Pilgrims and H1N1

By: Rosemary Stephen, Elements: Environmental Health Intelligence

Every year millions of people go on pilgrimages. Pilgrims are classified into three groups: ‘religious pilgrims’ who visit religious shrines, ‘cultural pilgrims’ who visit places of cultural significance and ‘notable pilgrims’ high ranking individuals and leaders who travel for personal and political reasons [1]. Religious pilgrims, in particular, are people who journey to holy places to connect more closely with their religion. It is an act of faith and devotion. It gives the faithful the opportunity to strengthen their faith by being in contact with people who share the same beliefs [2].

In light of the world’s current concerns with H1N1, are pilgrims more at risk of contracting the virus or bringing the virus with them? Can countries ban pilgrimages altogether or force pilgrims to be immunized? Or to go even further, could the practice of kissing and shaking hands has a sign of love, friendship and respect be banned ?

Pilgrimage restrictions

Many countries are quite specific when it comes to the health requirements of travelers from abroad (including pilgrims); they require a vaccination certificate as proof of protection against specific communicable diseases. This certificate is then a guarantee that travelers will not spread diseases or themselves become infected while traveling. Immunization requirements are set into three categories: Routine, Recommended and Required. Routine vaccinations protect travelers from diseases that are common in different parts of the world, but not necessarily present in their home country. Recommended vaccinations prevent the importation of infectious diseases across international borders. The type of vaccines recommended will depend on the destination, where you are traveling from, where your are traveling to (either in a rural or urban area), your age, your medical history and if you have been previously immunized [3]. Required vaccinations are vaccines for which you must show proof before entering a country. An example of a required vaccination is Yellow Fever which is required for traveling to South America and Sub-Saharan countries [4].

Muslim pilgrims travel to Mecca in Saudi Arabia to worship Allah [5]. This pilgrimage, or Hajj, is one of the five pillars of Islam. The Hajj is an annual event, this year taking place in November. Saudi Arabia has set up a detailed plan for the upcoming pilgrimage. The plans include a two pronged focus, one on the health of pilgrims coming in to the country and the second on facilities within the country for pilgrims. There will be health screenings at all airports and ports of entry [6] and pilgrims arriving for the Hajj will be required to present a certificate of vaccination against H1N1 with their visas (the H1N1 vaccine must be received two weeks prior to applying for a visa) [7]. Proof of other immunizations will also be necessary, including meningococcal meningitis, yellow fever and polio. As a final step, pilgrims have been advised that “people with chronic diseases, children, the pregnant and the elderly should not travel to the holy sites this year” [8].

In Saudi Arabia, Mohammed Obeid Al Mazrouie, the head of the Official Hajj Mission, explains that the second focus of the plan is to provide internal support for the pilgrims including “… H1N1 vaccines and medicines for all pilgrims, be they citizens or expatriate residents“. There are also fully manned and equipped isolation facilities located in the cities of Makkah, Mina and Arafat to deliver health and administrative services to pilgrims in need. Educational workshops for Hajj operators, administrators, doctors and members of the Official Hajj Mission have been set up to teach how to identify H1N1 and how to mitigate the impact of the virus. Ten hot lines will be available for reporting infected cases among UAE pilgrims. Part of the plan also included the inspection of 171 housing facilities for pilgrims; only 10 were found not to have put the necessary preparations in place [9].

Some countries with a high number of potential pilgrims are also taking steps to control the spread of H1N1. The Indian Minister of State for External Affairs Shashi Tharoor said that “those with swine flu symptoms may not be allowed to leave the country for the Hajj” [10]. Tunisia and Iran have gone even further and are preventing their citizens from traveling to Saudi Arabia to attend Hajj. This decision was taken based on the fear that pilgrims might contract H1N1. This was a follow-up on a ban on their citizens making the Umrah pilgrimage this year [11]. Iran even canceled “all flights to Saudi Arabia during the holy fasting month of Ramadan for the Umrah or minor pilgrimage to minimise the spread of A(H1N1) influenza” [12].

