#17,135
Even when we are not in the midst of a COVID pandemic, mass gathering events like Carnival in Rio, the Super Bowl, Mardi Gras, Chunyun (aka the Chinese New Year), the Summer & Winter Olympics, Umrah and the Hajj pose public health challenges not only for the host country, but for the world at large.
In all of these events hundreds of thousands - sometimes millions - of people travel from all over the world to spend a few days or a week in a common, usually crowded, location where they can easily exchange viruses - both common and exotic - before returning home.
While COVID - and more exotic threats like MERS-CoV, Ebola, or Avian Flu - are often the first things we think of, most infectious illnesses acquired during these mass gathering/migration events are far more common; seasonal flu, pneumonia, vector borne infections (Zika, CHKV, Dengue, Malaria,Yellow Fever, etc.), norovirus, etc.
- In 2010, in The Impact Of Mass Gatherings & Travel On Flu Epidemics , we looked at a study published in BMC Public Health, that looked at and attempted to quantify the impacts of mass gatherings and holiday travel on the spread of an influenza epidemic.
- And in 2011, in Viruses With A Ticket To Ride, we looked at a study that appeared in BMC Infectious Diseases, that looked at the incidence of ARI (Acute Respiratory Infection) presenting within 5 days of train or tram travel in the UK. They found that recent bus or tram use within five days of symptom onset was associated with an almost six-fold increased risk of consulting for ARI.
- The EID Journal: Respiratory Viruses & Bacteria Among Pilgrims During The 2013 Hajj found 8 of 10 pilgrims tested showed nasal or throat acquisition of respiratory pathogens during their pilgrimage, and another study by the same author found the most common cause of hospitalization during the Hajj is pneumonia (20%).
Infected travelers likely brought the West Nile Virus to the United States in 1999, introduced Chikungunya to the Americas in 2013, spread seasonal flu viruses every year, and helped to efficiently disperse COVID, the 2009 H1N1 influenza pandemic, and this year's Monkeypox viruses around the globe.
Between our concurrent COVID pandemic, the recent surge in RSV infections around the globe, and the return of an aggressive H3N2 flu strain this year - with 1.5 million visitors expected - the FIFA World Cup being held over the next 3 weeks in Qatar is well poised to make its own contribution to the spread of infectious diseases this year.
The ECDC has published a Risk Assessment, and we have a journal pre-proof from New Microbes and New Infections called Infection risks associated with the 2022 FIFA world cup in Qatar to look at. First, from the ECDC:
Mass gathering monitoring - the FIFA World Cup 2022 Qatar
Overview:
The 2022 FIFA World Cup is taking place between 20 November and 18 December 2022 in Qatar. Thirty-two countries are participating in this event, including nine EU Member States: Belgium, Croatia, Denmark, France, Germany, the Netherlands, Poland, Portugal, and Spain. A total of 64 matches will take place in eight stadiums spread across five Qatari cities. It is expected that approximately 1.5 million football fans from around the world will travel to Qatar during this event, some of them staying outside of the country. The FIFA Fan Festival will take place at the Al Bidda Park in Doha, and will be open every day of the tournament from 19 November to 18 December.
As of 24 November 2022, ECDC and networking partners, through epidemiological surveillance, have detected no events of public health concern in Qatar, its neighbouring countries and the countries participating in the 2022 FIFA World Cup. Four retrospective cases of MERS-CoV were reported in Saudi Arabia.
One signal that may be of interest was detected in a country participating in the World Cup, but does not pose a threat in relation to this event: on 23 November 2022, a fatality related to the ongoing shigellosis outbreak in Tunisia was reported. Previously, the Tunisian Ministry of Health issued a recommendation to apply hand-hygiene measures amid an upsurge of shigellosis cases (number not specified) among children since September 2022.
Here we provide a short epidemiological summary related to global or regional public health threats from infectious diseases:
COVID-19: Since the beginning of the pandemic and as of 17 November 2022, the Qatar Ministry of Public Health (Qatar MoPH) has reported 474 883 SARS-CoV-2 positive cases including 684 deaths. Qatar has a relatively high vaccination rate for COVID-19 with 98.86% of eligible individuals being fully vaccinated with the primary series (Qatar MoPH, WHO), and there is a decreasing trend in the number of COVID-19 cases in Qatar since late September 2022. From 1 November 2022, visitors are no longer required to present a negative COVID-19 PCR or rapid antigen test result before travelling to Qatar.
MERS-CoV: No new cases have been reported in Qatar during the monitoring week 14–17 November 2022. Overall in 2022, there were two cases of MERS-CoV reported in Qatar, and 25 cases since 2012. WHO reported four additional MERS-CoV cases in Saudi Arabia, detected from 29 December 2021 to 31 October 2022. The most recent case was reported on 9 November 2022. Overall, globally over 2 600 cases of MERS-CoV have been reported since 2012.
Monkeypox: No new cases have been reported in Qatar since September 2022. Overall, five cases of monkeypox were reported in Qatar in 2022, and the first case was imported.
