Tuberculosis and mass gatherings—opportunities for defining burden, transmission risk, and the optimal surveillance, prevention, and control measures at the annual Hajj pilgrimage

• The ease of international travel is responsible for the spread of tuberculosis (TB) across the world.
• Accurate data on the actual burden of TB and the transmission risk associated with mass gatherings are scarce and unreliable.
• Every year an estimated 10 million pilgrims from 184 high TB endemic countries travel to Saudi Arabia to perform the Hajj and Umrah pilgrimages.
• The Hajj pilgrimage provides unique opportunities to conduct high quality priority research studies on TB.
• Research opportunities for defining the TB burden, transmission risk, and the optimal surveillance, prevention, and control measures at the annual Hajj pilgrimage are discussed.

SummaryTuberculosis (TB) is now the most common infectious cause of death worldwide. In 2014, an estimated 9.6 million people developed active TB. There were an estimated three million people with active TB including 360 000 with multidrug-resistant TB (MDR-TB) who were not diagnosed, and such people continue to fuel TB transmission in the community. Accurate data on the actual burden of TB and the transmission risk associated with mass gatherings are scarce and unreliable due to the small numbers studied and methodological issues. Every year, an estimated 10 million pilgrims from 184 countries travel to the Kingdom of Saudi Arabia (KSA) to perform the Hajj and Umrah pilgrimages. A large majority of pilgrims come from high TB burden and MDR-TB endemic areas and thus many may have undiagnosed active TB, sub-clinical TB, and latent TB infection. The Hajj pilgrimage provides unique opportunities for the KSA and the 184 countries from which pilgrims originate, to conduct high quality priority research studies on TB under the remit of the Global Centre for Mass Gatherings Medicine. Research opportunities are discussed, including those related to the definition of the TB burden, transmission risk, and the optimal surveillance, prevention, and control measures at the annual Hajj pilgrimage. The associated data are required to develop international recommendations and guidelines for TB management and control at mass gathering events.