Other countries are facing similar dilemmas. In Costa Rica, the government Health Ministry canceled an August pilgrimage to San Jose’s Cartago church, which houses the ‘Black Madonna’, for fear of widening the spread of H1N1. Since Costa Rica’s death toll from H1N1 was 17 at the time of this decision [13], they estimated that, if they allowed the pilgrimage, 20,000 or more pilgrims could contract H1N1. The Health Ministry decided instead that the Madonna be taken to visit five different cities within Costa Rica and that special services were to be held outdoors [14]. The Ministry did not, however, cancel a soccer game at the Fello Meza stadium. This decision was highly criticized by the clergy, but Maria Luisa Avila, Costa Rica’s Minister of Health, explained that “while the pilgrimage would involve up to 2 million people concentrated in a cathedral in a small town, a football game would involve only 20,000 people”. In Chile, the Ministry of Health exercised its authority by canceling La Tirana Religious Festival, the country largest religious celebration held in July, because of a high incidence of H1N1 cases; the municipality of La Tirana is in a region that has seen “the third-highest concentration of A/H1N1 “swine flu” infections among Chile’s regions” [15]. The ministry decided that overcrowding caused by an expected 200,000 or more pilgrims would have posed a serious health risk.

Kissing, Hugging and Hand Shaking

Kissing both cheeks, hugging and shaking hands are natural social practices that are followed by numerous religious groups and even whole nationalities. Scientific studies stress that “touching is good for us”; it is proven to increase self confidence, decrease blood pressure, increase sociability and decrease social aggressiveness [16]. Unfortunately, kissing, hugging and hand shaking are all now discouraged because such actions may facilitate the spread H1N1 [17].

The health concerns over these social practices means that all pilgrims now will have to be mindful when greeting others or when handling religious artifacts. India’s External Affairs Ministry has issued an advisory asking pilgrims who plan to make the annual pilgrimage to Saudi Arabia not to shake hands or to hug in greeting during the Hajj, unless it is a mandatory religious activity [18]. In Italy, the archbishop of Naples has forbade the practice of kissing a relic in a glass vial containing the dry blood of St Januarious (Gennaro). The faithful are allowed only to touch this relic with their forehead [19]. This decision followed the death of a 51 year old man with chronic health problems who may have contracted H1N1 while being cared for in an hospital or a nursing home. He, it seems, did not kiss the vial himself, but his death raised the possibility of pilgrims kissing the vial and either passing the virus on to others or contracting the virus themselves [20, 21, 22].

In France, l’Office fédéral de la santé publique made several health recommendations regarding the traditional practice of drinking wine from a communal cup and the preparation of the blessed bread for communion at Mass. Wine drinking should now be done from small individual cups and the people responsible for cutting the bread must wash their hands thoroughly before preparing the bread. In some churches, the preparation of the wine and bread is handled by only one person thereby limiting contact and the spread of viruses.

As for kissing and shaking hands, the French Health Ministry is recommending people avoid close contact which includes “La Bise” (kissing), shaking hands and caressing the face of others, especially sick people. The main thrust of the government is to “encourage people to wash their hands frequently” and to follow sound personal hygiene such as “coughing into their sleeves or tissues and having a 3 ft (1 m) buffer zone between people or wearing a mask if this distance cannot be maintained” [23, 24].

In the United States, the Conference of Catholic Bishops, Committee on Divine Worship has released a FAQ/Guidelines about H1N1. They recommend that priests, deacons, and extraordinary ministers of Holy Communion follow good hygiene practices, to wash their hands before Mass begins or to use alcohol base anti-bacterial solution before and after Holy Communion. They also suggest that sick people should not be allowed to drink directly from the communal cup but instead to drink from small, individual glasses [25].

Another country which will soon be receiving pilgrims, more precisely “Olympic Pilgrims” is Canada. Olympic officials have advised athletes to avoid kissing, shaking hands and hugging. They recommend instead to bump elbows [26]. As for religious practices, Canada is now following similar recommendations as those initiated in the United States [27]; parishioners are asked to limit physical contact such as sharing of the cup, hand shaking and hugging [28].

Conclusion

Every year, millions of people around the world go on pilgrimages. Religious pilgrims, in particular, are at risk of contracting H1N1 during their travels to holy places. Health authorities in Saudi Arabia have taken strong precautions for this year’s Hajj, setting up traveling restrictions and requiring proof of H1N1 vaccination. Tunisia and Iran are actually preventing their pilgrims from attending Hajj this year. Costa Rican health authorities, instead of having its pilgrims go to one holy site, have decided to bring the Madonna to 5 cities, decreasing the number of pilgrims in one area. Kissing and shaking hands is now being discouraged because of the potential of spreading H1N1. Numerous countries have advised their people to avoid these practices altogether. The 2010 Winter Olympics will see a new form of greeting in the form of an ‘elbow bump’.

Endnotes:

Hajj pilgrimage: The annual Islamic pilgrimage to Mecca sees millions of Muslims from around the world perform the Hajj pilgrimage. Every Muslim who is able must perform the Hajj once in his lifetime. This year, it will be held in November 2009 (1E, 2E).

