures and the spread of SARS from human to human.

Attitude toward travel health and preventive measures of pilgrims during hajj

As demonstrated in [Table 2] and Appendix A, 294 pilgrims (76.6%) of the respondents supported the opinion that travel does not increase risk if you are in good health. Furthermore, about 70% agreed that visiting a physician before travel is essential. The majority (73.7%) reported that personal hygiene protects from many diseases. Most of the (65%) participants expected the physicians to prescribe antibiotics when they have a common cold. A slight majority (53.6%) of participants wished to be able to purchase antibiotics over the counter from pharmacies without a prescription. Two hundred and twenty-seven pilgrims (59.1%) approved that the risk percentage of getting SARS disease during Hajjis was minimal if any, while about 33.1% disagreed. A high majority, (78.4%) and (64.3%) respectively, agreed that washing hands with soap and water for at least 30 seconds could prevent transmission of respiratory infectious diseases, and reducing contact with livestock can stop the spread of these diseases.
Table 2: Attitude assessment among the participated Hajj pilgrims

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Of the participating pilgrims, 63% believed that medications for fever and pain could not alleviate symptoms of SARS. 69% agreed that Hajj pilgrims must acknowledge themselves with necessary information about respiratory infectious diseases before coming to Hajj while just about 23% disagreed.

Nevertheless, some participating pilgrims reflected a negative attitude about preventive measures. Around 40% indicated that the risk of catching SARS during Hajj is not existing. However, only 35% indicated that avoiding contact with live animals like camels can reduce the spread of respiratory infectious diseases. Furthermore, of the participants, 22% were unable to abide by personal sanitation practices, especially washing hands using water and soap. To sum up, the results demonstrated some negative attitudes among the respondents toward the preventive procedures that can be taken to minimize the spread of transferrable diseases such as those caused by SARS.

Practices of participants regarding travel health

As shown in [Table 3] and Appendix A, the results showed that most of the respondents complied with the measures needed to stop the spread of infection during Hajj. Three hundred and seven participants (80%) practice covering their mouth when sneezing or coughing. Furthermore, about 76% agreed that it is necessary to wash hands after sneezing or coughing. Furthermore, washing hands before preparing or eating foods and after contact with possible contaminated surfaces or materials during Hajj came to (78.4%) and (74.7%), respectively. In addition, most respondents (80.5%) agreed to avoid close contact with people when they are sick during Hajj, and 75% agreed to wear a facemask in heavily crowded areas.
Table 3: Practices assessment toward travel health

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More than 76% agreed to refer to a health-care professional if they have fever, cough, or difficulty in breathing during Hajj. In addition, 260 pilgrims (67.6%) supported minimizing any contact with the mouth, eyes, or nose. Moreover, 249 pilgrims (64.4%) agreed to use pest control measures. However, about 60% of the participants did not mind sharing food and drink utensils with other people during Hajj, while just 32% disagreed. This relatively high percentage of respondents who agreed to share their foodstuff with other pilgrims underscores the importance of addressing this habit in campaigns that aim to raise awareness about the dangers of SARS and the measures that can be taken to stop its spread among pilgrims.

In a nutshell, the examination of the knowledge, attitudes, and practices of the selected sample of pilgrims regarding diseases caused by viruses revealed a general lack of knowledge and negative attitude among the respondents toward preventive measures against infectious diseases in Hajj gatherings. This lack of knowledge, along with negative attitudes toward preventative measures, may create challenges for any attempt to curb the spread of infectious diseases caused by, for example, SARS. With these results in mind, it can also be concluded that the knowledge and attitudes toward SARS among the respondents are mostly not adequate if compared to their habits toward preventive practices.

Relationship between socio-demographic factors and the knowledge, attitudes, and practices variables

The study findings show that there was no statistically significant correlation between the age of the respondents, the living arrangements, and the employment type, on the one hand, with the knowledge, attitudes, and practice variables examined in this study, on the other hand. However, there was a statistically significant positive correlation between the education level and each of these three variables (P < 0.01). Pilgrims holding university degrees and higher reported higher knowledge rates, more positive attitudes, and better practices concerning preventive measures than those with the lowest education degrees, certificates, and no education.

Similarly, there was a significant correlation between the number of times people attended Hajj and the knowledge, attitudes, and practice variables (P < 0.01). Thus, pilgrims who came to Saudi Arabia more than once during the Hajj season seem to be positively influenced by this experience compared to those who performed Hajj for the first time.

