3%, p < 0.001) compared with those born in North Africa. Overall, 135 (21.3%) pilgrims had traveled and planned to travel outside France, both before and after the pilgrimage. Our results show a complex pattern of international travel in French pilgrims participating in the Hajj of 2010. Two-thirds of them underwent a trip to their country of origin in North Africa, 1 to 4 months before traveling from France to Saudi Arabia and a quarter planned to go back to North Africa after a short stop-over in France, following the Hajj. Angiogenesis inhibitor This reflects

France’s past colonial history in Algeria, Morocco, and Tunisia and the post-colonial migrations. Therefore, French pilgrims arriving to Saudi Arabia may both present with long incubation communicable diseases, acquired in North Africa and short incubation infections acquired in France. In case of acquisition of communicable diseases during their stay in Saudi Arabia, French pilgrims will have the potential to spread infectious disease agents not only in France, but also in North Africa. This was particularly worrying during the Hajj of

2009 regarding the risk of spread of influenza A H1N1 09.6 Collaborative sentinel surveillance networks monitoring disease trends among travelers offer valuable tools for evaluating travel health issues. However, the major multinational sentinel networks addressing travel health issues globally (GeoSentinel and EuroTravNet) are mainly based in industrialized countries and do not include sites in North Africa.7,8 The EuroTravNet center in Marseille captures only few cases of Hajj-associated 3-deazaneplanocin A datasheet infectious diseases in returned French

pilgrims, although cohort studies have demonstrated that most pilgrims Exoribonuclease departing from Marseille get ill during their stay in Saudi Arabia.9 This is due in part to the mild nature of Hajj-associated diseases that are not likely to be seen at a specialized clinic, but also to the fact that a significant proportion of travelers may exhibit symptoms in North Africa rather than in Marseille. Therefore, surveillance of Hajj-associated infectious diseases in French pilgrims should be coordinated between France and North African countries. In this perspective, collaboration with EpiSouth network, a recently born network aiming to improve communicable disease surveillance in the Mediterranean area could be useful.10 Our study is limited to a small cohort of pilgrims from one large city in France and although it is a tradition in Muslim communities that many pilgrims travel after Hajj in the Middle East and Indian subcontinent,6 our results cannot be extrapolated to all pilgrims. Better linked surveillance for travelers, including pilgrims to the Hajj, is needed by health information system development such as real time electronic reporting, rapid data collection and post-event reporting using mobile phone technology and social networking, and rapid laboratory testing where possible to improve outbreak detection and control.