Background
 
Hajj is one of the largest mass gatherings on earth that take place annually in Mecca, Saudi Arabia where two to three million people assemble from all corners of the world. During Hajj over 70,000 emergency room visits occur in the pilgrimage sites of Makkah and Medina, of these about 12,000 (i.e., about one sixth) needs hospital admission [1]. In-hospital mortality in Makakh at the of Hajj rises up to 4%, whereas it is 1% in Medina during the same period [1]. This excessive disease burden greatly strains the health care system in Makkah [2]. To tackle this situation, about 20,000 health care workers (HCWs) are mobilised to pilgrimage sites, about 70% of whom are comprised of physicians, nurses and allied health care workers. During a typical Hajj season a doctor treats over 600 ill pilgrims and a nurse looks after about 400 patients [1]. Health care workers themselves fall victim of various infectious hazards at the time of Hajj that result from intense exposure to a large number of ill pilgrims’ superadded on exhaustion, high work load and inadequate adherence to protective measures. For instance, Al-Asmary and colleagues found that a quarter of HCWs in Hajj medical admission developed ARI, contact with pilgrims was a significant risk factor for acquisition of this infection  [3]. Additionally, an ill HCW remains infectious to other patients and co-workers. Therefore, preventive measure including vaccination and use of personal protective measures are vital for HCWs.
 
Saudi Arabian authority has made quadrivalent meningococcal vaccine mandatory for all workers, including HCWs, who have not been vaccinated in the past 3 years [4]. Despite the mandatory requirement of meningococcal vaccine, its uptake among HCWs during the Hajj 2003 and 2009 was 82.4% and 67.1% respectively [5, 6]. Influenza and hepatitis B vaccines are also recommended for HCWs [ref.]. The uptake of seasonal influenza vaccine among HCWs during the Hajj 2003 and 2009 was 5.9% and 65.6% respectively, and the uptake of pandemic vaccine during the Hajj 2009 was 47% [5-7]. There has been very limited research to explore the uptake of other preventive measures such as facemask use and hand hygiene in HCWs, which are summarised in Table 1 [3, 5-8]; and the knowledge, attitude and practices of HCWs concerning these preventive measures is almost non-existent. Secondly, although the coverage of these preventive measures has been suboptimal in this highly vulnerable population, few studies have attempted to explore the underlying causes.  To this end, this study aims to identify the infection control measures practiced by trainee HCWs, understand their knowledge, attitudes and beliefs, and explore the facilitators and barriers of using those measures.
 
 
 
Introduction
 
Pilgrimage of the largest gatherings in the world where a small area for a short period of up to six days in Mecca, Saudi Arabia where two million to three million pilgrims to perform the Hajj in the month of Dhul Hijjah each year HJ. Therefore, occurs more than 70 emergency room visitors in pilgrimage sites of Mecca and Medina, and of these about 12, 000 (about one-sixth) needs hospitalization [1]. In hospital deaths in Mecca for Hajj rises up to 4%, while it is 1% in Medina during the same period [1]. This excessive disease burden straining too much of the health care system in [2] Mecca. To address this situation, some 20, 000 health-care workers (HCWs) to sites of pilgrimage, about 70% of them are composed of physicians, nurses and allied healthcare workers. During a typical pilgrimage more than 600 pilgrims addresses physician and nurse looks after about 400 patients [1].  Health care workers themselves victims of various infectious risks at the time of the pilgrimage caused by massive exposure to a large number of pilgrims ill “superadded to exhaustion and a high workload and insufficient commitment to preventive measures. For example, he found the Al-Asmary and his colleagues that a quarter of HCWs in admission Hajj medical develop acute respiratory infections, and connect with a great risk factor for acquisition of pilgrims this infection [3]. In addition, still a HCW with infectious disease to other patients and coworkers. Therefore, as a preventative measure including vaccination and the use of personal protective measures vital to HCWs. the quadrivalent meningococcal has been made compulsory by Saudi Arabia authority for all workers in Hajj, including health care workers, who have not been vaccinated in the last three years [4]. In previous research, there was no focus on the health workers took the vaccination or not we are focusing on this research [3-8].  Health care workers who have taken the seasonal influenza vaccine during Hajj 2003 and 2009 were 5.9% and 65.6% respectively, and who took the vaccine of pandemic in 2009 were 47% [5-7]. Researches that they explore about preventive measures such as the mask and hand hygiene in health workers was limited and were more focused on knowledge, attitude and practices of HCWs [3, 5-8]. Therefore, it will be the aim of the study in this research to identify the infection control measures practiced by trainee HCWs, understand their knowledge, attitudes and beliefs, and explore the facilitators and barriers of using those measures.
Discussion
 