  Discussion Top

The outbreak of SARS and other respiratory infectious diseases worldwide caused tremendous fear not only to public health but also to the way of living. To control the outbreak of this emerging infectious disease, preventative measures, and knowledge about the disease play an essential role in reducing infection rates. Only limited studies are conducted during the hajj seasons in Saudi Arabia. This descriptive and quantitative study that was conducted in Almadinah Almunawwarah, highlighted the practices, knowledge, and attitudes related to preventive measures against infectious diseases. Worldwide many studies conducted to assess the knowledge, attitudes, and practice toward various diseases, including influenza,[26] SARS, and other diseases among other population,[27],[28] but there were lack of studies among hajj pilgrims in Saudi Arabia, therefore, this study would add a significant contribution to the upcoming studies.

The analyses conducted in this study revealed negative attitudes and a general lack of knowledge that some pilgrims have toward preventive measures against these diseases. The lack of knowledge and negative attitudes match the results obtained from a survey of Australian pilgrims.[29] In the same line, there is a similar lack of knowledge about MERS-CoV among French pilgrims,[30] which was like the results collected from Turkish pilgrims.[16] Nearly 65% of the French,[30] 45% of the Turkish,[31] and only 35% of the Australian pilgrims[29] were aware of the MERS. However, according to the French study,[30] French pilgrims were more serious about taking preventive measures. For example, most French pilgrims (90%) used hand sanitizers and wore masks compared to (70%) of our study participants who used hand sanitizers and wore masks only in crowded places. Although earlier findings suggested that an alcohol gel-based hand sanitizer can reduce infection rates and provide an additional tool for an effective infection control program.

The current findings suggest using more accurate public health education methods to correct misconceptions highlighted in this study. There have been numerous campaigns launched in the Kingdom to alert people about possible means of transmitting SARS. However, there is a need to intensify the measures and get the audience more involved using, for example, media and social media resources to help provide more information and educational support to pilgrims. Health-care professionals and Imams (clergymen) can benefit from the findings of this study and, in turn, play an influential role by familiarizing pilgrims with SARS when they visit immunization health centers or mosques. Moreover, travel agency representatives can incorporate the findings into their informative sessions to clarify the misconceptions about the spread of SARS and other infectious diseases. For example, the results can be included in tutorial videos to be shown to pilgrims going to Makkah and Almadinah Almunawwarah.

Thus, these findings confirmed that international engagement is vital to strengthen Hajj infectious diseases preventive measures. This can be achieved through the involvement of all countries in supporting the international health regulations and through global cooperation in the field of surveillance and warning of outbreaks and responding to their requirements. This is also achieved through the exchange of knowledge, technologies, and materials openly, including viruses and other laboratory samples, which is imperative to achieving the optimum level of safe global public health. In addition, global responsibility for capacity building within the framework of public health infrastructure in all countries is needed across all sectors within governments. Moreover, work to increase the international and national resources is necessary for training and surveillance, building laboratory capacity, establishing response networks, and launching prevention campaigns.[32]

  Conclusion Top

The study showed that knowledge, attitude, and practices toward preventive measures against infectious diseases, such as SARS, among the respondents are mainly less satisfactory if compared to their habits regarding protective practices. However, there are significant opportunities to improve awareness among Hajj pilgrims about the importance of using preventive health measures. The results also revealed some misconceptions about treatment, preventive measures, and the symptoms of SARS. The results suggest that to reduce the spread of infection caused by viruses like SARS, the health authorities in the Kingdom and the countries of indigenous pilgrims are highly urged to make extra efforts in educating pilgrims and use all practical and influential means to spread health information among travelers, whether while providing advice before traveling or at the point of entry into the Kingdom of Saudi Arabia.[28]


There are some shortcomings in measuring the variables of knowledge, attitude, and practices due to the low awareness of the importance of pretravel health advice. These shortcomings were reflected by the low referral to travel medical specialists to get medical advice regarding travel vaccinations against respiratory diseases, traveler's diarrhea, typhoid, and injuries. Hence, travel agencies could be provided with educational materials developed by travel medicine clinics and can also play a role in referring travelers to travel clinics which would be the best strategy to improve pilgrims' health.

Ethical approval

The Ethical Approval was obtained from the Institutional Ethics Committee College of Medicine, King Saud University, Riyadh, Saudi Arabia, with the following approval number (E-19-4052). Approved on August 27, 2019.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3]


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