Preventive measures against MERS-CoV for Hajj pilgrims
Authors: Philippe Gautret, Samir Benkouiten, Imane Salaheddine, Philippe Parola, Philippe Brouqui
Journal: The Lancet Infectious Diseases (2013)

Assiri and colleagues1Assiri A Al-Tawfiq JA Al-Rabeeah AA et al.Epidemiological, demographic, and clinical characteristics of 47 cases of Middle East respiratory syndrome coronavirus disease from Saudi Arabia: a descriptive study.Lancet Infect Dis. 2013; 13: 752-761Summary Full Text Full Text PDF PubMed Scopus (1112) Google Scholar provide a clinical synopsis of 47 cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection identified between September, 2012, and June, 2013, in Saudi Arabia. Of note is the high rate of underlying comorbidity in patients with MERS (table). Since the first cases were reported in April, 2012, from Jordan, most cases have been reported from Saudi Arabia where the Hajj, the largest religious mass gathering, takes place annually. Given the predicted population movements out of Saudi Arabia, potential for worldwide spread of MERS-CoV exists according to Kahn and colleagues.2Khan K Sears J Hu VW et al.Potential for the international spread of Middle East respiratory syndrome in association with mass gatherings in Saudi Arabia.PLoS Curr. 2013; (published online July 17.)https://doi.org/10.1371/currents.outbreaks.a7b70897ac2fa4f79b59f90d24c860b8Crossref Scopus (58) Google Scholar By contrast, Breban and colleagues3Breban R Riou J Fontanet A Interhuman transmissibility of Middle East respiratory syndrome coronavirus: estimation of pandemic risk.Lancet. 2013; 382: 694-699Summary Full Text Full Text PDF PubMed Scopus (298) Google Scholar calculated that the risk of MERS-CoV to have pandemic potential does not exceed 5%, but they did not take into account the effect of Hajj mass gathering in their scenario.TableAge and comorbidities in patients with Middle East respiratory syndrome coronavirus and in French Hajj pilgrimsPatients with MERS (n=47)French pilgrims participating to the Hajj 2012 (n=167)French pilgrims in preparation for the Hajj 2013 (n=114)Mean (range) age (years)56 (14–94); 43% >60; 0% <1259 (21–83); 39% >65; 0% <1255 (10–83); 30% >65, 2% <12Any comorbidity45 (96%)96 (58%)33 (29%)Diabetes32 (68%)46 (28%)21 (18%)Chronic kidney disease*23 patients were part of an outbreak centered around a haemodialysis unit.23 (40%)0 (0%)1 (1%)Chronic heart disease13 (28%)12 (7%)6 (5%)Chronic lung disease12 (26%)13 (8%)7 (6%)Malignant disease1 (2%)0 (0%)0 (0%)Immune deficiency3 (6%)†Steroid use.0 (0%)0 (0%)PregnancyNot documented0 (0%)0 (0%)Disorder for which the MoH recommends postponing Hajj..99 (59%)55 (48%)MoH=Saudi Ministry of Health.* 23 patients were part of an outbreak centered around a haemodialysis unit.† Steroid use. Open table in a new tab MoH=Saudi Ministry of Health. The Saudi Ministry of Health (MoH) recommends that elderly people (older than 65 years), people with chronic diseases (eg, heart disease, kidney disease, respiratory disease, and diabetes), and pilgrims with immune deficiency (congenital and acquired), malignant disease, and terminal illnesses, as well as pregnant women and children (younger than 12 years), postpone the performance of the Hajj and Umrah for their own safety. The US CDC also encourages pilgrims travelling to Saudi Arabia for Hajj or Umrah to consider this advice. By contrast, WHO and the European CDC do not recommend the application of any travel restriction in relation with MERS-CoV. During the Hajj, 2012, we did a cohort survey of 167 French pilgrims with the purpose of investigating nasal virus carriage acquisition.4Gautret P Charrel R Belhouchat K et al.Lack of nasal carriage of novel corona virus (HCoV-EMC) in French Hajj pilgrims returning from the Hajj 2012, despite a high rate of respiratory symptoms.Clin Microbiol Infect. 