 
 
 
 
Methods
 
An anonymous cross sectional survey conducted among trainee HCWs who worked or volunteered during the Hajj 2015. In this survey only HCWs who are resident in Saudi Arabia (may or may not be Saudi citizen) will be recruited, overseas HCWs who accompany the pilgrims or work in Hajj medical missions will be excluded.
Data on demographics including age, gender, co-morbidities and vaccination record (e.g., meningococcal, influenza and hepatitis B vaccination rates) were collected. The questionnaire also evaluated the knowledge, attitude and practices regarding various preventive measures (e.g., hand hygiene, use of personal protective measures, and their understanding about the risk of common infectious diseases as well as uncommon diseases of public health significance, such MERS-CoV and Ebola will be explored. Moreover, the survey investigated the facilitators and the barriers to actual infection control practices during Hajj.
Sample size??
Recruitment method???
Statistical analysis was performed using the Statistical Package for Social Sciences (SPSS) v.19.0 (SPSS, Inc., Chicago, IL, USA). Pearson correlation coefficients and chi-square tests were used to assess variables and determine associations and correlations. Two-tailed p values <0.05 were considered statistically significant in Univariate analysis.
 
This study was reviewed and approved by KAMC IRB registered at the National BioMedical Ethics Committee, King Abdulaziz City for Science and Technology (Registration no. H-02-K-001).
Results
 
A total number of 124 HCWs who participated in the study during hajj 2015, their age was in the range group between 20-88 years with a median age of 27 years. The percentage of male of HCWs (69.4%) was more than female (30.6%), Saudi HCWs (91.9%) and non-Saudi was (8.1%). Majority of position health care workers was students (36.3%), nurses (31.5%) and physicians (16.9%). 93% of HCWs do not have chronic diseases, namely diabetes, hypertension, asthma, high cholesterol, other lung diseases, malignancy and heart diseases. Most HCWs had work experience in Hajj more than one to less than 6 times (50%), and who attended more than five times was (20%), whereas 30% of HCWs attended Hajj for the first time.
Health care workers who have committed to take vaccinations (meningococcal meningitis, seasonal influenza, pneumococcal and hepatitis B vaccines) before going to work for Hajj is shown in table 1.
The HCWs got at least one vaccine before come to work in Hajj was 84.7%.  The percentages of taken meningococcal meningitis and seasonal influenza vaccines were relatively high (77% and 67%, respectively). Female of HCWs uptake the vaccines more than male. 77% of uptake vaccines who they follow health authority’s advice/recommendation. The HCWs who didn’t want to get sick/acquire a transmissible disease at Hajj were 49%. 45% of HCWs said the vaccine is effective in protective in protecting us against disease, and 30% of them said by receiving vaccine, we can prevent passing disease to patients or co-workers. Also, some of HCWs believe they can avoid taking sick leave by receiving vaccine (13%).  Other of the HCWS prefer to use other preventive measures (e.g. facemasks, gloves), didn’t take the vaccine, as they had to pay for it, they rely on their own body’s immunity, they don’t worry about getting sick and they were afraid of having vaccine side effects (14.2%, 3.3%, 7.5%, 7.5% and 7.5%, respectively).  The HCWs who did not receive any vaccines were already up to date with vaccination, so there is no take any other vaccine (40%), they don’t know what vaccines should be taken to participate at Hajj were 39%.  MERS Corona virus(MERS-CoV), Ebola (40%), influenza (40%), blood borne diseases (e.g. hepatitis) (41%), and pneumonia (31%). Compliance with wearing facemask constantly during work hours was noted in 86% of male HCWs, 100% of female. 83.5% of HCWs used facemask to protect themselves from diseases, and 70.9% of them believe the facemask is effective in preventing infections. The HCWs use facemask to protect others, to protect them from air pollution, recommended by a friend or colleague, or recommended by place of work were (67.1%, 62%, 29.1%, 46.8%, respectively). The HCWs use facemask because they are at greater risk were 39.2%, and it is easy to use were 57%. The main reasons for they didn’t use facemask or used it only rarely were hard to breath with it (60%), and facemask does not protect from respiratory infections (13.3%). The HCWs didn’t use facemask because it made them feel isolated in their work place (17.8%), and because it was not available in their work place (11.1%). The HCWs said there is no need to use it were 31.1%. Approximately 93.5% of HCWs did hand washing. The most of HCWs did practice hand hygiene   because of effective in preventing infections were 68.5%, while 8.1% of them didn’t practice hand hygiene in Hajj. 66.9% of opinion of HCWs in what stops they being able to use appropriate infection control measures while working during Hajj was workload. 57.9% of female HCWs believe the facemask more effective from the face veil (Niqab).
 
