By Carol A. Kemper, MD, FACP

Travel Recommendations for Hajj

SOURCE: Weekly Epidemiological Record no. 26/27; July 1, 2016:331-340.

Travel to the Middle East for Hajj has regained its popularity, with an estimated 2 million people anticipating travel to Mecca this September. Many will stay in the massive tent city, Mina, 8 km outside of the city, where conditions are crowded. Recommendations for travel for Hajj, based on the World Health Organization (WHO) guidelines, were last published in Infectious Disease Alert in 2012. The following is a summary of current recommendations for travel to Hajj published in the Weekly Epidemiological Record last month, as well as other appropriate suggestions. In addition to the following requirements and recommendations for entry visas to Hajj and Umrah 2016, the Saudi government plans to provide electronic bracelets for visitors to improve security.

Meningococcal Vaccine: Proof of meningococcal vaccination with the tetravalent vaccine ACYW135 is required for all travelers 2 years of age or older to obtain a visa. Both polysaccharide and conjugate vaccines are acceptable, but the name of the vaccine must be clearly spelled out on the vaccine card. The vaccine must be administered not less than 10 days nor more than three years before arrival. In addition, to reduce the carrier rate, the Saudi Arabian Ministry of Health will administer prophylactic antibacterials (ciprofloxacin 500 mg x 1) to adults and children older than 12 years of age arriving from the African continent.

Polio: For those traveling from the United States and regardless of a prior history of polio vaccination, you must show proof of receipt of at least one dose of oral polio vaccine (OPV) or inactivated poliovirus vaccine (IPV) within the previous 12 months and not less than four weeks prior to departure. In addition, travelers from countries endemic for polio will receive one dose of OPV at border points on arrival to Saudi Arabia.

Influenza: Annual influenza vaccination is recommended, especially for pregnant women, the elderly, those with chronic health conditions, and small children.

MMR and Tdap: Current vaccination is routinely recommended.

Hepatitis B Vaccine (HBV): A common ritual for men participating in Hajj is to have their heads shaved. While licensed barbers legally are required to employ a fresh blade with each new customer, illegal street vendors may not follow the law. It is therefore recommended that travelers consider HBV vaccination.

Malaria: Malaria is not present in Mecca, although it is present in the southwestern areas of Saudi Arabia. Travelers planning to visit this more rural region should consider malaria prophylaxis.

Yellow Fever: Certification of vaccination is required only if arriving from a country or area at risk for yellow fever.

Dengue and Zika Viruses: The mosquito that carries dengue virus, Aedes aegypti, has not been detected in Hajj or Umrah area for many years, although it may be found elsewhere in Saudi Arabia, and theoretically carries a risk of dengue and other viral agents. Zika virus has not been detected in Saudi Arabia.

Specific Recommendations for Women: Women should consider hormonal therapy to avoid having a menstrual cycle at this time.

General Recommendations: Practice good hand washing; wear regular surgical masks in crowded places or when in contact with ill persons; do not drink raw camel milk or camel urine or eat inadequately cooked meat; drink plenty of fluids and replenish electrolytes in the heat.

Dung and Tetracycline

SOURCE: Hammer TJ, Fierer N, Hardwick B, et al. Treating cattle with antibiotics affects greenhouse gas emissions, and microbiota in dung and dung beetles. Proc Biol Sci 2016;283.

In one of the first studies of its kind, these authors examined the effect of antibiotic administration to cattle on dung beetle microbiota and gas emissions from cow patties in the field. Antibiotics have significant effects on livestock gut microbiota, which could affect the gut flora of dung beetles, and may have cascading environmental effects.

Fresh samples of dung were collected from five cows treated for three days with tetracycline and from five untreated control cows. The dung then was separated into patties and placed in the field. Dung beetles (Aphodius fossor) were added to two-thirds of the patties, and then samples of the dung were analyzed at various intervals for up to 73 days for beetle content, microbial flora, and gas emissions. This duration of time was sufficient to gauge any effect on the next generation of dung beetles and their larvae. Efflux of methane, carbon dioxide, and nitrous oxide was measured.

Beetles’ density, weight, and sex were measured at intervals, and microbial flora analyzed using 16s rRNA primers and sequencing. Administration of tetracycline to the target animal had no effect on beetle size, reproductive capacity, or survival. Larval weight was unaffected, and the number of offspring was similar between treated and control cow patties. The use of antibiotics in the target animal had a clear effect on beetle microbiota, however. Generally, beetles have a less diverse microbiota than their diet. While dung was dominated by Clostridia, spirochetes, and Bacteroidia, less than 1% of dung microbiota was present in the beetles, the latter of which were dominated by bacilli and other proteobacteria/gammaproteobacteria (more of what is referred to as “archaea”). In other words, the beetles completely transform what they’re eating, and dominant beetle microbes are rare in dung. Despite this, antibiotic treatment had a clear effect on the dung beetles’ microbiota although it’s not clear whether this was a “nutritional effect” or how this occurred.

Generally, the presence of beetles in dung diminishes efflux of methane from cow patties. In contrast, methane gas emissions from dung from treated animals were increased by > 100%. Efflux of CO2 and N2O were similar from treated and untreated cows’ patties.

The effect of tetracycline on target livestock was nowhere near as great as the mortal effect of certain antiparasiticides (e.g., ivermectin and other avormectins) which destroy the dung beetles in excrement for months and months leaving undigested cow and sheep patties to solidify like fossilized rocks in the field.