Respiratory symptoms during Hajj: Reflections and public health lessons from a pilgrim

Hajj ranks among the world’s most significant annual mass gatherings, uniting millions of pilgrims from diverse nations and socio-demographic groups. Although the pilgrimage holds profound significance, it also poses distinct public health challenges, especially concerning the spread of respiratory illnesses. The term “Hajj cough” is often used by pilgrims to refer to the cough and upper respiratory symptoms that are commonly experienced during or soon after the pilgrimage.

Respiratory tract infections are consistently reported as one of the most common health problems affecting Hajj pilgrims. Several factors lead to the high incidence of respiratory symptoms during Hajj. These include crowding, prolonged close contact with other pilgrims, physical fatigue, sleep deprivation, exposure to heat and dust, and frequent transitions between outdoor environments and air-conditioned accommodations.

My personal experience with Hajj cough

I encountered two episodes of respiratory illnesses during Hajj. The initial event took place a few days after my arrival in Makkah. The episode started with a sore throat, which was soon accompanied by a mild productive cough. Fortunately, the symptoms stayed mild and subsided without greatly impacting my daily activities and ibadah, lasting approximately five to six days. The second occurrence happened later in Aziziyah, following my return from Masyair (which refers to the days and sacred sites of the peak pilgrimage rituals during the Islamic Hajj). This episode was significantly more intense. It began with a sore throat, then progressed to a runny nose, a productive cough with greenish sputum and chills in the evening. Although the symptoms were still manageable, this experience underscored how easily respiratory illnesses can spread during Hajj, especially after the physically demanding days of Masyair.

Listening carefully in the prayer room in Dar Al Hamd, Aziziyah, one could hear many different kinds of coughs among the pilgrims – dry coughs, productive coughs, occasional throat clearing, and persistent coughing fits or paroxysmal coughs. Such observations are not surprising given the well-documented burden of respiratory illness among Hajj pilgrims. In crowded environments where individuals are in proximity for long durations, the likelihood of encountering respiratory pathogens is nearly unavoidable.

While respiratory infections frequently occur during Hajj, not every instance of coughing or upper respiratory symptoms during this period is caused by an infection. The dry, dusty conditions in Makkah, along with heat exposure, insufficient hydration, physical exhaustion, and other environmental stressors, can lead to throat irritation and coughing. These factors can affect even healthy pilgrims and may produce symptoms that resemble those of respiratory tract infections.

Prevention of Hajj cough

Although it may not be possible to eliminate the risk completely, several preventive measures can reduce the likelihood of acquiring respiratory ailments during Hajj.

1. Wear a face mask in crowded settings, particularly indoors and during peak congregation periods. Female pilgrims are generally not permitted to wear a face covering that directly touches the face while in the state of ihram except under specific circumstances, according to the relevant fiqh rulings. However, once the restrictions of ihram are lifted, mask use should be resumed as quickly as possible, especially in crowded environments where the risk of respiratory infection is high.

2. Perform regular hand hygiene using soap and water or alcohol-based hand sanitisers. Personal observations during Hajj suggested that hand hygiene practices were not always consistently followed, particularly after coughing, sneezing, or blowing one’s nose. Given the high density of pilgrims and the frequent sharing of common spaces, inadequate hand hygiene may facilitate the transmission of respiratory pathogens. Regular hand cleaning, especially after contact with respiratory secretions and before meals, remains one of the simplest and most effective preventive measures.

3. Maintain adequate hydration throughout the day. An interesting observation during Hajj is that some pilgrims deliberately limit their water intake to reduce the need for toilet visits, especially as this may require them to renew their ablution (wudhu’) before prayer. While understandable, this practice may inadvertently increase the risk of dehydration, fatigue, and throat irritation. A practical approach is to drink small amounts of water regularly, perhaps a few sips every 30 minutes, rather than waiting until one feels thirsty or consuming large amounts at one time.

4. Ensure sufficient rest whenever possible. Many pilgrims make it a personal goal to perform all five daily prayers in Masjid al-Haram, and this often involves repeated journeys to and from the mosque each day. Combined with the heat, crowding, and physical exertion associated with Hajj, such routines can gradually lead to fatigue. In our enthusiasm to maximise acts of ibadah, we may sometimes overlook the importance of rest and recovery. Adequate sleep, short periods of rest between prayers, and a balanced intake of nutritious food are essential for maintaining energy levels and supporting the body’s ability to resist illness.