Umrah pilgrimage: Umrah is a pilgrimage to Mecca that can be undertaken any time of the year. It is not compulsory, but it is highly recommended in Islam (3E, 4E).

Ramadan: Ramadan is a period of fasting that lasts for a lunar month. Muslim believers will fast between sunrise and sunset. This year, Ramadan started 20 Aug and ended on 18 Sept 2009 (5E).

Communion: Communion in Christian belief represents the Last Super where Jesus had a meal with his disciples. Bread and wine were part of that meal which came to symbolize the “Eucharist” or thanksgiving to God. Consuming consecrated bread and wine is seen as entering into a close relationship with Christ (6E, 7E).

Rosemary Stephen (2009). Pilgrims and H1N1. Elements: Environmental Health Intelligence

References:

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[3] What You Need to Know About Vaccinations and Travel: A Checklist (2007) Centers for Disease Control and Prevention (CDC). (On-line) Available: http://wwwnc.cdc.gov/travel/content/vaccinations.aspx. Cited 2009 Oct 16.

[4] What You Need to Know About Vaccinations and Travel: A Checklist (2007) Centers for Disease Control and Prevention (CDC). (On-line) Available: http://wwwnc.cdc.gov/travel/content/vaccinations.aspx. Cited 2009 Oct 16.

[5] Once in a lifetime; About 2 million Muslims make Mecca pilgrimage (2009) BNET. (On-line) Available: http://findarticles.com/p/articles/mi_qn4179/is_20040131/ai_n11810273/. Cited 2009 Oct 20.

[6] Huda. H1N1 Prevention During Hajj 2009 Saudi Arabia Taking Measures to Prevent Spread of Swine Flu During Pilgrimage (2009) About.com: Islam. (On-line) Available: http://islam.about.com/od/hajj/a/hajj2009h1n1.htm. Cited 2009 Oct 08.

[7] Jordanian pilgrims to take H1N1 vaccine (2009) Arabian Business.com. (On-line) Available: http://www.arabianbusiness.com/568167-jordanian-pilgrims-to-take-h1n1-vaccine. Cited 2009 Oct 08.

[8] Saudis Want Pilgrims Vaccinated Against H1N1(2009) Kuwait Times. (On-line) Available: http://www.arabtimesonline.com/kuwaitnews/pagesdetails.asp?nid=36896&ccid=9. Cited 2009 Oct 08.

[9] Arafah A. H1N1 Vaccination, Isolation Facilities for Haj Pilgrims (2009) Khaleej Times online. (2009) (On-line) Available: http://www.khaleejtimes.com/DisplayArticle08.asp?xfile=data/theuae/2009/October/theuae_October146.xml&section=theuae. Cited 2009 Oct 08.

[10] Flu vaccination mandatory for Haj pilgrims: Tharoor (2009) Indo Asian News Service (On-line) Available: http://trak.in/news/flu-vaccination-mandatory-for-haj-pilgrims-tharoor/10235/. Cited 2009 Oct 08.

[11] Flu vaccination mandatory for Haj pilgrims: Tharoor (2009) Indo Asian News Service (On-line) Available: http://trak.in/news/flu-vaccination-mandatory-for-haj-pilgrims-tharoor/10235/. Cited 2009 Oct 08.

[12] Iran restricts hajj pilgrims over H1N1 (2009) Asiaone Health. (On-line) Available: http://health.asiaone.com/Health/News/Story/A1Story20090830-164436.html. Cited 2009 Ont 08.

[13] Flu, cancelled pilgrimage leads to harsh words between Costa Rican bishop and government (2009) Assist News Service (ANS). (On-line) Available: http://www.assistnews.net/Stories/2009/s09070204.htm. Cited 2009 Oct 19.

[14] Flu, cancelled pilgrimage leads to harsh words between Costa Rican bishop and government (2009) Assist News Service (ANS). (On-line) Available: http://www.assistnews.net/Stories/2009/s09070204.htm. Cited 2009 Oct 19..

[15] Battey, C., Chile cancels La Tirana religious festival to prevent flu outbreak.(2009) The Sandiago Times. (On-line) Available: http://www.santiagotimes.cl/santiagotimes/index.php/2009070216599/news/cultural-news/chile-cancels-la-tirana-religious-festival-to-prevent-flu-outbreak.html. Cited 2009 Oct 27.

