Hajj-associated viral respiratory infections: A systematic review

Screening for Middle East respiratory syndrome coronavirus among febrile Indonesian Hajj pilgrims: A study on 28,197 returning pilgrims

There were 211,000 Indonesian Hajj pilgrims going to Mecca through 11 main airports in 2015 who were at risk of contracting the Middle East respiratory syndrome coronavirus (MERS-CoV). We aimed to find out whether there was any occurrence of MERS-CoV by performing screening on 28,197 returning pilgrims. Those with a body temperature of > 38 °C and respiratory symptoms were sent to the airport clinic to have an oropharyngeal swab and a bacterial culture. Fifteen pilgrims had fever (> 38 °C) accompanied by respiratory symptoms; of these, 12 patients were diagnosed with upper and lower respiratory tract infections and three patients with pneumonia. However, none of them were found to be infected with MERS-CoV. The bacterial cultures showed evidence of normal flora growth.

A systematic review of emerging respiratory viruses at the Hajj and possible coinfection with Streptococcus pneumoniae

Background

The annual Hajj to the Kingdom of Saudi Arabia attracts millions of pilgrims from around the world. International health community's attention goes towards this mass gathering and the possibility of the development of any respiratory tract infections due to the high risk of acquisition of respiratory viruses.

Method

We searched MEDLINE/PubMed and Scopus databases for relevant papers describing the prevalence of respiratory viruses among Hajj pilgrims.

Results

The retrieved articles were summarized based on the methodology of testing for these viruses. A total of 31 studies were included in the quantitative/qualitative analyses. The main methods used for the diagnosis of most common respiratory viruses were polymerase chain reaction (PCR), culture and enzyme-linked immunosorbent assay (ELISA). Influenza, rhinovirus and parainfluenza were the most common viruses detected among pilgrims. Coronaviruses other than MERS-CoV were also detected among pilgrims. The acquisition of MERS-CoV remains very limited and systematic screening of pilgrims showed no infections.

Conclusions

Well conducted multinational follow-up studies using the same methodology of testing are necessary for accurate surveillance of respiratory viral infections among Hajj pilgrims. Post-Hajj cohort studies would further evaluate the impact of the Hajj on the acquisition of respiratory viruses.

Approximate Bayesian algorithm to estimate the basic reproduction number in an influenza pandemic using arrival times of imported cases

BACKGROUND

In an influenza pandemic, arrival times of cases are a proxy of the epidemic size and disease transmissibility. Because of intense surveillance of travelers from infected countries, detection is more rapid and complete than on local surveillance. Travel information can provide a more reliable estimation of transmission parameters.

METHOD

We developed an Approximate Bayesian Computation algorithm to estimate the basic reproduction number (R₀) in addition to the reporting rate and unobserved epidemic start time, utilizing travel, and routine surveillance data in an influenza pandemic. A simulation was conducted to assess the sampling uncertainty. The estimation approach was further applied to the 2009 influenza A/H1N1 pandemic in Mexico as a case study.

RESULTS

In the simulations, we showed that the estimation approach was valid and reliable in different simulation settings. We also found estimates of R₀ and the reporting rate to be 1.37 (95% Credible Interval [CI]: 1.26-1.42) and 4.9% (95% CI: 0.1%-18%), respectively, in the 2009 influenza pandemic in Mexico, which were robust to variations in the fixed parameters. The estimated R₀ was consistent with that in the literature.

CONCLUSIONS

This method is useful for officials to obtain reliable estimates of disease transmissibility for strategic planning. We suggest that improvements to the flow of reporting for confirmed cases among patients arriving at different countries are required.

Influenza vaccination among Saudi Hajj pilgrims: Revealing the uptake and vaccination barriers

Background

Hajj is the world’s largest annual mass gathering that attracts two to three million Muslims from around the globe to a religious assemblage in Makkah, Saudi Arabia. The risk of acquisition and transmission of influenza among Hajj pilgrims is high. Therefore, influenza vaccination is recommended, and was monitored frequently among pilgrims from different countries. However, the vaccination uptake among Saudi pilgrims has not been assessed in recent years.

