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SASTM Newsflash - World - travel advise on MERS-CoV for pilgrimages


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World - travel advice on MERS-CoV for pilgrimages


World Health Organization interim travel advice on MERS-CoV for pilgrimages to the Kingdom of Saudi Arabia


25 Jul 2013


I. Introduction


An outbreak of the Middle East respiratory syndrome coronavirus (MERS-CoV), 1st reported in 2012, has affected 9 countries to date. WHO is coordinating the global response to this emerging virus according to the International Health Regulations (IHR 2005). This paper provides guidance to national authorities of countries from which pilgrims will be travelling in the coming months for Umra and Hajj for the prevention, detection and management of imported cases of MERS-CoV. At this time, the risk to an individual pilgrim of contracting MERS-CoV is considered very low.


II. Effective communication of risk information


It is important for countries to use all practical and effective means possible to communicate information on a range of issues before, during, and after Umra and Hajj to all key groups, including the



- travellers to Umra and Hajj, particularly vulnerable groups within this population;

- public health officials;

- health care staff responsible for the care of ill pilgrims;

- public transportation and tourism industries; and

- the general public.


2.1. Actions to take before Umra or Hajj


Countries should advise pilgrims that pre-existing major medical conditions (for example, chronic diseases such as diabetes, chronic lung disease, immunodeficiency) can increase the likelihood of illness, including MERS-CoV infection, during travel; thus, pilgrims should consult a health care provider before travelling to review the risk and assess whether making the pilgrimage is advisable.


Countries should make information known to departing pilgrims and travel organizations on general travel health precautions, (1) which will lower the risk of infection in general, including illnesses such as influenza and traveller's diarrhoea. Specific emphasis should be placed on:


- washing hands often with soap and water. When hands are not visibly dirty, a hand rub can be used;

- adhering to good food-safety practices, such as avoiding undercooked meat or food prepared under unsanitary conditions, and properly washing fruits and vegetables before eating them;

- maintaining good personal hygiene;

- avoiding unnecessary contact with farm, domestic, and wild animals.


Health advice should be made available to all departing travellers to Umra or Hajj by working with the travel and tourism sectors and placing such materials at strategic locations (for example, travel agent offices or points of departure in airports).


Different kinds of communication, such as health alerts onboard planes and ships, and banners, pamphlets and radio announcements at international points of entry, can also be used to reach travellers.


Travel advice should include current information on MERS-CoV and guidance on how to avoid illness while travelling.


Current WHO guidelines, or their national equivalents, on surveillance, (2) infection prevention and control measures (3) and clinical management (4) of MERS-CoV should be distributed to health care practitioners and health care facilities.


Countries should ensure that there are adequate laboratory services for testing for MERS-CoV and that information on laboratory services and clinical referral mechanisms is known to health care providers and facilities.


Medical staff accompanying pilgrims should be up to date on MERS-CoV information and guidance, including how to recognize early signs and symptoms of infection, who is considered to be in a high-risk group, and what to do when a suspected case is identified, as well as on simple health measures to reduce transmission.


2.2. Actions to take during Umra or Hajj


Travellers who develop a significant acute respiratory illness with fever and cough (severe enough to interfere with usual daily activities) should be advised to:

- minimize their contact with others to keep from infecting them;

- cover their mouth and nose with a tissue when coughing or sneezing and discard the tissue in the trash after use, and wash hands afterwards, or, if this is not possible, to cough or sneeze into upper sleeves of their clothing, but not their hands;

- report to the medical staff accompanying the group or to the local health services.


2.3. Actions to take after Umra or Hajj


Returning pilgrims should be advised that if they develop a significant acute respiratory illness with fever and cough (severe enough to interfere with usual daily activities) during the 2 weeks after their return, they should seek medical attention and immediately notify their local health authority.


Persons who have had close contact with a pilgrim or traveller with a significant acute respiratory illness with fever and cough (severe enough to interfere with usual daily activities) and who themselves develop such an illness should be advised to report to local health authorities to be monitored for MERS-CoV.


Practitioners and facilities should be alerted to the possibility of MERS-CoV infection in returning pilgrims with acute respiratory illness, especially those with fever and cough and pulmonary parenchymal disease (for example, pneumonia or the acute respiratory distress syndrome). If clinical presentation suggests the diagnosis of MERS-CoV, laboratory testing, (5, 6) in accordance with WHO's case definition (7) should be done and infection prevention and control measures implemented. Clinicians should also be alerted to the possibility of atypical presentations in patients who are immunocompromised.


