Al-Abri, S

Al-Tawfiq, JA

Azhar, E

El-Kafrawy, SA

Lee, SS

Merali, N

Shafi, S

Sharma, A

Zumla, A

English

UCL Discovery

International Journal of Infectious Diseases 123 (2022) 210–211 Contents lists available at ScienceDirect International Journal of Infectious Diseases journal homepage: www.elsevier.com/locate/ijid Infectious diseases threats at the Arba’een – a neglected but one of the largest annually recurring mass gathering religious events Shuja Shafi 1 , ∗, Esam Azhar 2 , 3 , Seif Al-Abri 4 , 5 , Avinash Sharma 6 , Nizar Merali 7 , Jaffar A Al-Tawfiq 4 , 8 , 9 , 10 , Sherif A El-Kafrawy 2 , 3 , Alimuddin Zumla 11 , 12 , Shui Shan Lee 4 , 13 1 Mass Gatherings and Global Health Network, London, United Kingdom 2 Special Infectious Agents Unit BSL-3, King Fahd Medical Research Center, King Abdulaziz University, Jeddah, 21589, Saudi Arabia 3 Department of Medical Laboratory Sciences, Faculty of Applied Medical Sciences, King Abdulaziz University, Jeddah, 21589, Saudi Arabia 4 International Society for Infectious Diseases 5 Directorate General for Disease Surveillance and Control, Ministry of Health, P.O. Box 393, 100, Muscat, Oman 6 DBT-National Centre for Cell Science, Pune, India 7 General Practice Direct, Harrow HA2 0RQ, London, United Kingdom 8 Infectious Disease Unit, Specialty Internal Medicine, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia 9 Indiana University School of Medicine, Indianapolis, USA 10 Infectious Disease Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA 11 Division of Infection and Immunity, University College London, United Kingdom 12 NIHR Biomedical Research Centre, UCL Hospitals NHS Foundation Trust, London, United Kingdom 13 Stanley Ho Centre for Emerging Infectious Diseases, The Chinese University of Hong Kong, Hong Kong, China a r t i c l e i n f o Keywords: Mass gathering Infectious diseases outbreaks Religious events Et2  2pip2  2ipstpa(STsto  Tlptlgvpleagdmh1(DITORIAL Mass gathering religious, sporting and festival events are known o pose major public health challenges worldwide ( Shafi et al., 016 ; Al Rabeeah et al., 2012 ; Blumberg et al., 2016 ; Memish et al.,019 ). Recent focus of these challenges has been on the im- ortation, transmission, and globalisation of a range of emerg- ng and re-emerging infectious diseases threats including Monkey- ox, COVID-19, Influenza and antibiotic resistance ( Aggrawal et al., 020 ; Goumballa et al., 2022 ; Zumla et al., 2022 ; Petersen et al.,022 ; Al-Ansari et al., 2021 ). All mass gathering religious events nvolve large numbers of pilgrims living and interacting together erforming religious rites in crowded conditions, exposing them- elves and the local population to various bacterial and viral infec- ions. Every year the Kingdom of Saudi Arabia (KSA) hosts the Hajj ilgrimage, one of the largest religious mass gatherings held on an nnual basis where up to 2 million people from over 180 coun- ∗ Correspondence: Dr Shuja Shafi. E-mail addresses: msshafi12@gmail.com (S. Shafi), eazhar@kau.edu.sa E. Azhar), salabri@gmail.com (S. Al-Abri), avinash.nccs@gmail.com (A. harma), nizarmerali@nhs.net (N. Merali), jaltawfi@yahoo.com (J.A. Al- awfiq), saelkfrawy@kau.edu.sa (S.A. El-Kafrawy), a.zumla@ucl.ac.uk (A. Zumla), slee@cuhk.edu.hk (S.S. Lee) . paahar2ttps://doi.org/10.1016/j.ijid.2022.09.010 201-9712/© 2022 Published by Elsevier Ltd on behalf of International Society for Infectio http://creativecommons.org/licenses/by-nc-nd/4.0/ ) ries, and one million local pilgrims assemble in the holy cities f Makkah and Madinah ( Shafi et al., 2016 ; Memish et al., 2019 ).he Kumbh Mela is held every four years and is the largest re- igious mass gatherings in the world attracting over 120 million ilgrims ( Aggrawal et al., 2020 ). The nature and degree of threats o global and host country health security of each individual re- igious mass gathering varies and depends on the number of pil- rims, the frequency of religious events and proportion of local ersus international pilgrims, countries of origin and pre-event ublic health preparations. The latter includes adherence to the atest recommended WHO health risk assessments for mass gath- ring events, host country travel advice including immunisations, vailable healthcare facilities and services provided to pilgrims. Whilst the Hajj pilgrimage has been the focus of attention of lobal public health bodies and has generated intense academic iscourse for the past decade ( Sweileh, 2022 ) due to a global re- it of origin of pilgrims and the emerging threats of new zoonotic athogens including MERS-CoV and SARS-CoV-2, other large annu- lly recurring mass gathering religious events have received less ttention but could potentially pose significant threats to global ealth security. The Grand Magal of Touba in Senegal, for example, ttracts millions of pilgrims, the public health issues of which have ecently been highlighted ( Petersen et al., 2022 ; Goumballa et al., 022 ). On 16 th -17 th September 2022, the Shiite religious pil- us Diseases. This is an open access article under the CC BY-NC-ND license S. Shafi, E. Azhar, S. Al-Abri et al. International Journal of Infectious Diseases 123 (2022) 210–211 gedsiotc2mgcsaiidiTassdo  LAiePetja2ecafcimfpf2  ttosaDAP(rpiaMRAAA  B  G  HKLM  PS  SZ  rimage Arba’een, the largest annually recurring regional religious vent, will take place and over 20 million pilgrims from the Mid- le East, particularly from Iran and within Iraq and other countries uch as Turkey, Nigeria and India will travel to Iraq. The pilgrimage s marked by long walks of up to 80 kilometres from the holy city f