Table 1 Summary of the studies that assessed infection control measures coverage among health care workers during Hajj
 
 

Reference Hajj year Setting Sample size
 
Mean age (range) %Male %Meningococcal
vaccination  rate %
%Influenza vaccination rate Other
Vaccinations (%coverage rate)
Facemask use (% compliance rate) Hand hygiene (% compliance rate) Other measures (%)
Madani et al [5] 2003 Mina and Arafat Hospitals 392 Nurses
46.5 (20-30)
Doctors
44
(40-51)
Nurse 22.8
Doctors 80.2
82.4 5.9 HBV:
3 doses (66.3)
2 doses (12.2)
1 dose (7.1)
NR NR NR
Al-Asmary et al [3]
 
2005 Hajj mission members of Al-Hada and Taif Military
Hospitals
250
 
37 87.2 NR 65.6 NR Always (44)
Intermittently
(48.8)
With alcoholic disinfectant:
Always (35.2)
Intermittently
(36)
NR
Memish et al [6] 2009 HCWs in ministry of health & medical mission 148
 
41 85 67.1 50.9 H1N1 (21.7)
HBV (73.3)
Tetanus (2.2)
MMR(1.9)
Always (48.7)
Sometimes (40.8)
Only when with patients (7.9)
Seldom (2.6)
 
(97.5) Cough etiquette (89)
Ahmed et al [7]
 
2009 National Guard hospital  employees
 
126
 
38.7 79.4 NR NR H1N1 (46.8) (50) (100) Eating Honey (15.8)
Citrus fruit (19.8)

 
 
 
 
 
 
 