5. Avoid unnecessary exposure to dust, smoke, and other respiratory irritants. One situation where this may be particularly relevant is during the mabit or spending the night in Muzdalifah. The constant movement of buses and large numbers of pilgrims can create a noticeably dusty environment. In my observation, some pilgrims were resting directly opposite areas where buses were parked or frequently passing by, potentially increasing their exposure to dust and exhaust fumes. This may be especially challenging for female pilgrims who remain in the state of ihram and may not be able to use face coverings in the usual manner. Where practical and permitted, pilgrims may wish to move to a less dusty location if they find themselves resting near bus routes or areas with heavy vehicle movement. Small adjustments such as these may help reduce throat irritation and respiratory discomfort.

6. Seek medical attention as soon as possible if symptoms worsen or are accompanied by fever, breathing difficulty, or persistent illness. In view of the spirit of perseverance, some pilgrims may be inclined to endure symptoms and continue with their activities despite feeling unwell. While the intention may be admirable, delaying medical assessment may allow potentially treatable conditions to worsen. Fortunately, Malaysian pilgrims are well supported by Tabung Haji healthcare teams, who are stationed at various locations in Makkah and other pilgrimage sites. Pilgrims should be aware that seeking medical attention is a sensible step towards safeguarding their health and enabling them to continue their pilgrimage safely.

7. Ensure that all required and recommended vaccinations are received before travel in accordance with the latest guidance from the Ministry of Health Malaysia and the Saudi Ministry of Health, including influenza and COVID-19 vaccines where indicated.

The curious case of the healthy mutawwif

During my stay, interestingly, I noticed that the mutawwifs appeared remarkably healthy despite being continuously surrounded by sick pilgrims. (A mutawwif is a guide who manages and instructs pilgrims while they perform the Hajj and Umrah rituals in the Holy Land.) I rarely heard any of them coughing and did not notice routine mask use among them. This observation raises interesting questions. One possible explanation is that experienced mutawwifs may have developed practical habits that reduce their risk of illness, such as maintaining good hydration, managing fatigue, recognising early symptoms and adopting preventive behaviours that may not be immediately obvious to pilgrims.

Another possibility is that, as individuals who accompany Hajj and Umrah pilgrims year after year, they have become accustomed to the local environment and may possess a degree of acquired immunity to commonly circulating respiratory pathogens.

The risk of acquiring respiratory infections during Hajj is not uniform across pilgrims. Susceptibility is influenced by a range of host-related factors, including age, pre-existing medical conditions, vaccination status, prior immunity, sleep quality, psychological stress, and individual preventive practices.

While these explanations remain speculative, the observation highlights the need for further research into factors associated with resilience and protection against respiratory illnesses in mass gathering settings.

Respiratory symptoms and cough are common experiences during Hajj and represent a significant public health concern in mass gathering settings. My own experience with two episodes of respiratory illness during the pilgrimage serves as a reminder that all individuals are susceptible. While complete prevention may not be possible, adherence to basic public health measures as mentioned can help reduce the risk of respiratory illness and support a safer pilgrimage experience.

References

Deris, Z. Z., Hasan, H., Sulaiman, S. A., Wahab, M. S. A., Naing, N. N., & Othman, N. H. (2010). The prevalence of acute respiratory symptoms and role of protective measures among Malaysian Hajj pilgrims. Journal of Travel Medicine, 17(2), 82–88. 

Memish, Z. A., Zumla, A., Alhakeem, R. F., Assiri, A., Turkestani, A., Al Harby, K. D., Alyemni, M., Dhafar, K., Gautret, P., Barbeschi, M., McCloskey, B., Heymann, D., Al Rabeeah, A. A., & Al-Tawfiq, J. A. (2014). Hajj: infectious disease surveillance and control. Lancet (London, England), 383(9934), 2073–2082. 

Saudi Ministry of Health. (2025). Health requirements and recommendations for travellers to Saudi Arabia for Hajj and Umrah. Ministry of Health, Kingdom of Saudi Arabia. https://www.moh.gov.sa/HealthAwareness/Pilgrims-Health/Documents/Hajj-Health-Requirements-English-language.pdf

World Health Organization. (2015). Public health for mass gatherings: Key considerations. World Health Organization. https://iris.who.int/handle/10665/162109