Najaf to Karbala by pilgrims from all age groups and ethnici- ies, different walks of life, with elderlies pushed in armchairs, and hildren carried by families ( Karampourian et al., 2018 ; Lami et al., 019 ). During the Arba’een, pilgrims are provided with free accom- odation, food, and drinks by volunteers along the walking routes. To date, the Arba’een has remained relatively neglected by lobal public health authorities due to its regional Middle East fo- us and frequent interruptions to attendance for pilgrims from out- ide Iraq. Whilst accurate data are unavailable in the literature, the nnual numbers and flow of pilgrims for the Arba’een have been nterrupted several times over the years due to political instabil- ty, safety and security issues. Since the Iraq war ended over two ecades ago in 2003 the Arba’een has continued to attract a grow- ng number of pilgrims from outside Iraq ( Al-Ansari et al., 2021 ). he tens of millions pilgrims impose a substantial burden on Iraq’s lready fragile and non-resilient health infrastructure. Public health urveillance and control measure for infectious diseases constitute ignificant challenges during the Arba’een due to high population ensity, pilgrims’ relatively low perception and lack of awareness f health risks ( Hamdanieh et al., 2021 ; Karampourian et al., 2018 ;ami et al., 2019 ) The potential risk of infectious diseases outbreaks at the rba’een could be extraordinary, and the range of conditions may nclude not just COVID-19 but also Monkeypox, meningococcal dis- ases, and other respiratory tract infections ( Al-Ansari et al., 2021 ; etersen et al., 2022 ; Zumla et al, 2022 ). Mass gathering religious vents also impose a high burden on health services of host coun- ries due to the repeated occurrence of traumatic and crush in- uries, large loads of non-communicable diseases, co-morbidities, nd heat-related disorders (Shafi Shafi et al., 2016 ; Memish et al., 019 ). As with other mass gathering religious events, accurate vidence-based data on the burden of communicable and non- ommunicable diseases at the Arba’een are generally not avail- ble. These are required for supporting the development of ef- ective prevention, surveillance, and management programmes for ontrolling infectious diseases and related public health conditions, mplementing a system of real-time monitoring of diseases and orbidity patterns, utilising modern information-sharing platforms or rapid decision-making. The evidence base is also essential to romulgate WHO event-based planning and prevention guidelines or all future mass gathering religious pilgrimages ( Petersen et al., 022 ; Zumla et al., 2022 ). It is the responsibility of the host coun-ries, public health professionals and academics to share informa- ion and experiences at mass gathering religious events in support f the development and implementation of effective and respon- ive systems, which are essential for ensuring that all pilgrims have  healthy and spiritually rewarding experience. 211 eclaration of Competing Interest All authors declare no conflicts of interest. cknowledgements Sir Alimuddin Zumla is co-principal investigator of The an-African Network on Emerging and Re-Emerging Infections PANDORA-ID-NET, CANTAM-3, and EACCR-3) funded by the Eu- opean and Developing Countries Clinical Trials Partnership, sup- orted by the EU Horizon 2020 Framework Programme. Sir Al- muddin Zumla is in receipt of an UK-NIHR Senior Investigator ward and is a Mahathir Science Award and EU-EDCTP Pascoal ocumbi Prize Laureate. eferences ggrawal 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. Int J Infect Dis 2020;101:167–73. doi: 10.1016/j.ijid.2020.09.1424 . l-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 Ar- baeen: Implications for COVID-19 and Other Pandemics. Int J Environ Res Public Health 2021;18(6):3287. doi: 10.3390/ijerph18063287 . l Rabeeah A, Memish ZA, Zumla A, Shafi S, McCloskey B, Moolla A, et al. Massgatherings medicine and global health security. Lancet 2012;380(9836):3–4. doi: 10.1016/S0140-6736(12)61073-3 . lumberg L, Regmi J, Endricks T, McCloskey B, Petersen E, Zumla A, et al. Host-ing of mass gathering sporting events during the 2013-2016 Ebola virus out- break in West Africa: experience from three African countries. 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JMIR Public Health Surveill 2019;5:e14510. doi: 10.2196/14510 . emish ZA, Steffen R, White P, Dar O, Azhar EI, Sharma A, et al. Massgatherings medicine: public health issues arising from mass gather- ing religious and sporting events. Lancet 2019;393(10185):2073–84. doi: 10.1016/S0140-6736(19)30501-X . etersen E, Asogun D, Ntoumi F, Zumla A. Infection control at mass religious gath- erings. BMJ 2022;378. doi: 10.1136/bmj-2022-072884 . hafi S, Dar O, Khan M, Khan M, Azhar EI, McCloskey B, et al. The annual Hajjpilgrimage-minimizing the risk of ill health in pilgrims from Europe and op- portunity for driving the best prevention and health promotion guidelines. Int J Infect Dis 2016;47:79–82. doi: 10.1016/j.ijid.2016.06.013 . weileh WM. Health-related research publications on religious mass gatherings of Muslims: a bibliometric analysis (1980-2020). Trop Dis Travel Med Vaccines 2022;8:1. doi: 10.1186/s40794-021-00158-y . umla A, Traore T, Amao L, Ntoumi F, Sharma A, Azhar EI, et al. 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Infectious diseases threats at the Arba'een – a neglected but one of the largest annually recurring mass gathering religious events

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

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