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Infectious diseases threats at the Arba'een – a neglected but one of the largest annually recurring mass gathering religious events

Open AccessPublished:September 12, 2022DOI:https://doi.org/10.1016/j.ijid.2022.09.010

      Keywords

      EDITORIAL

      Mass gathering religious, sporting and festival events are known to pose major public health challenges worldwide (
      • Shafi S
      • Dar O
      • Khan M
      • Khan M
      • Azhar EI
      • McCloskey B
      • et al.
      The annual Hajj pilgrimage-minimizing the risk of ill health in pilgrims from Europe and opportunity for driving the best prevention and health promotion guidelines.
      ;
      • Al Rabeeah A
      • Memish ZA
      • Zumla A
      • Shafi S
      • McCloskey B
      • Moolla A
      • et al.
      Mass gatherings medicine and global health security.
      ;
      • Blumberg L
      • Regmi J
      • Endricks T
      • McCloskey B
      • Petersen E
      • Zumla A
      • et al.
      Hosting of mass gathering sporting events during the 2013-2016 Ebola virus outbreak in West Africa: experience from three African countries.
      ;
      • Memish ZA
      • Steffen R
      • White P
      • Dar O
      • Azhar EI
      • Sharma A
      • et al.
      Mass gatherings medicine: public health issues arising from mass gathering religious and sporting events.
      ). Recent focus of these challenges has been on the importation, transmission, and globalisation of a range of emerging and re-emerging infectious diseases threats including Monkeypox, COVID-19, Influenza and antibiotic resistance (
      • Aggrawal V
      • Dikid T
      • Jain SK
      • Pandey A
      • Khasnobis P
      • Choudhary S
      • et al.
      Disease surveillance during a large religious mass gathering in India: The Prayagraj Kumbh 2019 experience.
      ;
      • Goumballa N
      • Hoang VT
      • Diouf FS
      • Mbaye B
      • Parola P
      • Sokhna C
      • et al.
      Risk factors for symptoms of infection and the acquisition of pathogens among pilgrims at the Grand Magal of Touba, 2017-2021.
      ;
      • Zumla A
      • Traore T
      • Amao L
      • Ntoumi F
      • Sharma A
      • Azhar EI
      • et al.
      Reducing the threat of epidemic-prone infections at mass gathering religious events.
      ;
      • Petersen E
      • Asogun D
      • Ntoumi F
      • Zumla A.
      Infection control at mass religious gatherings.
      ;
      • Al-Ansari F
      • Mirzaei M
      • Al-Ansari B
      • Al-Ansari MB
      • Abdulzahra MS
      • Rashid H
      • et al.
      Health Risks, Preventive Behaviours and Respiratory Illnesses at the 2019 Arbaeen: Implications for COVID-19 and Other Pandemics.
      ). All mass gathering religious events involve large numbers of pilgrims living and interacting together performing religious rites in crowded conditions, exposing themselves and the local population to various bacterial and viral infections. Every year the Kingdom of Saudi Arabia (KSA) hosts the Hajj pilgrimage, one of the largest religious mass gatherings held on an annual basis where up to 2 million people from over 180 countries, and one million local pilgrims assemble in the holy cities of Makkah and Madinah (
      • Shafi S
      • Dar O
      • Khan M
      • Khan M
      • Azhar EI
      • McCloskey B
      • et al.
      The annual Hajj pilgrimage-minimizing the risk of ill health in pilgrims from Europe and opportunity for driving the best prevention and health promotion guidelines.
      ;
      • Memish ZA
      • Steffen R
      • White P
      • Dar O
      • Azhar EI
      • Sharma A
      • et al.
      Mass gatherings medicine: public health issues arising from mass gathering religious and sporting events.
      ). The Kumbh Mela is held every four years and is the largest religious mass gatherings in the world attracting over 120 million pilgrims (
      • Aggrawal V
      • Dikid T
      • Jain SK
      • Pandey A
      • Khasnobis P
      • Choudhary S
      • et al.
      Disease surveillance during a large religious mass gathering in India: The Prayagraj Kumbh 2019 experience.
      ). The nature and degree of threats to global and host country health security of each individual religious mass gathering varies and depends on the number of pilgrims, the frequency of religious events and proportion of local versus international pilgrims, countries of origin and pre-event public health preparations. The latter includes adherence to the latest recommended WHO health risk assessments for mass gathering events, host country travel advice including immunisations, available healthcare facilities and services provided to pilgrims.
      Whilst the Hajj pilgrimage has been the focus of attention of global public health bodies and has generated intense academic discourse for the past decade (
      • Sweileh WM.
      Health-related research publications on religious mass gatherings of Muslims: a bibliometric analysis (1980-2020).
      ) due to a global remit of origin of pilgrims and the emerging threats of new zoonotic pathogens including MERS-CoV and SARS-CoV-2, other large annually recurring mass gathering religious events have received less attention but could potentially pose significant threats to global health security. The Grand Magal of Touba in Senegal, for example, attracts millions of pilgrims, the public health issues of which have recently been highlighted (
      • Petersen E
      • Asogun D
      • Ntoumi F
      • Zumla A.
      Infection control at mass religious gatherings.
      ;
      • Goumballa N
      • Hoang VT
      • Diouf FS
      • Mbaye B
      • Parola P
      • Sokhna C
      • et al.
      Risk factors for symptoms of infection and the acquisition of pathogens among pilgrims at the Grand Magal of Touba, 2017-2021.
      ). On 16th -17th September 2022, the Shiite religious pilgrimage Arba'een, the largest annually recurring regional religious event, will take place and over 20 million pilgrims from the Middle East, particularly from Iran and within Iraq and other countries such as Turkey, Nigeria and India will travel to Iraq. The pilgrimage is marked by long walks of up to 80 kilometres from the holy city of Najaf to Karbala by pilgrims from all age groups and ethnicities, different walks of life, with elderlies pushed in armchairs, and children carried by families (