  Meningococcal meningitis vaccine Seasonal influenza vaccine Pneumococcal vaccine Hepatitis B vaccine
  Uptake Non-uptake Unsure Uptake Non-uptake Unsure Uptake Non-uptake Unsure Uptake Non-uptake Unsure
Gender        
Male 52(60.5%) 31(36%) 3(3.5%) 52(60.5%) 31(36%) 3(3.5%) 12(14%) 65(75.6%) 9(10.4%) 31(36%) 52(60.5%) 3(3.5%)
Female 34(89.5%) 3(7.9%) 1(2.6%) 31(81.6%) 6(15.8%) 1(2.6%) 5(13.2%) 30(79%) 3(7.8%) 10(26.3%) 24(63.2%) 4(10.5%)
Position        
Allied HCW 8(66.7%) 4(33.3%) 0(0%) 5(41.7%) 7(58.3%) 0(0%) 0(0%) 11(91.7%) 1(8.3%) 4(33.3%) 8(66.7%) 0(0%)
Students 33(73.3%0 10(22.2%) 2(4.4%) 27(60%) 14(31.1%) 4(8.9%) 5(11.1%) 31(68.9%) 4(8.9%) 12(26.7%) 27(60%) 6(13.3%)
Lab Specialist 2(100%) 0(0%) 0(0%) 2(100%) 0(0%) 0(0%) 0(0%) 2(100%) 0(0%) 2(100%) 0(0%) 0(0%)
Nurses 31(79.5%) 8(20.5%) 0(0%) 28(71.8%) 11(28.2%) 0(0%) 7(17.9%) 31(79.5%) 1(2.6%) 17(43.6%) 21(53.8%) 1(2.6%)
Pharmacists 4(80%) 1(20%) 0(0%) 5(100%) 0(0%) 0(0%) 0(0%) 5(100%) 0(0%) 0(0%) 4(100%) 0(0%)
Physicians 17(80.9%) 3(14.3%) 1(4.8%) 16(76.2%) 5(23.8%) 0(0%) 4(19%) 16(76.2%) 1(4.8%) 6(28.6%) 15(71.4%) 0(0%)
Hajj Experience        
First time 26(70.3%) 9(24.3%) 2(5.4%) 25(67.6%) 9(24.3%) 3(8.1%) 7(18.9%) 24(64.9%) 6(16.2%) 12(32.4%) 23(62.2%) 2(5.4%)
>1 to <6 48(77.4%) 13(21%) 1(1.6%) 38(61.3%) 23(37.1%) 1(1.6%) 8(12.9%) 48(77.4%) 6(9.7%) 18(29%) 39(62.9%) 5(8.1%)
>5 21(84%) 4(16%) 0(0%) 20(80%) 5(20%) 0(0%) 2(8%) 23(92%) 0(0%) 11(44%) 14(56%) 0(0%)
Seriously to diseases        
Influenza 39(79.6%) 10(20.4%) 0(0%) 17(34.6%) 11(22.4%) 1(2%) 8(16.3%) 38(77.6%) 3(6.1%) 17(34.7%) 30(61.2%) 2(4.1%)
Pneumonia 28(73.7%) 9(23.7%) 1(2.6%) 23(60.5%) 14(36.8%) 1(2.6%) 4(10.5%) 27(71.1%) 14(36.8%) 16(42.1%) 22(57.9%) 0(0%)
Blood borne diseases (e.g. hepatitis) 37(72.5%) 5(9.8%) 2(3.9%) 32(62.7%) 18(35.3%) 1(2%) 7(13.7%) 35(68.6%) 9(17.6%) 19(37.3%) 31(60.8%) 1(1.9%)

 
 
 
 
 
 
 
 
 
 
 
 

