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Although MERS has technically been detected in Middle Eastern residents since before the Hajj of 2012, the number of cases that first year was very low, and only marginally higher in 2013. It wasn’t until the spring surge of 2014 that the number of infections in any single month exceeded 40.
On the three months leading up to last year’s Hajj, however, we saw the number of cases declined markedly (see chart above).
This year is a bit different. Instead of the expected summer decline, Saudi Arabia has reported a substantial jump in MERS cases over the past 60 days.
With the Hajj about to begin, there is understandably concern over the potential spread of the virus, particularly since respiratory infections are the most commonly reported illness among religious pilgrims (see EID Journal: ARI’s In Travelers Returning From The Middle East). This study also found that `Pneumonia is the leading cause of hospitalization at Hajj, accounting for approximately 20% of diagnoses on admission.’
Last year, in EID Journal: Respiratory Viruses & Bacteria Among Pilgrims During The 2013 Hajj, we looked at another study that examined a small group of French pilgrims (n=129) both before and after attending the Hajj, and compared nasal swabs. They found:
. . . that performing the Hajj pilgrimage is associated with an increased occurrence of respiratory symptoms in most pilgrims; 8 of 10 pilgrims showed nasal or throat acquisition of respiratory pathogens.
Against this background `noise’ of ubiquitous, but relatively benign respiratory infections – spread across roughly 2 million pilgrims - finding and identifying mild or moderate MERS infections will present quite a challenge to the Saudi MOH.
Even without an emerging coronavirus, the logistics of providing free medical care for several million pilgrims during the Hajj is a daunting one. Many pilgrims are elderly, have chronic conditions, and live in countries where access to modern medical care may be limited. Quite a few arrive in the Kingdom already in dire need of medical care.
Two years ago, in MERS, Mass Gatherings & Public Health, we looked at some of the immense challenges that Saudi Arabia faces each year with the Hajj.
Emergence of medicine for mass gatherings: lessons from the Hajj
Prof Ziad A Memish MD , Gwen M Stephens MD, Prof Robert Steffen MD , Qanta A Ahmed MD
(Excerpt)
Within the immediate vicinity of the Hajj, there are 141 primary health-care centres and 24 hospitals with a total capacity of 4964 beds including 547 beds for critical care. The latest emergency management medical systems were installed in 136 health-care centres and staffed with 17 609 specialised personnel. More than 15 000 doctors and nurses provide services, all at no charge.
Late last month it was announced that Camel Sacrifice would be Prohibited To Help Prevent MERS during the Hajj, and the Saudi MOH Health Tips to Be Followed During Hajj – which remarkably, doesn’t specifically mention MERS – strongly encourages the use of face masks to prevent `respiratory diseases’, stating:
Using face-masks, especially in overcrowded places, and changing them every now and then (in accordance with the manufacturer's instructions) helps protect you from the infectious diseases transmitted through coughing or sneezing.
Last month the World Health Organization published interim updated guidance on MERS and mass gathering events. While a diplomatically `generic’ document – one that does not specifically reference the Hajj, Umah or Saudi Arabia - there is little doubt on the primary focus of this document.
Interim guidance
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Authors:
WHO
Publication details
Editors: WHO
Publication date: 5 August 2015
Languages: Arabic, English, French, Russian, SpanishDownloads
Overview
This document presents organizers and hosts of international mass gatherings with proposed steps to improve public health preparedness to prevent, contain, and mitigate the impact of Middle East respiratory syndrome coronavirus (MERS-CoV). This document is based on current evidence generated among scientific disciplines, operational research, and academic networks related to mass gatherings.
This document provides guidance in six areas:
1) Enhanced surveillance;
2) Command and control arrangements that link actions across agencies;
3) Travel health planning;
4) Clinical management of confirmed MERS-CoV cases;
5) Infection prevention and control; and
6) Risk communication.
Although the Saudi government does a remarkable job every year accommodating millions of religious pilgrims, their record of `risk communications’ and sharing information with rest of the world regarding MERS has left much to be desired.
A concern that was raised in uncharacteristically blunt terms just a couple of weeks ago in WHO Statement On The 10th Meeting Of the IHR Emergency Committee On MERS.
In this document, the WHO pointedly reminds `host countries’ that:
Public health authorities in host countries preparing for mass gatherings should ensure that all recommendations and guidance issued by WHO with respect to MERS-CoV have been appropriately adopted into plans and made accessible to all concerned officials. Implementation and improvement of International Health Regulations (IHR) 20051 core capacities remains a priority.
As to whether we’ll see MERS transmission come out of this year’s Hajj?
While there are many things that the Saudi MOH can do to reduce the chances of that happening, there’s realistically not much they can do to prevent it if actively shedding MERS carriers (human or animal) manage to mingle among the Hajjis.
Which is why - probably through the end of October - public health agencies around the world are going to be on heightened alert for the possibility of seeing imported MERS cases.