Objective

This analysis aims to evaluate influenza vaccine uptake among Saudi Hajj pilgrims, and identify the key barriers to vaccination.

Method

Data on influenza vaccination were obtained from Saudi pilgrims who took part in a large trial during the Hajj of 2013, 2014 and 2015. Pilgrims were met and recruited in Mina, Makkah during the peak period of Hajj and were asked to complete a baseline questionnaire that recorded their influenza vaccination history, including reason(s) for non-receipt of vaccine.

Results

A total of 6974 Saudi pilgrims aged between 18 and 95 (median 34) years were recruited; male to female ratio was 1:1.2. Of the total, 90.8% declared their influenza vaccination history, 51.3% of them reported receiving influenza vaccine before travel to Hajj. The vaccination rates for the years 2013, 2014 and 2015 were 21.4%, 48.2% and 58.1%, respectively (P < 0.001). Of 1,269 pilgrims who were at higher risk of severe disease, 54.5% received the vaccine. Lack of awareness (47.5%), reliance on natural immunity (15.8%) and being busy (15.5%) were the main reasons for non-receipt.

Conclusion

These data from a convenience sample indicate that influenza vaccine uptake among Saudi Hajj pilgrims is increasing over years but still needs further improvement. Lack of awareness and misperceptions are the main barriers. Education of Saudi pilgrims and health professionals is required to raise awareness about influenza vaccination. Further studies are needed to understand pilgrims’ misperceptions.

Influenza virus but not MERS coronavirus circulation in Iran, 2013-2016: Comparison between pilgrims and general population

BACKGROUND

The pilgrimage to Mecca and Karbala bring many Muslims to a confined area. Respiratory tract infections are the most common diseases transmitted during mass gatherings in Hajj, Umrah and Karbala. The aim of this study was to determine and compare the prevalence of Middle East respiratory syndrome coronavirus (MERS-CoV) and influenza virus infections among Iranian general population and pilgrims with severe acute respiratory infections (SARI) returning from Mecca and Karbala during 2013-2016.

METHODS

During 2013-2016, a total of 42351 throat swabs were examined for presence of influenza viruses and MERS-CoV in Iranian general population and pilgrims returning from Mecca and Karbala with SARI by using one step RT-PCR kit.

RESULTS

None of the patients had MERS-CoV but influenza viruses were detected in 12.7% with high circulation of influenza A/H1N1 (47.1%).

CONCLUSION

This study showed the prevalence of influenza infections among Iranian pilgrims and general population and suggests continuing surveillance, infection control and appropriate vaccination especially nowadays that the risk of influenza pandemic threatens the world, meanwhile accurate screening for MERS-CoV is also recommended.

No MERS-CoV but positive influenza viruses in returning Hajj pilgrims, China, 2013-2015

Background

There is global health concern that the mass movement of pilgrims to and from Mecca annually could contribute to the international spread of Middle East Respiratory Syndrome Coronavirus (MERS-CoV). In China, about 11,000 Muslim pilgrims participate in the Hajj gathering in Mecca annually. This is the first report of MERS-CoV and respiratory virus molecular screening of returning pilgrims at points of entry in China from 2013 to 2015.

Methods and results

A total of 847 returning Hajj pilgrims participated in this study. The test results indicated that of the travelers, 34 tested positive for influenza A virus, 14 for influenza B virus, 4 for metapneumo virus, 2 for respiratory syncytial virus, and 3 for human coronavirus. There was a significant difference in the rates of positive and negative influenza virus tests between Hajj pilgrims with symptoms and those without. The detection rates of influenza virus were not significantly different among the three years studied, at 5.3, 6.0 and 6.3% for 2013, 2014 and 2015, respectively.

Discussion and conclusion

The MERS-CoV and respiratory viruses detection results at points of entry in China from 2013 to 2015 indicated that there were no MERS-CoV infection but a 5.7% positive influenza viruses in returning Chinese pilgrims.