ECDC assessment:
As is often the case with mass gathering events, during the 2022 FIFA World Cup in Qatar visitors may be most at risk of gastrointestinal illnesses and vaccine-preventable infections. Thus, travellers from the EU/EEA going to the event are advised to be vaccinated according to their national immunisation programme, and to ensure that they are vaccinated against seasonal influenza and have taken updated boosters for COVID-19, as recommended by respective national authorities. It is recommended to employ standard hygiene measures including regular handwashing with soap, drinking safe water (bottled, chlorinated or boiled before consumption), eating thoroughly cooked food and carefully washing fruits and vegetables with safe drinking water before consumption; and staying at home or in a hotel room when sick. The risk for EU/EEA citizens becoming infected with communicable diseases during the 2022 FIFA World Cup in Qatar is considered low if travellers observe the suggested measures before, during and after the event.
Actions:
The ECDC Epidemic Intelligence team is monitoring this event in collaboration with global partners between 14 November and 22 December 2022.
From Jaffar A. Al-Tawfiq et al. we get this discussion:
Infection risks associated with the 2022 FIFA world cup in Qatar
Jaffar A. Al-Tawfiq, Philippe Gautret, Patricia Schlagenhauf
PII: S2052-2975(22)00107-X DOI: https://doi.org/10.1016/j.nmni.2022.101055
(EXCERPT)
The Qatar ministry of health (QMoH) had released COVID-19 guidance and indicated that “currently there will be no vaccination requirement” [16]. Visitors are also not required to have pre-departure SARS-CoV-2 testing. The availability of effective COVID-19 vaccines and boosters should be utilized by visitors to Qatar to prevent the occurrence of COVID-19 during mass gatherings, at least in at risk attendees.
However, the emergence of variants of SARS-CoV-2 for which vaccine efficacy might be reduced, is seen as a major threat to ending the COVID-19 pandemic and points to the occurrence of outbreaks in MGs. Previous successful Qatari experience in organizing a major football match held outside during the pandemic (Amid Cup Footbal Final of Qatar) under strict control is reassuring [17].
Another possible respiratory tract illness is the Middle East Respiratory Syndrome Coronavirus (MERS-CoV). MERS-CoV had caused multiple hospital outbreaks in Saudi Arabia [18] and had caused limited number of cases in Qatar and the pattern was sporadic [19]. Epidemiologic data from Qatar showed the occurrence of of 28 cases of MERS (incidence of 1.7 per 1,000,000 population) and most cases had a history of contact with camels [20].
Thus, people with greater risk of developing severe disease are advised to avoid contact with dromedary camels, drinking raw camel milk or camel urine, or eating meat that has not been properly cooked [21].
Another infectious disease risk challenge at this time, is the occurrence of a multi-state monkeypox virus outbreak around the globe with the potential implication for MGs [22]. The number of reported cases to WHO is 79,641 as of 16 Nov 2022 [23]. One major difficulty with this virus is the difficulty in rapid detection of suspected cases, isolation of infected individuals and management of cases and contacts especially in large uncontrolled crowds [22]. To date, the State of Qatar had not reported any cases of monkeypox.
However, in the neighboring countries there had been limited number of cases (8 cases in Saudi Arabia, and 16 cases in United Arab Emirates) (Figure 2) [24]. The main transmission mode of the disease in the current outbreak is through close contacts, including notably sexual relations and the respiratory route plays a less important role if any [25]. Thus, it is important to avoid situations that put the individuals at risk of acquisition of monkeypox.
(SNIP)
In conclusion, the infectious disease risks associated with the FIFA World Cup 2022 this year in Qatar are dominated by the global concern about the ongoing COVID-19 pandemic with emergence of new variants and the threat of vaccine escape [32,33] and the occurrence of multistate outbreak of monkeypox.
Although in recent months, the trajectory of monkeypox cases points to decreasing numbers, this risk is still a significant challenge in the context of a football World Cup and possible sexual encounters.. Qatar, the hosting country, had made the health sector in the country ready for such occurrence. Continued surveillance and studies of the effect of MGs on the transmission of infectious disease continue to be an important aspect of MGs.
Novel technologies such as illness tracking Apps can [34] be considered for this and other large sporting and cultural events and should be employed to provide useful data for future MGs and enable recommendations for infectious disease prevention.
The number of MERS-CoV cases reported to WHO has substantially declined since the beginning of the ongoing COVID-19 pandemic. This is likely the result of epidemiological surveillance activities for COVID-19 being prioritized, resulting in reduced testing and detection of MERS-CoV cases.
In addition, measures taken during the COVID-19 pandemic to reduce SARS-CoV-2 transmission (e.g. mask-wearing, hand hygiene, physical distancing, improving the ventilation of indoor spaces, respiratory etiquette, stay-at-home orders, reduced mobility) are also likely reduce opportunities for onward human-to-human transmission of MERS-CoV.However, the circulation of MERS-CoV in dromedary camels is not likely to have been impacted by these measures. Therefore, while the number of reported secondary cases of MERS has been reduced, the risk of zoonotic transmission remains.
Even before the COVID pandemic, we'd seen estimates that the vast majority of MERS cases go undiagnosed (or unreported) in the Middle East (see EID Journal: Estimation of Severe MERS Cases in the Middle East, 2012–2016).
Admittedly, the chances of seeing an outbreak of MERS-COV come out of this venue are probably pretty low. And while it might have some impact on the generation and spread of one or more new COVID variants, directly linking them to this event might be difficult or impossible.
After nearly 3 years of pandemic lockdowns and social distancing, people understandably want to mingle, socialize, and travel. We are essentially social creatures, and the forced isolation of the past three years has exacted a heavy toll.
But mass gathering events provide target-rich environments for all types of opportunistic infectious diseases - meaning that like it or not - we must be prepared for the unexpected.