2013; 19: e315-e317Summary Full Text Full Text PDF PubMed Scopus (77) Google Scholar, 5Benkouiten S Charrel R Belhouchat K et al.Circulation of respiratory viruses among pilgrims during the 2012 Hajj pilgrimage.Clin Infect Dis. 2013; (published online Jul 19.)https://doi.org/10.1093/cid/cit446Crossref PubMed Scopus (99) Google Scholar In our cohort, 59% had at least one disorder for which the Saudi MoH recommends potential participant postpone doing the Hajj this year. No case of MERS-CoV nasal carriage was identified in our cohort, despite high rates of respiratory symptoms.4Gautret P Charrel R Belhouchat K et al.Lack of nasal carriage of novel corona virus (HCoV-EMC) in French Hajj pilgrims returning from the Hajj 2012, despite a high rate of respiratory symptoms.Clin Microbiol Infect. 2013; 19: e315-e317Summary Full Text Full Text PDF PubMed Scopus (77) Google Scholar However, we reported rapid acquisition of other respiratory viruses in pilgrims during their stay in Saudi Arabia—most notably, rhinovirus—emphasising the potential of these infections to spread in the pilgrims' home countries on their return.5Benkouiten S Charrel R Belhouchat K et al.Circulation of respiratory viruses among pilgrims during the 2012 Hajj pilgrimage.Clin Infect Dis. 2013; (published online Jul 19.)https://doi.org/10.1093/cid/cit446Crossref PubMed Scopus (99) Google Scholar The 2013 mandatory meningococcal vaccination campaign for Hajj was started on Aug 19, at our institution. Early results of the first week show that pilgrims preparing for Hajj this year were younger and less likely to present with comorbidity than in 2012; however, 48% had at least one disorder for which the Saudi MoH recommends to postpone the performance of the Hajj. Although our results cannot be extrapolated to all Hajj pilgrims, they clearly show that a substantial proportion of European pilgrims departing from southern France are unlikely to heed the recommendations set out by the Saudi MoH. Public health agencies are unanimous in recommending that pilgrims apply personal protective measures against respiratory infection (wearing of face masks, cough etiquette, hand hygiene, use of disposable tissues, and avoiding contact with sick people). Such measures have already been highly accepted by pilgrims.6Gautret P Soula G Parola P Brouqui P Hajj pilgrims' knowledge about acute respiratory infections.Emerg Infect Dis. 2009; 15: 1861-1862Crossref PubMed Scopus (31) Google Scholar The presence of MERS-CoV neutralising antibodies in dromedary camels in Oman and the Canary Islands might provide a clue as to a potential source for human infection, although the presence of MERS-CoV in camels has not been established.7Reusken CB Haagmans BL Müller MA et al.Middle East respiratory syndrome coronavirus neutralising serum antibodies in dromedary camels: a comparative serological study.Lancet Infect Dis. 2013; 13: 859-866Summary Full Text Full Text PDF PubMed Scopus (572) Google Scholar We recently investigated the willingness of French pilgrims to consume raw camel milk if offered during their stay in Saudi Arabia; 41% said that they would drink it if offered.8Gautret P Benkouiten S Gaillard C Parola P Brouqui P Camel milk-associated infection risk perception and knowledge in French Hajj pilgrims.Vector Borne Zoonotic Dis. 2013; 13: 425-427Crossref PubMed Scopus (19) Google Scholar Given that camel milk consumption in the Middle East is associated with several zoonotic infections, we recommend that Hajj pilgrims be cautioned against consuming unpasteurised dairy products. Following recent isolation of MERS-CoV from the faeces of a bat in Saudi Arabia, we recommend people avoid contact with both farm and wild animals.9Memish ZA Mishra N Olival KJ et al.Middle East respiratory syndrome coronavirus in bats, Saudi Arabia.Emerg Infect Dis. 2013; (published online Nov.)https://doi.org/10.3201/eid1911.131172Crossref PubMed Scopus (524) Google Scholar We declare that we have no conflicts of interest.