      • Karampourian A
      • Ghomian Z
      • Khorasani-Zavareh D.
      Exploring challenges of health system preparedness for communicable diseases in Arbaeen mass gathering: a qualitative study.
      ;
      • Lami F.
      • Hameed I
      • Jewad AW
      • Khader Y
      • Amiri M.
      Real-Time Surveillance of Infectious Diseases and Other Health Conditions during Iraq's Arbaeenia Mass Gathering: Cross-Sectional Study.
      ). During the Arba'een, pilgrims are provided with free accommodation, food, and drinks by volunteers along the walking routes.
      To date, the Arba'een has remained relatively neglected by global public health authorities due to its regional Middle East focus and frequent interruptions to attendance for pilgrims from outside Iraq. Whilst accurate data are unavailable in the literature, the annual numbers and flow of pilgrims for the Arba'een have been interrupted several times over the years due to political instability, safety and security issues. Since the Iraq war ended over two decades ago in 2003 the Arba'een has continued to attract a growing number of pilgrims from outside Iraq (
      • Al-Ansari F
      • Mirzaei M
      • Al-Ansari B
      • Al-Ansari MB
      • Abdulzahra MS
      • Rashid H
      • et al.
      Health Risks, Preventive Behaviours and Respiratory Illnesses at the 2019 Arbaeen: Implications for COVID-19 and Other Pandemics.
      ). The tens of millions pilgrims impose a substantial burden on Iraq's already fragile and non-resilient health infrastructure. Public health surveillance and control measure for infectious diseases constitute significant challenges during the Arba'een due to high population density, pilgrims’ relatively low perception and lack of awareness of health risks (
      • Hamdanieh L
      • Ostadtaghizadeh A.
      Arbaeen in the Context of the COVID-19 Pandemic.
      ;
      • Karampourian A
      • Ghomian Z
      • Khorasani-Zavareh D.
      Exploring challenges of health system preparedness for communicable diseases in Arbaeen mass gathering: a qualitative study.
      ;
      • Lami F.
      • Hameed I
      • Jewad AW
      • Khader Y
      • Amiri M.
      Real-Time Surveillance of Infectious Diseases and Other Health Conditions during Iraq's Arbaeenia Mass Gathering: Cross-Sectional Study.
      )
      The potential risk of infectious diseases outbreaks at the Arba'een could be extraordinary, and the range of conditions may include not just COVID-19 but also Monkeypox, meningococcal diseases, and other respiratory tract infections (
      • Al-Ansari F
      • Mirzaei M
      • Al-Ansari B
      • Al-Ansari MB
      • Abdulzahra MS
      • Rashid H
      • et al.
      Health Risks, Preventive Behaviours and Respiratory Illnesses at the 2019 Arbaeen: Implications for COVID-19 and Other Pandemics.
      ;
      • Petersen E
      • Asogun D
      • Ntoumi F
      • Zumla A.
      Infection control at mass religious gatherings.
      ;
      • Zumla A
      • Traore T
      • Amao L
      • Ntoumi F
      • Sharma A
      • Azhar EI
      • et al.
      Reducing the threat of epidemic-prone infections at mass gathering religious events.
      ). Mass gathering religious events also impose a high burden on health services of host countries due to the repeated occurrence of traumatic and crush injuries, large loads of non-communicable diseases, co-morbidities, and heat-related disorders (Shafi
      • Shafi S
      • Dar O
      • Khan M
      • Khan M
      • Azhar EI
      • McCloskey B
      • et al.
      The annual Hajj pilgrimage-minimizing the risk of ill health in pilgrims from Europe and opportunity for driving the best prevention and health promotion guidelines.
      ;
      • Memish ZA
      • Steffen R
      • White P
      • Dar O
      • Azhar EI
      • Sharma A
      • et al.
      Mass gatherings medicine: public health issues arising from mass gathering religious and sporting events.
      ). As with other mass gathering religious events, accurate evidence-based data on the burden of communicable and non-communicable diseases at the Arba'een are generally not available. These are required for supporting the development of effective prevention, surveillance, and management programmes for controlling infectious diseases and related public health conditions, implementing a system of real-time monitoring of diseases and morbidity patterns, utilising modern information-sharing platforms for rapid decision-making. The evidence base is also essential to promulgate WHO event-based planning and prevention guidelines for all future mass gathering religious pilgrimages (
      • Petersen E
      • Asogun D
      • Ntoumi F
      • Zumla A.
      Infection control at mass religious gatherings.
      ;
      • Zumla A
      • Traore T
      • Amao L
      • Ntoumi F
      • Sharma A
      • Azhar EI
      • et al.
      Reducing the threat of epidemic-prone infections at mass gathering religious events.
      ). It is the responsibility of the host countries, public health professionals and academics to share information and experiences at mass gathering religious events in support of the development and implementation of effective and responsive systems, which are essential for ensuring that all pilgrims have a healthy and spiritually rewarding experience.

      Declaration of Competing Interest

      All authors declare no conflicts of interest.

      Acknowledgements

      Sir Alimuddin Zumla is co-principal investigator of The Pan-African Network on Emerging and Re-Emerging Infections (PANDORA-ID-NET, CANTAM-3, and EACCR-3) funded by the European and Developing Countries Clinical Trials Partnership, supported by the EU Horizon 2020 Framework Programme. Sir Alimuddin Zumla is in receipt of an UK-NIHR Senior Investigator award and is a Mahathir Science Award and EU-EDCTP Pascoal Mocumbi Prize Laureate.

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