With Hanukkah and Christmas just recently past and Chinese New Year fast approaching, it seems a suitable time to consider the topic of religious celebrations and infectious diseases, no? 'Tis the spirit and all! I’ll be looking at one of most intriguing religious events in the world, the Islamic pilgrimage to Mecca known as the Hajj, and the special epidemiological event that accompanies it.
A Muslim praying at the Hajj with a backdop of thousands of pilgrims. Image: Hassan Ammar. Click for source.
The Hajj is a powerfully sacred and social event for Muslims. The importance of the pilgrimage to the Saudi Arabian desert city and the communal celebration of the prophet Muhammed cannot be understated - it’s a profoundly holy journey and religious duty that every Muslim is urged to complete at least once in their lifetime. It is also unique from an epidemiological standpoint: two to three million people from 70 countries meeting in one tiny place is the siren call for respiratory, water-borne and blood-borne microbial diseases.
So what does the Hajj consist of exactly? Depending on the lunar calendar, the Hajj may occur any time of the year; last year, the week-long event fell between November 4th to the 9th. The pilgrimage involves a series of performative rites that must be completed in the city of Mecca and its environs; these rites serve as a reenactment of the key historical events underpinning the birth of Islam. On the first day of the Hajj, pilgrims will walk counter-clockwise seven times around a rectangular building named the Kaaba located at the very center of Mecca. The Kaaba serves as an orientation point for Muslim prayer rituals and is considered the physical and spiritual nucleus of the Islamic religion. Pilgrims, also known as Hajjees will then run back and forth between the hills of Al-Safa and Al-Marwah a total of seven times and will end their day by drinking water from the holy Zamzam well.
A map showing the Hajj route and procession taken by pilgrims. Image: Creative Commons.
The second day is spent in vigil, praying to Allah and reciting the Quran at the granite hill of Mount Arafat, located just southeast of Mecca. The following day, pilgrims will gather in the thousands to perform a ritual enactment of the Stoning of the Devil by throwing pebbles at the three pillars of Jamarat in the small town of Mina. They then leave this area to shave their heads, perform a ritual animal sacrifice and go on to celebrate the religious holiday of Eid al-Adha. Their spiritual marathon is finally complete.
During this pilgrimage, Hajjees live in a spiritual state of purity called Ihram. Prior to entering this condition, pilgrims will ritually cleanse themselves, trim their nails and remove any unwanted body hair. From then on, men are dressed simply in two sheets of unstitched white cotton and a pair of plain sandals. Women wear the hijab, with their face and hands exposed. In this sanctified state, Hajjees are forbidden from shaving, trimming their nails, wearing scented toiletries, arguing or swearing along with a few other unbecoming behaviors.
The experience can be difficult for the heat-susceptible, agoraphobic, the frail or very young; Mecca during the Hajj is often stifling hot, humid and beyond overcrowded. Performing the rites with millions of other people over a wide geographical area can be physically strenuous and quite exhausting. There have been several recorded cases of fatal stampedes and crowd crushes during the jam-packed Stoning of the Devil, sunstroke and heat exhaustion are not uncommon, cholera outbreaks have historically plagued pilgrims, and pneumonia, meningitis and food poisoning have repeatedly occurred. Really, it goes without saying that if millions of international travelers converge in one city for a physically active, overcrowded affair, one should consider oneself lucky not to catch a respiratory or diarrheal bug.
You certainly wouldn’t expect to come down with a blood-borne transmitted virus and nasty chronic disease.
Regrettably, that scenario may not be that unlikely for male pilgrims on the verge of exiting Ihram; contracting HIV or any of the unsavory gang of hepatitis viruses such as hepatitis B, C or D (HBV, HCV or HDV) is quite possible due to the unseemly practice of communal shaving.
Following the Stoning of the Devil and the completion of their religious rites, Hajjees migrate to Mina where hundreds of barbers await with razor blades to shave the scalps of male pilgrims and where women will trim a finger-length lock of hair. This last ritual seals the deal, so to speak, allowing pilgrims to compete their observance of the Hajj. Saudi officials require all barbers to be licensed though makeshift barbers still abound, waiting on roads for eager pilgrims with razors in hand (1). Pilgrims may also buddy up to shave each other's scalps. These unlicensed barbers and pilgrims can often be found reusing unsterilized blades to communally head-shave Hajjees, a fabulous technique for transmitting blood-borne diseases (BBDs).
