Iran Notifies WHO Of 1 MERS Case

 

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Last summer the Iranian government notified the World Health Organization of a cluster of MERS cases that appears to have started  with an unidentified `woman who had an Influenza Like Illness (ILI) and had travelled to Saudi Arabia to perform Umra’ , who likely infected an Iranian woman (with no history of travel or camel contact) sometime in early May, who in turn, is suspected of infecting her younger sister (who also had no travel history or camel contact).

 

The WHO risk assessment published in February of 2015, stated:

 

The WHO team concluded that the cluster of MERS-CoV cases in Kerman, Iran, in May and June 2014, showing epidemiological evidence of healthcare-associated transmission, could possibly have been caused by a combination of factors. These included inconsistent application of infection prevention and control measures in a healthcare setting at the beginning of the outbreak, as well as weakness in the surveillance system to actively follow and identify cases.

 

Today, in the first report out of Iran in nearly a year, we learn that Iran has recently notified the World Health Organization of a new MERS case.   Like last summer’s case, this patient appears to have had contact with recently returned Umrah travelers to Saudi Arabia.

 

 

Middle East Respiratory Syndrome coronavirus (MERS-CoV) – Iran

Disease outbreak news
8 May 2015

On 1 May 2015, the National IHR Focal Point for the Islamic Republic of Iran notified WHO of 1 additional case of Middle East respiratory syndrome coronavirus (MERS-CoV) infection.

Details of the case are as follows:

A 61-year- old male from Kahnooj city developed symptoms on 18 March and was admitted to hospital in Kahnooj city on 26 March. The patient was transferred to another hospital in Kerman city on 28 March. He has no comorbidities. On 13 March, the patient had contact with two individuals with influenza-like illness (ILI) who returned from Umrah on 10 March. He has no history of contact with other known risk factors in the 14 days prior to onset of symptoms. The patient was discharged from hospital on 27 April.

Contact tracing of household and healthcare contacts is ongoing for this case. Also, investigation of the two ILI cases is ongoing. The two ILI cases have no history of exposure to any of the known risk factors while performing Umrah.

Globally, WHO has been notified of 1112 laboratory-confirmed cases of infection with MERS-CoV, including at least 422 related deaths.

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Second Indonesian Pilgrim Positive For MERS In Jeddah

Credit Wikipedia

 

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Despite assurances by local officials and headlines in the Arabic press calling the  MERS scare ‘overblown’, we really don’t know just how this emerging coronavirus story will play out.  It may remain primarily a localized problem, or if we are really lucky, recede back to whence it came. 

 

But there are no guarantees of either of those outcomes.

 

As a major hub of international travel, one that receives millions of religious pilgrims every year, the Arabian peninsula is perhaps better suited than most places to disseminate an emerging disease – even one that (for now) doesn’t appear to be easily transmissible.

 

Currently, there are media reports of suspected cases being tested in India, Pakistan, Egypt, and Indonesia – plus many other places I’m sure.   Two places keeping excellent track of these reports are FluTrackers and Crofsblog. 

 

So far, we are told that most of these suspected cases have tested negative – but given the surge in cases in Saudi Arabia and the UAE over the past month - the odds increasingly favor seeing more exported cases of MERS turn up around the world. 

 

Today the Jakarta Post is reporting that two Indonesians on Umrah in Saudi Arabia have contracted the virus, and one has died.  The survivor is isolated in King Fahd hospital in Jeddah.  The fact that they fell ill before returning home was more a matter of luck than of design.

 

Second Indonesian found with MERS in Saudi Arabia

The Jakarta Post, Jakarta | National | Sat, May 10 2014, 3:00 PM

An Indonesian citizen in Saudi Arabia has been diagnosed with  Middle East respiratory syndrome (MERS) Coronavirus.

According to a press release from the Indonesia Consulate General in Jeddah, Jumallang Kaneng Lejja, 84, had arrived in Saudi Arabia to go on umrah (minor haj pilgrimage) on April 15, and was scheduled to return to Indonesia on April 25, as reported by tribunnews.com.

Jumallang, from Makassar, South Sulawesi, was admitted into the King Fahd Specialist Hospital on April 28 complaining of chest pains.

