Saudi Arabia (KSA) hosts the annual Hajj pilgrimage to Makkah (Mecca), the holiest city of Islam. More than 3 million people come from over 180 countries to participate during the 12^th month of the Islamic calendar. Hajj is one of the Five Pillars of Islam and must be undertaken by all able-bodied adult Muslims who can afford it. Several million more pilgrims participate in Umrah, another pilgrimage to Makkah that can be undertaken at any time of the year. Jeddah is the second largest city in KSA and the principal international travel gateway to Makkah.

Millions of pilgrims each year come from outside KSA [1] , and over 50% from regions where tuberculosis is endemic, such as India, Pakistan, Bangladesh, southeast Asia and Africa. Asia and Africa account for 85% of global TB cases [2] . The Hajj represents a major infection challenge with few global equivalents. Pilgrims are mostly middle-aged and elderly, conditions during Hajj are overcrowded and hot, participants undertake exhausting rituals, suffer sleep deprivation and poor nutrition, and often already suffer from illnesses [3] . Studies have reported that >50% of Hajj participants suffer from coughs [4] , and upper respiratory tract infections are the most common disease during the Hajj [5] . These factors are highly conducive to the spread of TB. In one study, a TB immune response was found 3 months after returning home in 10% of pilgrims who had tested negative before attending the Hajj [6] . The risk of spread of TB among pilgrims has been well-documented [1] [2] [5] [7] . However, far less consideration has been given to the potential disease impact on the local resident population.

The overall TB incidence rate in KSA is approximately 16/100,000 and the death rate is approximately 1000 per annum; the incidence among Saudi nationals is 12/100,000 compared to 25/100,000 among non-nationals [3] - [8] . BCG vaccination is compulsory at birth in KSA, and TB treatment is free in government hospitals. However, the western region including Makkah and Jeddah has an incidence of 24/100,000, which is well above the national average and is rising rapidly, in contrast to the pattern elsewhere across KSA [2] [3] . Other reports put the incidence in this region as high as 64/100,000 [9] . The tuberculin sensitivity test (TST) rate in the Western province of KSA has been reported as 20% [10] . There is obvious potential for TB transmission from pilgrims to the local population with whom they are in frequent contact. Some non-Saudi pilgrims remain in the Makkah region for work, but tend to have poor healthcare and housing because of fear of deportation; it is considered likely that they contribute to the high incidence of TB in this region [2] . Furthermore, studies have highlighted significant positive TST rates among healthcare workers in KSA, which represents another potential route of transmission [11] . These considerations mean it is crucial to assess awareness and knowledge of TB in the population of Makkah and Jeddah.

In this work, we surveyed residents of these cities to assess their knowledge about the causes and infectivity of TB, and the prevention and treatment of the disease. Few previous studies have assessed awareness of TB among Saudi populations, but research into students at King Saud University, Riyadh, and in the general population of Jeddah has revealed that knowledge was poor even among well-educated people [9] - [12] . Our aim was to highlight any deficiencies in knowledge in the populations of Makkah and Jeddah to help improve awareness efforts.

We surveyed 1004 residents of the cities of Makkah and Jeddah, Saudi Arabia, a region where the population are at relatively high risk of exposure to TB because it is a center of large-scale, global pilgrimage. The respondents were divided by gender (male = 419, female = 585). Table 1 shows summary demographic information concerning the survey participants. Table 2 shows responses to questions on the spread of TB, and knowledge about the cause, infectivity and preventability of the disease. Table 3 reports answers to questions on treatment of TB and individual responses to symptoms.

The spread of TB by coughing or aerosol was recognized as a transmission route by 44.2% of males and 59.6% of females (P < 0.001 between the gender groups) who responded to our questions (Table 2). A substantial proportion of respondents said they did not know the route of transmission (22.3%), and many gave incorrect answers. Only 20.0% of our participants (201/1004) knew that TB is caused by bacteria; 38.1% thought the disease is viral and 38.6% did not know (Table 2). Around two-thirds knew

that TB is infectious (71.6% of females, 52.3% of males, P < 0.001), and 70.5% considered it preventable, with a significantly higher proportion of females than males knowing about preventability (P < 0.001). Participants were asked about the best method of preventing TB in a question that allowed a free choice of answer: 48.0% responded patient isolation and 15.2% answered vaccination (Table 2); females indicated vaccination in higher proportion than males, with a significant difference between genders (P = 0.008). Around two-thirds of respondents knew that TB is treatable (females significantly more than males, P = 0.040), but 58.7% did not know whether complete recovery is possible (no significant difference by gender) (Table 3). Only 50.6% of males and 38.3% of females (P < 0.001) would seek modern medical treatment if suffering from a cough with blood; females were considerably more likely than males (55.7% vs 43.4%, P < 0.001) to use traditional medicine (Table 3). If suffering a persistent cough (without blood), 15.5% of respondents would do nothing, while 45.6% of males and 53.0% of females (P = 0.031) would wait for some time before consulting a healthcare provider (Table 3). A pattern of a high proportion of “don’t know” responses was observed throughout our survey (Table 2 and Table 3).

Knowledge of TB is significantly associated with positive healthcare-seeking action [15] , increased compliance with treatment regimens and a higher cure rate [16] . TB control can be enhanced by improvement in knowledge and attitudes towards the disease [17] . Public awareness correlates with early detection of TB [12] . Meanwhile, baseline studies are important to highlight present deficiencies in knowledge and to track the progress of any public health education or policy measures taken in the future. Our results indicate a worrying lack of knowledge among the sampled population in Jeddah and Makkah.

This study provides a basis for discussions of public policy towards TB awareness and education in Saudi Arabia, especially in the west of the country which has a higher incidence of the disease and is a site of major pilgrimage for millions of visitors each year from countries where TB is endemic. Development of an evidence base for intervention into TB transmission is a priority for the KSA Ministry of Health [1] . Significant and urgent public education is required about the cause and treatment of TB. While extensive processes address the medical needs of visiting Hajj pilgrims, sufficient consideration must also be given to the health and awareness of the local population.

AlOtaibi, S.M., Almoshadq, A.F., Alghanmi, H.A., Aljuiad, F., Soliman, Y.R., Alzuair, A.T., Alzahrani, O.A., Algarni, A.A. and Ali, M.Y. (2016) Poor Knowledge of Tuberculosis among the Population of Jeddah and Makkah Saudi Arabia, a High-Risk Area. Journal of Tuberculosis Research, 4, 81-91. http://dx.doi.org/10.4236/jtr.2016.43010