Keywords
EDITORIAL
Mass gathering religious, sporting and festival events are known to pose major public health challenges worldwide (
Shafi et al., 2016
; Al Rabeeah et al., 2012
; Blumberg et al., 2016
; Memish et al., 2019
). 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 et al., 2020
; Goumballa et al., 2022
; - 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.
Travel Med Infect Dis. 2022; 49102418https://doi.org/10.1016/j.tmaid.2022.102418
Zumla et al., 2022
; Petersen et al., 2022
; - Petersen E
- Asogun D
- Ntoumi F
- Zumla A.
Infection control at mass religious gatherings.
BMJ. 2022; 378e072884https://doi.org/10.1136/bmj-2022-072884
Al-Ansari et al., 2021
). 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 et al., 2016
; Memish et al., 2019
). The Kumbh Mela is held every four years and is the largest religious mass gatherings in the world attracting over 120 million pilgrims (Aggrawal et al., 2020
). 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, 2022
) 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 et al., 2022
; - Petersen E
- Asogun D
- Ntoumi F
- Zumla A.
Infection control at mass religious gatherings.
BMJ. 2022; 378e072884https://doi.org/10.1136/bmj-2022-072884
Goumballa et al., 2022
). 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 (- 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.
Travel Med Infect Dis. 2022; 49102418https://doi.org/10.1016/j.tmaid.2022.102418
Karampourian et al., 2018
; Lami et al., 2019
). 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 et al., 2021
). 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 and Ostadtaghizadeh, 2021
; Karampourian et al., 2018
; Lami et al., 2019
)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 et al., 2021
; Petersen et al., 2022
; - Petersen E
- Asogun D
- Ntoumi F
- Zumla A.
Infection control at mass religious gatherings.
BMJ. 2022; 378e072884https://doi.org/10.1136/bmj-2022-072884
Zumla et al., 2022
). 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 et al., 2016
; Memish et al., 2019
). 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 et al., 2022
; - Petersen E
- Asogun D
- Ntoumi F
- Zumla A.
Infection control at mass religious gatherings.
BMJ. 2022; 378e072884https://doi.org/10.1136/bmj-2022-072884
Zumla et al., 2022
). 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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Published online: September 12, 2022
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