On April 29, the Health Ministry reported that another Indonesian —  NA, 61 — had died of MERS after being treated for seven days at King Saud Hospital in Jeddah, Saud Arabia.

(Continue . . .)

 

 

While it appears that nosocomial transmission of this virus currently plays a bigger part in its spread than does community transmission – and that good infection control procedures can contain it – thus far, hospitals in the Middle East haven’t demonstrated a lot of success in doing so.

Should this virus be exported to a region of the world where infection control and public health capabilities are less capable – say in parts of Asia or Africa - this virus could find an even more hospitable environment in which to flourish.

 

Which is why the international public health community must remain vigilant for any sign that this virus has gained a foothold outside of the Middle East.

KSA Limits Hajj & Umrah Visas Over MERS-CoV

 

Credit Wikipedia

 

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Yesterday (see KSA MOH Updates Health Protection Advice For Umrah & Hajj) Saudi Arabia’s MOH recommended that certain vulnerable groups (e.g. elderly, chronically ill, immunocompromised, pregnant, and children) postpone their Umrah or Hajj plans this year due to the MERS-CoV threat.

 

Overnight Crof carried an even more assertive report from the Arab Media (see Saudi Arabia: To halt MERS, no Hajj visas for old and sick) which moved these visa exclusions beyond mere `recommendations’.

 

This is a bit of a turn-around from statements made last month by the Saudi Ministry, which blamed the limiting of visas on `construction issues’ at the Grand Mosque.

 

It is probably no coincidence that these proactive steps are coming just as international experts are meeting to discuss how to deal with this emerging virus (see WHO On The MERS-CoV Emergency Committee Meeting). A consensus statement is expected late next week.

 

While no travel restrictions are currently imposed or recommended, that was surely one of the options under discussion.

 

KSA may be hoping that these preemptive steps will negate the need to impose further restrictions. 

 

As Ramadan is already underway (and runs through August 7th), it is unclear whether these policy changes will impact Umrah visitors this summer.

 

Public health officials around the globe are on alert for the possibility of seeing travelers returning from Saudi Arabia with the virus (see MMWR: MERS-CoV Update & MERS: Singapore MOH Puts Quarantine Chalets On Standby)

 

This story, from the FARS news agency, is typical of the coverage this morning.

 

 

Saudi Arabia Warns Pilgrims over Coronavirus

TEHRAN (FNA)- Health officials in Saudi Arabia asked pilgrims visiting its holy sites to wear masks in crowded places to stop the spread of the MERS coronavirus.

 

A list of requirements issued by the health ministry also tells elderly people or those with chronic diseases to postpone their pilgrimage, BBC reported.

 

Thirty-eight people have died from the virus in Saudi Arabia.

 

Millions of Muslims from around the world are expected to take part in the Hajj this October.

 

Once a year, pilgrims make the journey to Mecca in Saudi Arabia and pray together before the Kaaba.

 

Muslims also travel to the site at other times, as well as visiting the Masjid Al-Nabawi, or Mosque of the Prophet (PBUH), in Medina.

 

Health officials urged people taking part to maintain personal hygiene standards, use a tissue when sneezing and coughing, and have the necessary vaccinations.

 

The MERS (Middle East respiratory-syndrome) coronavirus emerged in the Arabian peninsula in September 2012 and is part of a large family of viruses, which includes the common cold and Sars (severe acute respiratory syndrome).

 

The World Health Organization has so far confirmed of a total of 80 cases of infection, including 44 deaths worldwide.

 

Saudi Arabia introduced requirements for polio immunization certificates in 2003 after fears of a resurgence of the virus.

KSA MOH Updates Health Protection Advice For Umrah & Hajj

 

 

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Last month the Kingdom of Saudi Arabia announced an abrupt Limit to Umrah & Hajj Visitors this year, citing construction as the Grand Mosque as the primary reason behind a 20% cutback in Visas.

 

Many observers believed the recent surge in MERS-CoV cases were the real reason behind this decision - but until today - we’ve not seen any official acknowledgment of that from the MOH.  

 

Today the MOH published (in Arabic) updated requirements and advice for Hajj and Umrah visitors this year (h/t Ironorehopper on FluTrackers).

