Hajj Pilgrims’ Knowledge about Acute Respiratory Infections

To the Editor: Hajj pilgrimage is a yearly event in which >2 million Muslims from around the world gather in Mecca, Saudi Arabia. Such high density of crowding presents a risk for local outbreaks and for worldwide spread of infectious agents. Acute respiratory infection (ARI) is the leading cause of admission to Saudi hospitals during the Hajj (1). In Marseille, France, after administration of systematic questionnaires, we recorded attack rates of ARI up to 60% in co-horts of returned Hajj pilgrims in 2006 (2). This potential risk is of particular concern because of the infl uenza A pandemic (H1N1) 2009 virus (3). ARI transmission can be effi ciently reduced by simple, low-cost physical measures, including use of face masks and hand hygiene. Awareness and acceptability of these measures among pilgrims, however, are limited (4). We conducted a knowledge, attitudes , and practices survey that addressed these issues among Hajj pilgrims departing from Marseille during October and November 2008, several months before the outbreak of pandemic (H1N1) 2009 virus. A total of 528 persons (290 males, 238 females) who attended a pre-Hajj meningococcal vaccination campaign were invited to participate in a face-to-face interview during which they completed our questionnaire. We achieved a 100% response rate. Mean age of participants was 61 years (range 18–94 years). Most pilgrims were born in North Africa (92%), had education above a primary certifi cate (81%), were unemployed (56% of persons <65 years of age), and were traveling to Saudi Arabia for the fi rst time (78%). Ten percent had chronic pulmonary disease. We assessed knowledge of ARI using 18 questions about symptoms and sources of contamination. Knowledge questions were scored 1 for the correct answer and 0 for incorrect or " don't know " answers. Overall, the score of true responses was only 26% (interquartile range [IQR] 21%– 37%). Scores were higher for respondents <65 years of age (32% [IQR 21%–42%] vs. 26% [IQR 16%–32%], p<0.00001 by Kruskal-Wallis test). Scores were also higher for female pilgrims (32% [IQR 21%–37%] vs. 26% [IQR 21%–37%, p = 0.01). No other demographic or health factor had sig-nifi cant infl uence. Respondents believed the following were sources of contamination for ARI: sneeze and cough products (58.1%), dirty hands (43.9%), contact with ill persons (40.5%), saliva (17.2%), promiscuity (17.0%), food (12.1%), drink (9.1%), air conditioning (3.4%), and contact with animals (0.4%); 16.7% had no knowledge about ARI sources. When asked …