[16] Swine flu prompts calls for “kissing strike” in Spain (2009) Talk Back, Thinker.com. (On-line) Available: http://www.monstersandcritics.com/news/health/features/article_1498525.php/Swine-flu-prompts-calls-for-kissing-strike-in-Spain-News-Feature. Cited 2009 Oct 19.

[17] Swine flu prompts calls for “kissing strike” in Spain (2009) Talk Back, Thinker.com. (On-line) Available: http://www.monstersandcritics.com/news/health/features/article_1498525.php/Swine-flu-prompts-calls-for-kissing-strike-in-Spain-News-Feature. Cited 2009 Oct 19.

[18] India issues advisory on H1N1 flu for Haj pilgrims (2009) Indo Asian News Service, Trak.in News. (On-line) Available: http://trak.in/news/india-issues-advisory-on-h1n1-flu-for-haj-pilgrims/11198/. Cited Oct 08.

[19] Swine flu fears stop kisses for Italian saint (2009) International News France 24. (On-line) Available: http://www.france24.com/en/20090908-swine-flu-fears-stop-kisses-italian-saint. Cited 2009 Oct 16.

[20] Blood of St. Januarius Won’t Be Kissed This Year Because of Swine Flu (2009) Mystagogy (On-line) Available: http://www.johnsanidopoulos.com/2009/09/blood-of-st-januarius-wont-be-kissed.html. Cited 2009 Oct 19.

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[23] Les Eglises appliquent diversement les recommandations antigrippe (2009) ArcInfo.ch. (On-line) Available: http://www.arcinfo.ch/journal/nos-dossiers/sante/article/199246/les_eglises_appliquent_diversement_les_recommandations_antigrippe.html. Cited 2009 Oct 19.

[24] France Kisses Goodbye to ‘La Bise’ Amid H1N1 Fears (2009) FoxNews.com (On-line) Available: http://www.foxnews.com/story/0,2933,547383,00.html.Cited 2009 Oct 22.

[25] H1N1 Swine Influenza and the Liturgy (2009) Otwomd. (On-line) Available: http://bluepanjeet.net/2009/05/06/4797/h1n1-swine-influenza-liturgy/. Cited 2009 Oct 19.

[26] Puxley, C., 1 in 3 Canadians may decline handshakes over H1N1: poll (2009) thespec.com. (On-line) Available: http://www.thespec.com/News/BreakingNews/article/656434. Cited 2009 Oct 21.

[27] Winnipeg churches ban handshakes over H1N1 (2009) CBCNews.ca. (On-line) Available: http://www.cbc.ca/health/story/2009/09/27/270909-churches-winnipeg-h1n1.html. Cited 2009 Oct 21.

[28] Willick, F., Diocese flu precautions address communion, handshakes (2009) The Windsor Star. (On-line) Available: http://www.windsorstar.com/opinion/Diocese+precautions+address+communion+handshakes/2056525/story.html. Cited 2009 Oct 22.

Endnote References:

[1E] Tunisia first country to prohibit Haj because of swine flu (2009) Trak.in News. (On-line) Available: http://trak.in/news/tunisia-first-country-to-prohibit-haj-because-of-swine-flu/11166/. Cited 2009 Oct 08.

(2E) Huda. H1N1 Prevention During Hajj 2009 Saudi Arabia Taking Measures to Prevent Spread of Swine Flu During Pilgrimage (2009) About.com: Islam. (On-line) Available: http://islam.about.com/od/hajj/a/hajj2009h1n1.htm. Cited 2009 Oct 08.

(3E) Tunisia first country to prohibit Haj because of swine flu (2009) Trak.in News. (On-line) Available: http://trak.in/news/tunisia-first-country-to-prohibit-haj-because-of-swine-flu/11166/. Cited 2009 Oct 08.

(4E) Hajj and Umrah Pilgrimage (2009) Fitfortravel. (On-line) Available: http://www.fitfortravel.nhs.uk/advice/advice-for-travellers/hajj-and-umrah-pilgrimage.aspx. Cited 2009 Oct 16.

(5E) Ramadan 2009 (2009) Ramadan. (On-line) Available: http://www.submission.org/ramadan/about-R.html. Cited 2009 Oct 16.

(6E) What is Communion (2009) Uniting Church in Australia. (On-line) Available: http://www.wa.uca.org.au/home/kids-zone/communion/. Cited 2009 Oct 27.

(7E) Communion (Christian), Wikipedia. (On-line) Available: http://en.wikipedia.org/wiki/Communion_(Christian). Cited 2009 Oct 27.

Tagged as: Disease, H1N1, Pandemic