 

The most notable change is they are now publically citing MERS-CoV as the reason why the elderly, those with chronic illnesses, immune dysfunctions, as well as pregnant women and children ought not to make a pilgrimage this year.

 

Here is a machine translation of today’s statement (bolding mine).

 

Hajj and Umrah requirements for the year 1434 AH

September 04, 1434  (July 12th, 2013)

Ministry of Health issued health requirements that must be met in coming for Umrah and Hajj 1434 H as part of precautionary measures for disease virus Koruna new (MERS-COV) and so out of the keenness of the Government of the Custodian of the Two Holy Mosques in maintaining the health of everyone and provide an atmosphere healthy and safe, God willing, for the pilgrims and pilgrims to perform This all rites smoothly and health and contentment.

 

I have included these requirements issued by the ministry's recommendation to postpone the performance of Umrah and Hajj this year for the elderly and people with chronic diseases as patients heart, kidney, respiratory and diabetes, as well as patients with immune deficiency congenital and acquired, in addition to ill tumors, as well as pregnant women and children.

 

It also included requirements set of tips and guidance health awareness for citizens, residents and pilgrims of them; pollutants to wash your hands thoroughly with soap and water or disinfectant other allocated to it, especially after coughing and sneezing, as well as the use of tissue when coughing or sneezing and dispose of the waste basket, in addition to not touch eyes, nose and mouth by hand, and the reduction of direct contact with the injured and non-participation tools personal, as well as the wearing of masks in crowded locations, and maintaining personal hygiene as a whole.

 

These requirements also included on the next to get a valid certificate of vaccination against meningitis before the advent of the Kingdom of not less than 10 days and not more than 3 years, as well as get a certificate of vaccination against polio-affected countries, according to specific requirements.

 

Also included stipulations importance of vaccination against seasonal flu vaccine, especially for people with chronic diseases such as heart, kidney, diabetes and respiratory and neurology as well as diseases of HIV congenital and acquired, and metabolic diseases, as well as pregnant women and children less than 5 years and those with obesity.

 

 

The advice to wear a facemask is not exactly new, as ARIs (Acute Respiratory Infections) have been common health complaints during the Hajj and Umrah, and calls for wearing masks have been made often over the years.

 

Last year, in The Hajj: communicable and non-communicable health hazards and current guidance for pilgrims masks were recommended to reduce the spread of TB and other respiratory illnesses, and similar calls have been made in the past, including in 2009 during the H1N1 pandemic.

 

The wearing masks is mentioned repeatedly on the KSA MOH web page on Health Tips to Be Followed During Hajj.  A couple of examples include:

 

• Face-masks are recommended at crowded and congested places, especially during circumambulation of the Ka'ba (Tawaf), stoning (Rajm), and walking between Safa and Marwa (Sa'i). They should be changed regularly (every six hours), or when dirty, in accordance with the guidelines provided by the manufacturer, along with washing hands with water and soap when taking them off.
• 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.

 

Compliance with this advice is apparently difficult, as Islam teaches that women may not `cover their face’ while in Ihram (a sacred state which a Muslim must enter in order to perform the Hajj or Umrah).

During the 2009 Pandemic the Grand Mufti of Saudi Arabia permitted the use of masks while performing the Umrah, stating that it was not the same as `covering the face’, but stated `that it should not be used unless needed.’

 

In the November 2009 edition of the EID Journal, a report entitled Hajj Pilgrims’ Knowledge about Acute Respiratory Infections

 

Saudi health authorities recommend use of surgical face masks (5); however, data conflict about the protective effect of such masks during the pilgrimage (5,6). Use of face masks varies according to the origin of Hajj pilgrims; in 1 study, only 15% of pilgrims from the Middle East, 17% from Europe and the United States, and 45% from Southeast Asia used a mask (4). Promotion and distribution of free masks increased their use from 34% to 81% in another cohort of Saudi pilgrims (6).

 

National Health Service for England does not advise the use of masks, considering compliance with this advice unlikely because many Muslims believe that covering the face during the Hajj is prohibited and because masks need to be of high quality and changed at least every 6 hours to remain effective (7).