  Wearing facemask constantly during work hours Hand washing with water only
  0 1-6 >6 0 1-6 >6
Gender    
Male 12(14%) 40(46.5%) 34(39.5%) 3(3.5%) 46(53.5%) 37(43%)
Female 0(0%) 13(34.2%) 25(65.8%) 5(13.2%) 17(44.7%) 16(42.1%)
Position    
Allied HCW 1(8.3%) 7(58.3%) 4(33.3% 1(8.3%) 6(50%) 5(41.7%)
Students 3(6.7%) 20(44.4%) 22(48.9%) 2(4.4%) 26(57.8%) 17(37.8%)
Lab Specialist 1(50%) 1(50%) 0(0%) 0(0%) 1(50%) 1(50%)
Nurses 4(10.5%) 13(34.2%) 21(55.2%) 3(7.7%) 14(35.9%) 22(56.4%)
Pharmacists 2(40%) 2(40%) 1(20%) 1(20%) 4(80%) 0(0%)
Physicians 1(4.8%) 9(42.9%) 11(52.4%) 1(4.8%) 12(57.1%) 8(38.1%)
Hajj Experience    
First time 1(2.7%) 21(56.8%) 15(40.5%) 2(5.4%) 22(59.5%) 13(35.1%)
>1 to <6 6(9.7%) 21(33.9%) 35(56.5%) 2(3.2%) 32(51.6%) 28(45.2%)
>5 5(20%) 11(44%) 9(36%) 4(16%) 9(36%) 12(48%)
Seriously to diseases    
Influenza 4(8.2%) 19(38.8%) 26(53%) 4(8.2%) 22(44.9%) 23(46,9%)
Pneumonia 5(13.2%) 33(86.8%) 0(0%) 0(0%) 22(57.9%) 16(42.1%)
Blood borne diseases (e.g. hepatitis) 2(3.9%) 49(96.1%) 0(0%) 2(4%) 27(52.9%) 22(43.1%)

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Health Care Workers
Discussion
Due to their direct contact with patients, health care workers usually have a heightened risk of been infected with contagious diseases. During the Hajj period, there is always a high concentration of individuals in Mecca, which provides a conducive environment for the outbreak of various contagious diseases. Therefore, these study revealed the level of awareness among HCWs on how to prevent acute respiratory infections (ARI). It also showed the measures that they were undertaking and the effectiveness of these tactics. In general, proper training, vaccination of HCWs, as well as pilgrims, can limit the emergence and spread of flu-related ailments.
Demographic Characterization
In the research, a majority of participants were male, who were 69.4% of the population and female 30.6%. The high concentration of male doctors indicated that health care is a male dominated profession in Saudi Arabia. The uptake of vaccination in Mecca was statistically low, at 84.7%. This low level was in agreements with results from a research by Ghabrah et al. (3), which indicated that vaccination rate among health care workers is 84.2%. Further, this low level of vaccination was associated with the high level of flu outbreaks during Hajj. From the research, it was observed that there was a high rate of disease outbreaks among HCWs, which may be attributed to lack of undertaking appropriate preventive measures. At least 53% of all HCWs had suffered from influenza in the past one year.
Vaccination Uptake and Associated Factors
The vaccination uptake was observed to be low based on international standards. There was only an uptake of vaccination by 84.7% of HCWs. It was also observed that female take vaccines more than male HCWs, which may be due to their social role. There was still a high proportion of individuals who did not take vaccine due to lack of knowledge of their effectiveness. 40%, cited that lack of knowledge as the cause of them not been vaccinated. These results aligned with those of Turkestani e al. (4), which showed the need for training in order to increase the rate of vaccination.
Concern of Disease
There was a significant level of lack of concern for the ARI. The sub-optimal level of immunization was by itself an indication of this lack of concern. Among male patients, the percentage of non-uptake of vaccines was 36% for meningococcal meningitis, 36% for seasonal influenza, 75.6% for pneumococcal, and 60.5% for Hepatitis.  A similar trend was observed among female HCW with 7.9% non-uptake for meningococcal meningitis, 15.8% for seasonal flu, 79% for pneumococcal, and 63.2% for Hepatitis B vaccine. These rates indicated that the rate of uptake was relative to the severity of the disease. Further, women and men had a higher uptake of meningococcal meningitis and seasonal influenza vaccine, which was an indication of the associated risk of occurrence of these diseases.
Non-Pharmaceutical Measure
Hand washing and wearing of facemasks were used to assess the effectiveness of non-pharmaceuticals methods in preventing ARIs. From the study, it was observed that experienced workers mostly disinfect their hands before starting their tasks. The rates were 45.3% for those who disinfect more than 6 times, 51.6% for those who disinfect between 1 and six, and 3.2% for those who disinfect only once. On the first time HCWs, the rates were 5.4%, 59.5%, and 35.1% for 0 disinfection, a disinfection of 1-6 times, and for disinfection of more than 6 respectively. In general, the study showed that more experienced HCWs were more careful about health hygiene as a means of preventing infection.
In terms of health care profession, HCWs with more knowledge were found o be more careful in ensuring there was no contamination. Among physicians, the usage of face masks was 4.8%, 42.9%, and 52.4% when working for 0 hours, 1 to 6 hours, and when working for more than 6 hours. On a similar note, these individuals indicated high levels of hand acre hygiene. When working for 0 hours, the level was 4.8%, when working for between 1 and 6 hours the rate was 57.1%, finally, it was 38.1% when working for more than 6 hrs. Among students, the rate was 6.7%, 44.4%, and 48.9% for 1, 1-6, and more than 6 hours respectively. Hand washing was 4.4%. 57.8%, and 37.8% for 0, 1-6, and more than 6 hours respectively. This study collaborates studies by previous research by Al-Ghamdi and Kabbash (2), which found that an increase in HCW’s knowledge reduces the chances of cross-infections.
Facemasks and Niqabs
The use of facemasks was higher among experienced female HCWs than on experienced male HCWs. In male HCWs, the use of masks was 14% for those with less than one year experience, 46.5% for those with experience of 1-6 years, and 39.5% for those with an experience of more than 6 years. Among women, the rate was 0% fro those with experience of less than a year, 34.2% for those with experience of 1-6 years, and 65.8% for those with experience of more than 6 years. According to Al-Asmary et al. (1), facemasks and niqabs do not offer any protection against acute respiratory tract infection. Since facemasks and niqab are not designed to prevent the flow of particulate respirators, they cannot effectively prevent the spread of acute respiratory tract infections. From this perspective, the use of these gadgets was based on perceived prevention ability and not actual proven ability. To sum up, the use of surgical masks should be discontinued and instead, HCW should use N95 masks, which are designed to filter particulates, they should also use alcohol-based disinfectants, increase the level of training and awareness in order to encourage HCWs to prevent against risks of infections with ARI.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
References
 
