13–0.57, p < 0.001] and disposable handkerchiefs (11.0% vs 35.7%; RR = 0.22, 95% CI = 0.09–0.53, p < 0.001); myalgia was less frequently reported in those using hand disinfectant (6.1% vs 20.1%; RR = 0.25, 95% CI = 0.11–0.56, p < 0.001), and fever was less frequently reported in those vaccinated against pneumococcal infections (8.3% vs 14.6%; RR = 0.22, 95% CI = 0.06–0.73, p = 0.007). Of the

Jeddah recommendations, the most challenging was that the population groups considered Roscovitine chemical structure at high risk for complications from influenza should voluntarily refrain from the Hajj of 2009.1 Although our results cannot be extrapolated to all Hajj pilgrims, they clearly indicated that European pilgrims departing from southern France were INCB024360 datasheet unlikely to have heeded the recommendations from the expert conference.7 This was mainly due to the effect

of the high proportion of older Hajjis with underlying chronic conditions. Several limitations of our study must be acknowledged. Reported symptoms were not specific and may be due to non-influenza respiratory infections. Only testing for influenza at or after Hajj would acquire more accurate data. The reliability of reported symptoms and preventive measures taken by telephone interviews may be questionable, and a significant proportion of the enrolled pilgrims were lost prior follow-up. Nevertheless, our results showed that French pilgrims had significant adherence to individual preventive measures during the Hajj of 2009. While the proportion of French pilgrims who suffered a cough during their stay in Saudi Arabia in 2009 (48.5%) was slightly less than that observed in those participating in the Hajj of 2006 (60.6%) and 2007 (61.1%), when no specific preventive measure was proposed with the exception of the influenza vaccination,8,9 our results suggest that vaccination against influenza and the use of surgical face masks were not efficient against respiratory infections to in the context of the 2009 Hajj pilgrimage. Similar results were observed in Malaysian pilgrims during the Hajj of 2007.10 Therefore, these preventive measures probably did not account for the low number of H1N1

cases reported during the Hajj of 2009. Further investigation, including large-scale prospective testing of the effectiveness of preventive measures, particularly surgical face masks and N95 mask use, should be of interest to identify the preventive measures that should be recommended during the pre-travel consultation with future Hajj pilgrims. The highest percentages of H1N1 cases observed in Saudi Arabia before the Hajj were in individuals under the age of 30, and individuals over the age of 50 were less susceptible to infection by the virus but were more severely affected when infected.2–4 Therefore, the large proportion of older individuals in the Hajj population may have been responsible for the low number of H1N1 cases recorded during the pilgrimage.