 

Recent studies demonstrated that surgical and N95 masks were equally effective in preventing spread of PCR-detectable influenza virus when used by infected patients. These masks also were potentially effective at preventing respiratory virus acquisition by household contacts of infected persons when worn by healthy persons. However, effectiveness depended largely on adherence to mask use (8,9).

 

And finally, I should point out that the World Health Organization has not (at this time) issued any advice for religious pilgrims to Saudi Arabia to wear masks (see WHO: MERS, Masks, And The Media).

Belgium: Virologist Warns On Hajj

Credit Wikipedia

 

 

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A bit of a media storm has erupted in Belgium this morning over advice given to Moslems from virologist and National Flu Commissioner, Dr. Marc Van Ranst, not to attend this year’s Umrah or  Hajj.

 

Last month, you may recall, Saudi Arabia abruptly announced limits to religious tourist visas (see KSA To Limit Umrah & Hajj Visitors), citing ongoing construction at the Holy Mosque as limiting the number of pilgrims they could accommodate.

 

 

Unstated, but widely assumed to be a factor, is the ongoing outbreak of MERS-CoV in the Kingdom, which has infected at least 64 people, killing 36 (see KSA Announces Two More MERS-CoV Deaths).

 

The Saudi Embassy has specifically asked that the following groups do not attend this year `for their own safety’: The elderly, the terminally ill, pregnant women, and children.

 

All able bodied Muslims are required to make at least one major pilgrimage to Mecca during their lifetime, at the time of the hajj. This is known as the fifth pillar of Islam, and is one of the duties incumbent upon all Muslims.

 

The faithful may also make `lesser pilgrimages’, called  omra (or Umrah), at other times of the year. These minor pilgrimages don’t absolve the faithful of making the hajj journey unless they take place during Ramadan.

 

As a result, the Kingdom of Saudi Arabia (KSA) receives more than 7 million visitors each year, with most of them arriving during the month of Ramadan (this year: July 8th-August 7th) and during the Hajj in October.

 

The waiting list for obtaining a visa can exceed a decade in some countries, making the decision to postpone a pilgrimage an extraordinarily difficult one.

 

Which probably explains some of the reaction today from the calls of Professor Marc Van Ranst of the Katholieke Universiteit Leuven to avoid traveling to Saudi Arabia this year due to the MERS-CoV threat.

 

 

Typical of the reporting overnight - from VTM Nieuws - this report:

 

 

Another report, this time from De Standaard, indicates that the Deputy Prime Minister, Didier Reynders (MR), isn’t convinced of the threat.

 

"First need advice for discouraging hajj '

Today at 09:47 by jvt | Source: Belga

For Foreign Affairs would advise against travel to Mecca is necessary to first clear information about the possible risk. As Foreign Minister Didier Reynders (MR) to the call of virologist Marc Van Ranst responding. Who fears that the annual hajj MERS the new virus will spread worldwide.

 

"It is not the job of Foreign Affairs to tell if there is a risk or not, without clear and comprehensive information", said the Deputy Prime Minister during Wednesday Morning.

 

Reynders was responding to the call of virologist Marc Van Ranst in the newspaper De Morgen to discourage to participate in the pilgrimage to Mecca. Part Belgian Muslims this year

(Continue  . . .)

 

 

Another voice in this debate is that of of Belgium’s League of Muslims spokesman, Farid El Machaoud, whose comments appeared today in KNACK.BE.

 

While not conceding that an epidemic currently exists - Machaoud agreed that if conditions should warrant it – travel to this year’s Hajj could be prohibited.

 

League of Muslims in Belgium: "In case of epidemic Mecca pilgrimage should be banned '

(EXCERPT)

Farid El Machaoud, spokesman for the League of Muslims in Belgium, said in The Morning on Radio 1 that the call of Van Ranst 'is quite normal. " "If there is indeed an epidemic, then travel to Mecca not only discouraged, but simply prohibited. '

 

El Machoud feels that a good explanation to the people's needs, "so there is no political game is made of." El Machaoud: "Islam is always authenticated, so many people are paranoid. Some may think that nothing is going on, but it is a way to prevent them Muslims go to Mecca. " He argues for a consultation with the board of theologians, "which obviously open to that message."