III. Measures at borders and for conveyances


WHO does not recommend the application of any travel or trade restrictions or entry screening.


WHO encourages countries to raise awareness of this travel advice to reduce the risk of MERS-CoV infection among pilgrims and those associated with their travel, including transport operators and ground staff, and about self-reporting of illness by travellers.


As required by the IHR, countries should ensure that routine measures are in place for assessing ill travellers detected on board conveyances (such as planes and ships) and at points of entry, as well as measures for safe transportation of symptomatic travellers to hospitals or designated facilities for clinical assessment and treatment.


If a sick traveller is on board a plane, a passenger locator form (8) can be used. This form is useful for collecting contact information for passengers, which can be used for follow-up if necessary.


Communicated by: ProMED-mail


Given the as yet unknown reservoir of the MERS-CoV, the continued appearance of new cases in Saudi Arabia and the observed increased severity of infection in individuals with pre-existing diseases, the above WHO travel recommendations seem highly appropriate and are mirroring those recommendations given by the Saudi government with respect to pilgrims for this year's (2013) Umra and Hajj.


There is evidence of continued transmission of the MERS-CoV in the Middle East, although during the period of April 2012 (when the 1st outbreak in an ICU in Jordan occurred) up through the present (as of 26 Jul 2013), there have been a total of 91 laboratory confirmed cases and 46 deaths (a case fatality rate of 50.5 per cent), suggesting that transmission, while occurring, is occurring at a relatively low rate.

There have been a number of infections with either mild or no clinical illness associated with the infections in otherwise healthy individuals. There are still more questions than answers with respect to the epidemiology and transmission of this virus and of the actual infection rate in the population. It is possible that there are many more subclinical infections than have been identified as yet.


In a publication released today (26 Jul 2013), Assiri A et al, presented data on 47 cases of MERS-CoV in Saudi Arabia. In the abstract of their paper, they mention:



"47 individuals (46 adults, one child) with laboratory-confirmed MERS-CoV disease were identified; 36 (77 per cent) were male (male:female ratio 3.3:1). 28 patients died, a 60 per cent case-fatality rate. The case fatality rate rose with increasing age.

Only 2 of the 47 cases were previously healthy; most patients (45 [96 per cent]) had underlying comorbid medical disorders, including diabetes (32 [68 per cent]), hypertension (16 [34 per cent]), chronic cardiac disease (13 [28 per cent]), and chronic renal disease (23 [49 per cent]). Common symptoms at presentation were fever (46 [98 per cent]), fever with chills or rigors (41 [87 per cent]), cough (39 [83 per cent]), shortness of breath (34 [72 per cent]), and myalgia (15 [32 per cent]). Gastrointestinal symptoms were also frequent, including diarrhoea (12 [26 per cent]), vomiting (10 [21 per cent]), and abdominal pain (8 [17 per cent]). All patients had abnormal findings on chest radiography, ranging from subtle to extensive unilateral and bilateral abnormalities. Laboratory analyses showed raised concentrations of lactate dehydrogenase (23 [49 per cent]) and aspartate aminotransferase (7 [15 per cent]) and thrombocytopenia (17 [36 per cent]) and lymphopenia (16 [34 per cent]).



"Disease caused by MERS-CoV presents with a wide range of clinical manifestations and is associated with substantial mortality in admitted patients who have medical comorbidities. Major gaps in our knowledge of the epidemiology, community prevalence, and clinical spectrum of infection and disease need urgent definition."





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The content and opinions are neither pre-screened nor endorsed by the SASTM. The content should neither be interpreted nor quoted as inherently accurate or authoritative.

The information provided in SASTM Newsflashes is collected from various news sources, health agencies and government agencies. Although the information is believed to be accurate, any express or implied warranty as to its suitability for any purpose is categorically disclaimed. In particular, this information should not be construed to serve as medical advice for any individual. The health information provided is general in nature, and may not be appropriate for all persons. Medical advice may vary because of individual differences in such factors as health risks, current medical conditions and treatment, allergies, pregnancy and breast feeding, etc. In addition, global health risks are constantly evolving and changing. International travelers should consult a qualified physician for medical advice prior to departure.

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