Undiagnosed Active Pulmonary Tuberculosis among Pilgrims during the 2015 Hajj Mass Gathering: A Prospective Cross-sectional Study

Abstract

Mass gatherings pose a risk for tuberculosis (TB) transmission and reactivation of latent TB infection. The annual Hajj pilgrimage attracts 2 million pilgrims many from high TB-endemic countries. We evaluated the burden of undiagnosed active pulmonary TB in pilgrims attending the 2015 Hajj mass gathering. We conducted a prospective cross-sectional study in Mecca, Kingdom of Saudi Arabia, for nonhospitalized adult pilgrims from five high TB-endemic countries. Enrollment criteria were the presence of a cough and the ability to produce a sputum sample. Sputum samples were processed using the Xpert MTB-RIF assay. Data were analyzed for drug-resistant TB, risk factors, and comorbidities by the country of origin. Of 1,164 consenting pilgrims enrolled from five countries: Afghanistan (316), Bangladesh (222), Nigeria (176), Pakistan (302), and South Africa (148), laboratory results were available for 1,063 (91.3%). The mean age of pilgrims was 54.5 (range = 18-94 years) with a male to female ratio of 2.6:1; 27.7% had an underlying comorbidity, with hypertension and diabetes being the most common, 20% were smokers, and 2.8% gave a history of previous TB treatment. Fifteen pilgrims (1.4%) had active previously undiagnosed drug-sensitive pulmonary TB (Afghanistan [12; 80%], Pakistan [2; 13.3%], and Nigeria [1; 6.7%]). No multidrug-resistant TB cases were detected. Pilgrims from high TB-endemic Asian and African countries with undiagnosed active pulmonary TB pose a risk to other pilgrims from over 180 countries. Further studies are required to define the scale of the TB problem during the Hajj mass gathering and the development of proactive screening, treatment and prevention guidelines.

Management of hospitalized drug sensitive pulmonary tuberculosis patients during the Hajj mass gathering: A cross sectional study

“…Most TB cases in the current study were males and over half were above 50 years old with primary or no formal education. This is in accordance with global and Hajj-related data and established risk factors for TB [1,7,10,12]. However, the prevalence of coexisting chronic diseases (63%, 17/27) among TB patients, especially diabetes, was higher than that reported internationally as well as previous studies among Hajj pilgrims with TB [7,[12][13][14].…”

“…Around 28% (8/29) of the TB cases reported being current smokers and a similar proportion (5/18) indicated that they did smoke in the past. This is higher than that reported in another study among Hajj pilgrims with TB (13.3%) [7] but lower than figures from some international reports [15,16]. Other risk factors for TB such as visit to, or residence in high-burden countries and occupational exposure were uncommon among TB patients in the study and so was previous Hajj or Umrah performance.…”

“…Other risk factors for TB such as visit to, or residence in high-burden countries and occupational exposure were uncommon among TB patients in the study and so was previous Hajj or Umrah performance. While the latter events are not an established risk factor for TB transmission, Hajj is a risk of TB infection and both clinically-recognized or undiagnosed active TB have been reported at the pilgrimage [7,10,17].…”

“…Key to achieving these targets is the early diagnosis and appropriate management of TB cases worldwide according to national and international guidelines [3][4][5][6]. This includes in the context of mass gatherings such as the annual Hajj in Makkah, Kingdom of Saudi Arabia (KSA), where over 2 million pilgrims, many originating from TB endemic areas, congregate in crowded settings and worship under conditions that increase the risk of TB transmission [7,8].…”

Mass gatherings medicine: public health issues arising from mass gathering religious and sporting events

“…37 A large percentage of Hajj pilgrims come from high tuberculosisendemic coun tries. The burden of undiagnosed active pulmonary tuberculosis in pilgrims attending the 2015 Hajj from five high tuberculosisendemic countries was evaluated by a study randomly screening 1164 pilgrims, 36 of which 15 had previously undiagnosed active pulmonary tuberculosis. With millions of pilgrims visiting Saudi Arabia from high tuberculosis endemic areas, cases of undiagnosed active pulmonary tuberculosis will continue to pose a risk to other pilgrims.…”