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Background  Food and water-borne diseases (FWBDs) are a health risk at the Hajj mass gathering. The current study documented the prevalence and management of gastrointestinal (GI) symptoms among pilgrims during the 2019 Hajj and assessed their knowledge and practice concerning food and water safety.    Method  An analytical cross-sectional study was conducted in Macca, Saudi Arabia, among adult Hajj pilgrims from 28 countries. Data was collected from 15th–20th August 2019 by facer-to-face interviews using an anonymous structured questionnaire. Basic demographic data as well as information regarding pilgrims’ knowledge and practice relating to food and water safety and any GI symptoms experienced during the Hajj was collected and analyzed.    Results  The study enrolled 1363 pilgrims with a mean age of 50.1 years (SD = 12.3) and 63.4% ( n  = 845) were male. At least 9.7% ( n  = 133) of pilgrims experience GI symptoms and 5.1% (69/1363) suffered diarrhea. Most respondents drunk bottled water (99.4%,  n  = 1324) and obtained their food from their hotel /Hajj mission (> 86%). In general, pilgrims had good knowledge and practice in relation to food and water safety, although risky practices were noted concerning keeping food at unsafe temperatures and hazardous sharing of food and water. Gender, nationality and suffering GI symptoms during Hajj were significantly associated with good knowledge and good practice. There was a moderate but statistically significant positive correlation between knowledge and practice scores (r s  = 0.41,  p  < 0.0001).    Conclusion  Despite overall good knowledge and self-reported practice, risky behaviors relating to food and water safety were identified among pilgrims, many of whom suffered from GI symptoms during Hajj. Our results can form the basis for developing tailored, targeted and effective interventions to improve pilgrims’ knowledge and behavior and reduce the burden of FWBDs at the Hajj and beyond.

Gastrointestinal symptoms and knowledge and practice of pilgrims regarding food and water safety during the 2019 Hajj mass gathering