Self-Brought Antibiotics and Their WHO AWaRe Composition at the Hajj: A Two-Season, Photo-Verified Pilot Study

Pilgrims bring their own medicines to the Hajj, but the antibiotics they carry have been described only through self-report. This pilot tested whether a photo-verified inventory of the medicine bag that pilgrims have with them is practicable, and estimated the carriage and WHO Access, Watch, Reserve (AWaRe) composition of self-brought antibiotics. International pilgrims were interviewed in Makkah, Mina and Arafat during Hajj 1445 AH (2024) and 1446 AH (2025), and every package in their bag was photographed. Of 60 pilgrims from 17 countries, 50 made a bag available; together, these held 190 items, including 48 systemic antibiotics of eleven agents. Thirty-four carried at least one antibiotic (68.0% of inventoried pilgrims, 95% CI 54.2–79.2). Access agents made up 58.3% of the antibiotics (95% CI 44.3–71.2), not significantly below the 70% target (p = 0.084); none were Reserve. Of the antibiotics, 27.1% had been bought without a prescription and 85.4% were incomplete packs. In a post hoc analysis resting on few items, the Access share rose as national prescription enforcement weakened, opposite to the exploratory hypothesis; this gradient is unreliable. Photo-verified inventory is practicable among pilgrims who agree to be interviewed, and these imprecise estimates can inform an adequately powered multinational study.