(Continue . . .)

 

 

While there is a general unease among many public health officials regarding this year’s Hajj and Umrah, quantifying the risks - when so little is known about the MERS coronavirus - has been impossible. 

 

Thus far, the World Health Organization has not issued any travel warnings to the Middle East regarding this virus, and the CDC’s travel advice is based on Watch - Level 1, Practice Usual Precautions.

 

The WHO’s Advice to travelers (Dated June 5th):

 

Advice to travellers:

(EXCERPT)

Although the source of the virus and the mechanism of transmission is unknown, it would be prudent to try to reduce the general risk of infection while travelling by:

• Avoiding close contact with people suffering from acute respiratory infections.
• Frequent hand-washing, especially after direct contact with ill people or their environment.
• Adhering to food safety and hygiene rules such as avoiding undercooked meats, raw fruits and vegetables unless they have been peeled, or unsafe water.
• Avoiding close contact with live farm or wild animals.

Travellers to the Middle East who develop symptoms either during travel or after their return are encouraged to seek medical attention and to share their history of travel. People with symptoms of acute respiratory infection should practice cough etiquette (maintain distance, cover coughs and sneezes with disposable tissues or clothing, and wash hands) and to delay travel until they are no longer symptomatic.

 

Based on the information available, WHO does not advise special screening at points of entry with regard to this event nor does it currently recommend the application of any travel or trade restrictions.

KSA To Limit Umrah & Hajj Visitors

Credit Wikipedia

 

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Without mentioning their recent MERS-CoV outbreaks (or increasing instability in the Middle East), Saudi Arabia has suddenly decided to limit the number of visitors to their holy sites this year during Umrah and the Hajj – citing ongoing construction at the Al-Masjid Al-Ḥarām (The `Grand Mosque’) in Mecca.

 

The multi-billion dollar expansion of this holy site began in 2007 and completion isn’t expected until 2020. Making a last-minute realization that they cannot handle their normal number of visitors a bit suspect.

 
Whatever the truth of the matter, this morning it is widely being reported that Saudi Arabia has asked foreigners to postpone their Hajj pilgrimage this year.

 

This from Xinhua News.

 

Saudi advises foreigners to postpone Hajj plans this year

(philstar.com) | Updated June 16, 2013 - 5:00pm

RIYADH (Xinhua) - Saudi Arabia has called upon foreign pilgrims to postpone their Hajj plans this year due to ongoing expansion work at Mekka's Grand Mosque, Arab News reported Sunday.

 

This was highlighted through a series of announcements through the Holy Qur'an television channel from Mekka, the government advised pilgrims intending to perform Haj and Umrah this year to postpone their plans to the Grand Mosque.

 

According to the newspaper, the unprecedented move aims at preventing congestion and stampedes as well as ensuring the safety of pilgrimages.

 

The call came after the government's decision to reduce the number of foreign pilgrims by 20 percent and domestic pilgrims by 50 percent this year. Grand Mufti Sheikh Abdul Aziz Al-Asheikh has backed the measure, saying that it was taken in public interest.

 

According to official figure, 3.161 million pilgrims preformed hajj last year; if counting illegal hajj performers, the number could be around 4 million.

 

 

All able bodied Muslims are required to make at least one major pilgrimage to Mecca during their lifetime, at the time of the hajj. This is known as the fifth pillar of Islam, and is one of the duties incumbent upon all Muslims.

 

The faithful may also make `lesser pilgrimages’, called  omra (or Umrah), at other times of the year. These minor pilgrimages don’t absolve the faithful of making the hajj journey unless they take place during Ramadan.

 

As a result, the Kingdom of Saudi Arabia (KSA) receives more than 7 million visitors each year, with most of them arriving during the month of Ramadan (this year: July 8th-August 7th) and during the Hajj in October.

 

With more than 1.5 billion Muslims around the world, the wait for a visa to partake in the Hajj or Umrah can literally take a decade or longer, and many devout save for much their lives in order to make this pilgrimage.

 

Which is why the surprise announcement earlier this week that Saudi Arabia would limit the number, and duration of Umrah visas this summer was met with considerable concern.