Influenza is more common than Middle East Respiratory Syndrome Coronavirus (MERS-CoV) among hospitalized adult Saudi patients

BACKGROUND

Since the initial description of Middle East Respiratory Syndrome Coronavirus (MERS-CoV), we adopted a systematic process of screening patients admitted with community acquired pneumonia. Here, we report the result of the surveillance activity in a general hospital in Saudi Arabia over a four year period.

MATERIALS AND METHODS

All admitted patients with community acquired pneumonia from 2012 to 2016 were tested for MERS-CoV. In addition, testing for influenza viruses was carried out starting April 2015.

RESULTS

During the study period, a total of 2657 patients were screened for MERS-CoV and only 20 (0.74%) tested positive. From January 2015 to December 2016, a total of 1644 patients were tested for both MERS-CoV and influenza. None of the patients tested positive for MERS-CoV and 271 (16.4%) were positive for influenza. The detected influenza viruses were Influenza A (107, 6.5%), pandemic 2009 H1N1 (n = 120, 7.3%), and Influenza B (n = 44, 2.7%). Pandemic H1N1 was the most common influenza in 2015 with a peak in peaked October to December and influenza A other than H1N1 was more common in 2016 with a peak in August and then October to December.

CONCLUSIONS

MERS-CoV was a rare cause of community acquired pneumonia and other viral causes including influenza were much more common. Thus, admitted patients are potentially manageable with Oseltamivir or Zanamivir therapy.

Communicable and non-communicable disease risks at the Grand Magal of Touba: The largest mass gathering in Senegal

BACKGROUND

An estimated 4-5 million individuals gather each year in the holy city of Touba, Senegal during the Grand Magal religious pilgrimage. Pilgrims come from across Senegal and the surrounding countries, as well as from countries outside Africa. It is the largest mass gathering (MG) of the Mouride community and the largest Muslim religious MG in West Africa.

METHOD

A cross-sectional study was conducted on all patients who attended a public healthcare structure during the November 2015 Grand Magal.

RESULT

Data were collected on a total of 32,229 healthcare contacts. The most frequent reasons for consultation were trauma, followed by fatigue and heatstroke. Infectious diseases were also prevalent with, notably, a high rate of febrile systemic illnesses and malaria, diarrheal diseases, and respiratory tract infections. Such results are likely to be linked to overcrowding and climatic conditions, the relative lack of sanitary facilities, and limited medical resources available during the event.

CONCLUSION

The context of the Grand Magal MG is unique, given its location in a tropical developing country and its international component which may favor the globalization of locally endemic diseases. As such, it warrants investment in modern methods for public health surveillance and planning of the event.

WITHDRAWN: Impact of the Hajj on pneumococcal carriage and the effect of various pneumococcal vaccines

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Acute respiratory infections among returning Hajj pilgrims-Jordan, 2014

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Surveillance for respiratory illness in Hajj pilgrims took place in Jordan in 2014.

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58% of the 125 subjects returning from Hajj tested positive for at least one virus.

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Rhino/enterovirus was the most commonly detected viral pathogen (47% of subjects).

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No cases of Middle East Respiratory Syndrome coronavirus were detected.

Background

The emergence of Middle East Respiratory Syndrome coronavirus (MERS-CoV) has prompted enhanced surveillance for respiratory infections among pilgrims returning from the Hajj, one of the largest annual mass gatherings in the world.

Objectives

To describe the epidemiology and etiologies of respiratory illnesses among pilgrims returning to Jordan after the 2014 Hajj.

Study design

Surveillance for respiratory illness among pilgrims returning to Jordan after the 2014 Hajj was conducted at sentinel health care facilities using epidemiologic surveys and molecular diagnostic testing of upper respiratory specimens for multiple respiratory pathogens, including MERS-CoV.

Results

Among the 125 subjects, 58% tested positive for at least one virus; 47% tested positive for rhino/enterovirus. No cases of MERS-CoV were detected.

Conclusions

The majority of pilgrims returning to Jordan from the 2014 Hajj with respiratory illness were determined to have a viral etiology, but none were due to MERS-CoV. A greater understanding of the epidemiology of acute respiratory infections among returning travelers to other countries after Hajj should help optimize surveillance systems and inform public health response practices.