Indeed, physicians associated with the Saudi Arabian Field Epidemiology Training Program describe the practice of communal head-shaving at the Hajj as an ‘optimum focal setting for the spread of serious BBDs’ (2). There’s a considerable amount of hair-raising unhygienic behaviors going on - not only are unsterilized razors reused on multiple individuals, barbers often do not wear gloves, incur many abrasions on their hands and dispose of the razors improperly.
Only a few studies have looked at the demographics and practices of these barbers but they have yielded some insightful data. A study in 1999 examined 158 barbers recruited from makeshift shaving sites near Jamarat. Eight nationalities were represented but the majority stemmed from three impoverished countries - 72 from Myanmar, 27 from Egypt and 22 from Bangladesh. Most interestingly, two-thirds of the barbers worked seasonally. They were not licensed professionals, but rather opportunistic seasonal workers that had worked at the Hajj for a median of two to five years (2).
The barbers reported each shave as lasting roughly two to ten minutes (3); these rapid-fire, assembly line-like operations can increase the likelihood of accidental nicks and grazes. Twenty-one percent of barbers report using a blade more than once (3). When razors are finally disposed of 83% will discard them on a ground densely covered in shorn hair instead of in the rubbish bins provided by Saudi authorities (3). This is of crucial consequence considering the numbers of pilgrims who are barefoot or wearing sandals. The head-shaving event also occurs in a very short time-frame overall, within a few hours in a circumscribed geographical area, compounding the likelihood of a BBD swap meet.
The eye-opening video below shows some of these seasonal barbers at work.
Around 90% of male pilgrims will have their scalps closely shaved (4). And pilgrims do indeed get nicks and abrasions: two separate studies found roughly 60% of Hajjees incurred scalp cuts (5)(6). There aren’t any studies examining the incidence or rate of BBD transmission among pilgrims during the Hajj so we’re unable to know how frightful of a problem this is. But consider this: many pilgrims come from regions of the world with high endemicity of BBDs such as Pakistan, Nigeria, Egypt and Turkey (2)(3)(5). And there are barbers working at the Hajj who have tested positive for BBDs - a study conducted in 1999 found that 10% tested positive for HCV and there was a positive correlation between barbers infected with HCV and the length of time they had worked at the Hajj (5). Though the epidemiological data is thin on what could actually is going on here, we can still state with some certainty that razor recycling shouldn’t be going on.
Hepatitis viruses are patient predators. They’ll stake out on bloody scalpels, syringes and surfaces for four days (HCV) or up to a week (HBV) until an open wound allows them to slink into a new body (7). It is for this very reason that Hepatitis B was one of the most commonly acquired infections in hospitals among medical personnel before the advent of the hepatitis A/B vaccine. When razor are used frantically and repeatedly to shave pilgrim’s heads, accidents will naturally happen. Skin catches on the blade. A microscopic cut, a slight nick and a drop of blood beads. Maybe in the hubbub, in the physical and spiritual heat of the moment, a barber grazes his bare hands and fingers on that pilgrim’s blood droplet. Or accidentally smears his own fresh blood, precipitated by a slip of the blade on an earlier scalp. The blood blends, indistinguishable from the other. Was that barber or pilgrim infected; did a virus slip between the two? In any case, another eager, awaiting Hajjee sits down for a shave and the razor is used again. This happens over and over and over, until the razor blade is finally deemed blunt and useless.
A public health poster in a Saudi Arabaian hospital warning pilgrims of the dangers posed by shaving during the Hajj. Image: Uknonwn. Click for source.
It’s a perverse tragedy that pilgrims exiting a state of profound spiritual and physical holiness may find their very blood contaminated by a barber with unhygienic practices. Pilgrims can become infected with a fatal illness that is clinically asymptomatic in its early stages only to fly back home to their communities oblivious of their condition. Catching the flu or pneumonia at the Hajj is one thing but bringing home a deadly viral illness is quite another.
