Monday, August 27, 2018

UK: PHE Advice To Travelers Returning From The Middle East

Credit ECDC


While the the total number of MERS-CoV cases exported from the Middle East since 2012 has remained small, their impact - such as we saw in South Korea during the summer of 2015 - can be tremendous (see Study: Burnout & PTSD Among Nurses Working During A Large MERS-CoV Outbreak - Korea, 2015).
Last week's report of an imported case in England (see UK PHE: Imported MERS Case In England (Leeds)) is reminder that - with an incubation period of up to 15 days - a MERS infected individual can often have a sizable window in which to travel before symptoms appear.
With the Hajj just ended, over the next couple of weeks hundreds of thousands of religious pilgrims will be leaving Saudi Arabia and flying to back to their home countries around the globe.

And if past years are any gauge, many will return home with mild respiratory infections. A 2012 study in Clinical Infectious Diseases (co-authored by Ziad Memish) - called Unmasking Masks in Makkah: Preventing Influenza at Hajj found:
Each year more than 2 million people from all over the world attend the Hajj pilgrimage to Saudi Arabia. At least 60% of them develop respiratory symptoms there or during outward or homebound transit [1, 2]
Since the initial signs of MERS infection are often similar to a cold or the flu, differentiating who is - and who isn't - infected can be a extremely difficult, even for doctors used to seeing cases (see Evaluation of a Visual Triage for the Screening of MERS-CoV Patients).
All of which means that airport screeners and thermal cameras have little hope in preventing entry of MERS infected travelers  (see Why Airport Screening Can’t Stop MERS, Ebola or Avian Flu).
Which has prompted many countries - including England - to advise travelers returning from the Middle East to be aware of changes in their health in the two weeks following their return, and to report any fevers, coughs, or respiratory illness to their doctor immediately. 

PHE Twitter Feed
The PHE blog Public Health Matters has more information in Middle East Respiratory Syndrome (MERS): Who is at risk?
Despite our annual concerns, we've never seen a major outbreak of MERS linked to religious pilgrims returning from the Hajj. Whether this has been a matter or luck, or is due to limitations in how well MERS circulates in the community, remains an open question. 
That said, three years ago we watched the tragic results of a single MERS  infected business traveler returning from the Middle East to South Korea.

Sparked by a just one case, MERS spread like wildfire due to a handful of `super spreaders', whose impact was magnified by overcrowded hospital Emergency Rooms and hospital wards (see Superspreaders & The Korean MERS Epidemiological Report).

This unprecedented nosocomial outbreak spread across 16 hospitals in South Korea, where more than 185 patients, family members and staff were infected (see June 2015 WHO MERS Situation Assessment For Korea), with at least 37 deaths.
Additionally, thousands of exposed individuals - while not infected - found themselves quarantined at home and undergoing daily medical checks for the 14 day incubation period.
While 99.999% of all returning Hajjis with respiratory symptoms will almost certainly have something far less exotic or dangerous than MERS, the experience of South Korea shows that it only takes one infected individual to slip through the cracks to spark a national crisis.

For more on the Korean experience, and how France handled their clinical management of suspected MERS cases in Paris between 2013 and 2016, you may wish to revisit last month's BMC Inf. Dis.: Clinical Management Of Suspected MERS-CoV Cases. 
And you'll find the CDC's advice to travelers, and clinicians, at MERS in the Arabian Peninsula.
While our focus today is on MERS, similar risks exist for a variety of emerging and re-emerging infectious diseases, including Ebola, Lassa Fever, Avian Flu, Nipah, and even Virus X  . . . the one that isn't on our radar screen yet.

In 2015. in TFAH Issue Brief: Preparing The United States For MERS-CoV & Other Emerging Infections, we looked at some of the steps that the United States needs to take to prepare for the arrival of MERS and other Emerging infections.

Because, in our increasingly mobile and interconnected global society, it is really just a matter of time.

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