 

Saudi Arabia limits Umrah visa validity to 2 weeks

SIRAJ WAHAB

Jeddah, June 9: The Hajj Ministry has decided to limit the validity of Umrah visas to only 14 days because of the ongoing work to expand the mataf — the cicumambulation area.

(Continue . . . )

Two days later, from the Jakarta Globe, we get:

Saudi Arabia Slashes Indonesia Hajj Quota By 20%

By Jakarta Globe on 7:16 pm June 11, 2013.

Indonesian Muslims planning to make a pilgrimage to Mecca for Idul Adha will have to wait even longer after Saudi Arabia cuts the nation’s quota by 20 percent this year, adding to a backlog that is already 12 years long.

 

(Continue . . . )

 

Overnight, the story appears to have grown, as the Saudi Gazette is now reporting that the limit on visitors has been extended not only to this year’s Hajj, but potentially to all Umrah and Hajj visitors over the next 2 or 3 years.

 

Reduction in numbers of Haj and Umrah visitors

MAKKAH — The Grand Mufti, Sheikh Abdulaziz Al-Alshaikh, head of the grand scholars committee, has supported the decision to reduce the number of Hajis and Umrah visitors during the coming two or three years, Al-Sharq newspaper reported.

 

(Continue . . . )

 

 

Even without an emerging coronavirus, the logistics of providing free medical care for several million pilgrims during the Hajj is a daunting one. Last month, 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.

 

 

As to whether MERS-CoV has anything to do with this week’s unprecedented decision to sharply curtail visitors to the Kingdom? 

It seems likely that it is at least one of the factors, but your guess is as good as mine.

MERS-CoV: Singapore Issues Umrah Health Advisory

 

 

 

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The sudden uptick in MERS-CoV (aka nCoV) cases in Saudi Arabia over the past month has led to cautions being issued today to Muslims in Singapore planning to visit the Middle East this summer.

 

All able bodied Muslims are required to make at least one major pilgrimage to Mecca during their lifetime, at the time of the hajj. This is known as the fifth pillar of Islam, and is one of the duties incumbent upon all Muslims.

 

The faithful may also make `lesser pilgrimages’, called  omra (or sometimes Umrah), at other times of the year.  These minor pilgrimages don’t absolve the faithful of making the hajj journey.

 

The hajj is roughly five months away (it occurs mid-October this year), but millions of Muslims take these lesser pilgrimages over the summer months.  

 

This from News Channel Asia.

 

MUIS, MOH issue health advisory on coronavirus to pilgrims

The Islamic Religious Council of Singapore (MUIS), working with the Health Ministry, has issued a health advisory on the novel coronavirus, now known as the Middle East Respiratory Syndrome Coronavirus (MERS-CoV).

(Continue . . . )

 

 

The advisory strongly advises Muslims with plans to visit the Kingdom of Saudi Arabia this summer to:

 

• Get vaccinated against influenza and meningitis
• If over 65, or suffering from chronic illness, to get the pneumococcal pneumonia vaccine
• Observe good personal hygiene and hand washing
• Observe good flu etiquette (cover coughs, sneezes, dispose of tissues properly)
• If unwell with fever or respiratory symptoms while traveling, or within 10 days of returning from the Middle East to don a mask and seek medical treatment promptly.
• Inform your doctor of any recent travel history to the Middle East. 

 

The long incubation period (believed to be approx. 10 days) - along with few clues as to the kinds of exposures that increase the risk of infection - have many countries with strong travel ties to Saudi Arabia on heightened alert.

 

Yesterday, in their updated rapid risk assessment, the ECDC had this to say:

 

ECDC supports the WHO travel advice which imposes no travel or trade restrictions in relation to novel coronaviruses. However, EU citizens travelling to the Arabian Peninsula and neighbouring countries need to be aware of the presence of MERS-CoV in this geographical area and of the small risk of infection. Member States may consider active information efforts for travellers to areas most at risk. 

 

 

While the absolute risk of contracting MERS is considered very low - with tens of thousands of pilgrims traveling to and returning from the Kingdom of Saudi Arabia each week - no one would be terribly surprised if sporadic MERS cases started turning up outside of the Middle East.