Hajj is the fifth of the five pillars of Islam. Any healthy Muslim adult is obliged to perform Hajj once in his/her life if he/she is financially and physically capable. The Hajj begins on the 8th day of Dhul-Hijjah, the 12th month of the lunar Islamic year, and ends on the 13th day of the same month. Hajj has to be performed in three main locations in Makkah, namely, the sacred Kaaba (in the holy city of Makkah), and Mena and Arafat, which are approximately 5 and 18 Kilometers far from Makkah, respectively. Approximately, 2–3 million pilgrims perform Hajj every year; one third of them come from within Saudi Arabia and two thirds come from other countries. Most pilgrims stay in fire-resistant air-conditioned camping tents in Mena during the entire Hajj period. Financially deprived pilgrims who can not afford to pay for the cost of staying in camps usually stay outdoor. Free medical care services are provided to pilgrims by the Saudi Ministry of Health.
The study was conducted over a 10-day period annually for four consecutive years during the Hajj period of the lunar Islamic year 1423 to 1426, corresponding to 2003 to 2006.
Audited Makkah hospitals
All MOH hospitals in Makkah were included in the audit, namely, Ajiad General Hospital (AGH), Alnoor Specialist Hospital (NSH), King Abdulaziz Hospital (KAH), King Faisal Hospital (KFH), the Maternity and Children Hospital (MCH), and Heraa General Hospital (HGH). Clinical services in AGH, HGH, KAH, KFH, and NSH included internal medicine, general surgery, orthopedic surgery, obstetrics and gynecology, pediatrics, critical care, ophthalmology, and ear, nose, and throat. In addition, the HGH had a neurosurgical service, and the NSH had both neurosurgical and vascular surgery services. The clinical services in the MCH included general pediatrics, neonatal and pediatric critical care, and obstetrics and gynecology. In addition to serving the population of Makkah, these six tertiary care hospitals provide medical care to pilgrims who come to Makkah to perform Hajj during the Hajj period and those who come to Makkah year-round to perform Omra which is similar to Hajj except for the fact that the pilgrims are not required to stay in Mena and Arafat and that there is no specified period of time to perform it. The Hajj period is considered to be a peak-period where additional health care workers are temporarily recruited mainly from other regions in Saudi Arabia and a few from outside the country to cover the extensive medical services provided to pilgrims during this period.
The audit tool used in this study was adapted from an Australian audit tool designed by the Victorian State Government Department of Human Services . Data were collected on standardized checklists on various infection control service items during surprise visits to the medical, pediatric, surgical, and critical care units, and the kitchens of the audited hospitals. Where satisfaction of an item was not possible by observation, a response obtained by staff questioning was accepted. The audit members comprised six infectious diseases consultants divided into three teams. Each team was assigned to review two different hospitals every year for four consecutive years.
Eleven areas of infection control service were identified for the audit, namely: hand washing, environmental cleaning, waste disposal, handling of clean linen, handling of soiled linen, standard and transmission-based precautions, single use policy, urinary catheter care, sterile wound dressing, food hygiene, and pests and animal control in clinical areas. The details of the items audited under each of these eleven areas are shown in an additional file [See Additional File 1]. The hospitals were expected to follow the guideline for isolation precautions in hospitals recommended by the Centers for Disease Control and Prevention (CDC) in 1996 . Any negative or unsatisfactory finding was given a score of zero; any positive or satisfactory finding was given a score of one; any partially met finding was given half a mark. When an item was not applicable to the hospital, it was marked as ''non-applicable'' (NA). Non-applicable items were not included in the final numeric score. If an item audited in different units in the same hospital received different scores, the lowest score was taken as the final score of that item. The total maximum score for handwashing was 21 marks, for environmental cleaning and sanitation, 19 marks, for waste disposal, 20 marks, for handling and storage of clean linen, 5 marks, for handling and storage of soiled linen, 10 marks, for standard and transmission-based precautions (contact, droplet, and airborne precautions), 32 marks, for single use policy, 3 marks, for urinary catheter drainage, 5 marks, for sterile wound dressing, 11 marks, for food hygiene, 13 marks, and for vector control in clinical areas, 6 marks. The percentage score of any area was calculated as the total marks obtained for the different items audited in the area (the numerator), divided by the total marks of the audited items (the denominator), and multiplied by a hundred.
In addition to the aforementioned areas, the audit included collecting information about the presence of an infection control committee in the hospital, whether the committee met regularly, whether the meetings were appropriately minuted, the number of infection control team staff, the presence of educational activities on infection control directed to health care workers, and the presence of surveillance data.
Feedback to the audited hospitals
The result of the audit for each hospital was confidentially sent to it within four weeks after the end of Hajj. Hospitals were expected to utilize the results of these audits to improve their infection control services.