The cost-effectiveness of testing and quarantine strategies to contain epidemic spread during the Hajj pilgrimage: A modelling study

The Hajj is an annual pilgrimage made by millions of Muslims to Mecca in the Kingdom of Saudi Arabia (KSA). The large number of international attendees at the Hajj increases the risk of global infectious disease spread. However, we know very little about the benefits, costs, and cost-effectiveness of testing and quarantining strategies to contain epidemic spread during mass gathering events. In this work we developed a stochastic discrete-time compartmental metapopulation model to simulate international epidemics of infectious pathogens and their potential importation into KSA during the Hajj. We used the model and an epidemic simulation study to evaluate the impact and cost-effectiveness of three testing and quarantining strategies for arriving pilgrims: randomly testing 99% of pilgrims, 80% of pilgrims, or using a symptom-based screening strategy. The simulations lasted 100 days, covering the 30 days before the Hajj and 65 days after the Hajj. Under the conditions assumed in our simulation study, there was strong evidence that testing and quarantining strategies are cost-effective measures for controlling epidemic threats at the Hajj. The median net monetary benefits of intervention strategies ranged from Intl$-41.89M [95% quantile range Intl$-42.37M to Intl$3.18B] to Intl$12.68B [Intl$-8.70B to Intl$13.82B] across scenarios with different pathogen characteristics (based on the natural histories of SARS-CoV-2 and H1N1 Influenza) and epidemic seed locations. Our results were sensitive to the data sources that were used to estimate the number of pilgrims travelling to KSA by origin country, with flight passenger statistics providing biased estimates of pilgrim numbers. Our work provides an adaptable tool to inform infectious disease risk assessments and evaluate the cost-effectiveness of possible disease control measures for the Hajj, and could be extended to other mass gathering events.