1.Almalki, M., G. Fitzgerald, and M. Clark, Health care system in Saudi Arabia: an overview. East Mediterr Health J, 2011. 17(10): p. 784-93.
 
2.Arabi, Y. and A. Al Shimemeri, Critical care medicine in Saudi Arabia. East Mediterr Health J, 2006. 12(1-2): p. 225-30.
 
3.Al-Asmary, S., et al., Acute respiratory tract infections among Hajj medical mission personnel, Saudi Arabia. International journal of infectious diseases, 2007. 11(3): p. 268-272.
 
4.Memish, Z.A. and A.A. Al Rabeeah, Health conditions for travellers to Saudi Arabia for the Umra and pilgrimage to Mecca (Hajj) – 2014. J Epidemiol Glob Health. 2014 Jun;4(2):73-5. doi: 10.1016/j.jegh.2014.02.002. Epub 2014 Apr 14.
 
5.Madani, T.A. and T.M. Ghabrah, Meningococcal, influenza virus, and hepatitis B virus vaccination coverage level among health care workers in Hajj. BMC infectious diseases, 2007. 7(1): p. 80.
 
6.Memish, Z.A., et al., The prevalance of respiratory viruses among healthcare workers serving pilgrims in Makkah during the 2009 influenza A (H1N1) pandemic. Travel medicine and infectious disease, 2012. 10(1): p. 18-24.
 
7.Ahmed, G.Y., et al., Acceptance and adverse effects of H1N1 vaccinations among a cohort of national guard health care workers during the 2009 Hajj season. BMC research notes, 2011. 4(1): p. 61.
 
8.Ghabrah, T.M., et al., Assessment of infection control knowledge, attitude and practice among healthcare workers during the Hajj period of the Islamic year 1423 (2003). Scandinavian journal of infectious diseases, 2007. 39(11-12): p. 1018-1024.