Clearly the provision of safe razor blades, screening and supervision of barbers and widespread education on this matter are desperately needed. In a study from 1998, 74% of Hajjees and 20% of barbers were unaware that diseases could be transmitted by used razor blades (3). Many pilgrims expressed more concern about the spread of visible skin diseases than anything else. The invisible nature of BBDs only helps to further conceal the potential for a BBD micro-epidemic at the Hajj.
Consideration of the provision of housing, sanitation and overall public health of these religious visitors is of enormous importance for Saudi Arabian officials planning for the Hajj, and they do a phenomenal super-human job of keeping millions of people safe and cared for by providing free health care, organizing the festivities and what not. Seven hospitals have been established to provide free medical services and can supply over 2000 beds for those requiring hospitalization (6). The Ministry of Health establishes infection control policies using current knowledge of ongoing global outbreaks, infectious disease epidemiology and established preventative medicine techniques (1)(5). By all accounts, they did a great job during the H1N1 flu pandemic in 2009 by requiring pilgrims to have flu shots, restricting visas for pilgrims from affected countries, setting up thermal sensors at airports to detect the feverish and deploying thousands of physicians throughout the pilgrim circuit (9). They also require all entering pilgrims to display certificates of vaccination for hepatitis A/B, meningococcal meningitis and yellow fever.
A pilgrim recieving a shave in a sanctioned barbershop during the Hajj. Image: Unknown. Click for sourece.
But keeping an eye on rogue unlicensed barbers can be difficult for officials considering the high crowd density and activity. Whatever may be the case, the seriousness of the matter can’t be ignored. A vigorous public health campaign as well as a serious crackdown on these barbers is needed in order to halt this hairy business. It’s been noted before that an epidemic of the flu, meningitis or cholera could easily bloom into a pandemic at the Hajj. Even so, the prospect of a multinational epidemic of BBDs spread by irresponsible hygiene practices is appalling. A hair-raising thought, indeed.
The hepatitis family, particularly the members B, C and D, is some real nasty shit. I didn’t go into any detail about their molecular biology but if you’re interested, please go here.
Go here to see the vaccinations required by the Saudi Ministry of Health for all visiting pilgrims.
For a list of every single conceivable disease you could catch during the pilgrimage, check out this baby.
An extremely helpful guide to how to handle oneself at the Hajj.
(1) ZA Memish. (2002) Infection control in Saudi Arabia: Meeting the challenge. Am J Infect Control. 30(1): 57-65 (2) The Saudi Arabian Field Epidemiology Training Program (2000) Blood-Borne Diseases Among Barbers During Hajj, 1419 H (1999). Saudi Epidemiology Bulletin: 7(1). Accessed online on Dec 10, 2011. Link. (3) Saudi Arabian Field Epidemiology Training Program (1998) Head-shaving practices of barbers and pilgrims to Makkah, 1998 Saudi Epidemiology Bulletin. 5(3): 18-19 (4) SM Rafiq, H Rashid, E Haworth & R Booy. (2009) Hazards of hepatitis at the Hajj. Travel Med InfectDis. 7(4): 239-46 (5) Rashid H & Shafi S. (2006) Blood borne hepatitis at Hajj. J of Hep Mon. 6(2): 87-88 (6) Alrabeh AM, El-Bushra HE, Al-Sayed MO, et al. (1998) Behavioral risk factors for disease during Hajj: the second survey. Saudi Epidemiol Bull. 5(3). Accessed online on Dec 10, 2011. Link. (7) CDC; Division of Viral Hepatitis. (2009) Hepatitis B FAQs for the Public. Accessed online on January 4, 2012. Link. (8) Omar Sacirbey, 2009, Will flu epidemic slow the Hajj? Chron.com (Online). Accessed online on Dec 10, 2011. Link.
Memish ZA (2002). Infection control in Saudi Arabia: meeting the challenge. American journal of infection control, 30 (1), 57-65 PMID: 11852419