Travellers and influenza: risks and prevention

BACKGROUND

Influenza viruses are among the major causes of serious human respiratory tract infection worldwide. In line with the high disease burden attributable to influenza, these viruses play an important, but often neglected, role in travel medicine. Guidelines and recommendations regarding prevention and management of influenza in travellers are scarce. Of special interest for travel medicine are risk populations and also circumstances that facilitate influenza virus transmission and spread, like travel by airplane or cruise ship and mass gatherings.

METHODS

We conducted a PUBMED/MEDLINE search for a combination of the MeSH terms Influenza virus, travel, mass gathering, large scale events and cruise ship. In addition we gathered guidelines and recommendations from selected countries and regarding influenza prevention and management in travellers. By reviewing these search results in the light of published knowledge in the fields of influenza prevention and management, we present best practice advice for the prevention and management of influenza in travel medicine.

RESULTS

Seasonal influenza is among the most prevalent infectious diseases in travellers. Known host-associated risk factors include extremes of age and being immune-compromised, while the most relevant environmental factors are associated with holiday cruises and mass gatherings.

CONCLUSIONS

Pre-travel advice should address influenza and its prevention for travellers, whenever appropriate on the basis of the epidemiological situation concerned. Preventative measures should be strongly recommended for travellers at high-risk for developing complications. In addition, seasonal influenza vaccination should be considered for any traveller wishing to reduce the risk of incapacitation, particularly cruise ship crew and passengers, as well as those participating in mass gatherings. Besides advice concerning preventive measures and vaccination, advice on the use of antivirals may be considered for some travellers.

Cross-sectional survey and surveillance for influenza viruses and MERS-CoV among Egyptian pilgrims returning from Hajj during 2012-2015

BACKGROUND

Approximately 80 000 Egyptians participate in Hajj pilgrimage annually. The purpose of this study was to estimate influenza virus and MERS-CoV prevalence among Egyptian pilgrims returning from Hajj.

STUDY

A cross-sectional survey among 3 364 returning Egyptian pilgrims from 2012 to 2015 was conducted. Nasopharyngeal (NP) and oropharyngeal (OP) swabs were collected from all participants. Sputum specimens were collected from participants with respiratory symptoms and productive cough at the time of their interview. Specimens were tested for influenza viruses, and a convenience sample of NP/OP specimens was tested for MERS-CoV. Thirty percent of participants met the case definition for influenza-like illness (ILI), 14% tested positive for influenza viruses, and none tested positive for MERS-CoV. Self-reported influenza vaccination was 20%.

CONCLUSIONS

High prevalence of reported ILI during pilgrimage and confirmed influenza virus on return from pilgrimage suggest a continued need for influenza prevention strategies for Egyptian Hajj pilgrims. An evaluation of the Ministry of Health and Population's current risk communication campaigns to increase influenza vaccine use among pilgrims may help identify strategies to improve vaccine coverage.

The Role of Clinical Virology Laboratory and the Clinical Virology Laboratorian in Ensuring Effective Surveillance for Influenza and Other Respiratory Viruses: Points to Consider and Pitfalls to Avoid

Influenza and respiratory viruses have a global impact on public health. Clinical virology laboratories and laboratorians play an important role in not only the diagnosis but also the surveillance of these pathogens. Surveillance for influenza and other respiratory pathogens is important, as it informs public health decision making in terms of influenza vaccine and antiviral effectiveness, informs clinicians and public health practitioners about the pathogenicity of specific viral strains, guides clinical practice, and supports laboratory panning activities. Key background issues include the following: the fact that the laboratory is only one of several data providers to a surveillance system, the biologic nature of influenza and respiratory viruses and the laboratory needs to keep up to date on the diagnosis of these agents, the need for laboratorians to be involved in case definition development, the impact of push and pull data flow models on laboratory resources, and the fact that laboratories may be asked to provide more than just test results to surveillance programs. This review also identifies some key issues or questions that arise during the pre-analytic, analytic, and post-analytic phases that could impact on the ability of the laboratory to link to surveillance programs. Finally, issues surrounding virus characterization programs and how they link to surveillance programs are identified and discussed.