Respiratory viruses and bacteria among pilgrims during the 2013 Hajj

Respiratory viral infections during Hajj seasons

Respiratory viral infections pose a public health concern during mass gathering (MG) events. Sustainable and continuous surveillance of respiratory viruses remains a priority to early identify and prevent potential outbreaks. This article reviews recent literature addressed the prevalence and diversity of circulating respiratory viruses during Hajj pilgrimage, one of the largest planned religious MG events held annually in Saudi Arabia. The variation between studies with respect to study design, sample size, time of sample collection (pre-, during, and pos-Hajj), type of participants (e.g., symptomatic vs. a symptomatic pilgrims), and laboratory procedure was highlighted. The majority of these studies were conducted on the 2019 Hajj season or earlier, prior to the emergence of COVID-19 which had significant impact on the past three Hajj seasons (2020, 2021, and 2022). A summary about key aspects related to organization of Hajj during COVID-19 pandemic and the implementation of exceptional infection control strategies is provided.

The relationship between hand hygiene and rates of acute respiratory infections among Umrah pilgrims: A pilot randomised controlled trial

BACKGROUND

There is a lack of randomised controlled trials (RCTs) investigating the role of hand hygiene in preventing and containing acute respiratory infections (ARIs) in mass gatherings. In this pilot RCT, we assessed the feasibility of establishing a large-scale trial to explore the relationship between practising hand hygiene and rates of ARI in Umrah pilgrimage amidst the COVID-19 pandemic.

METHODS

A parallel RCT was conducted in hotels in Makkah, Saudi Arabia, between April and July 2021. Domestic adult pilgrims who consented to participate were randomised 1:1 to the intervention group who received alcohol-based hand rub (ABHR) and instructions, or to the control group who did not receive ABHR or instructions but were free to use their own supplies. Pilgrims in both groups were then followed up for seven days for ARI symptoms. The primary outcome was the difference in the proportions of syndromic ARIs among pilgrims between the randomised groups.

RESULTS

A total of 507 (control: intervention = 267: 240) participants aged between 18 and 75 (median 34) years were randomised; 61 participants were lost to follow-up or withdrew leaving 446 participants (control: intervention = 237:209) for the primary outcome analysis; of whom 10 (2.2 %) had developed at least one respiratory symptom, three (0.7 %) had 'possible ILI' and two (0.4 %) had 'possible COVID-19'. The analysis of the primary outcome found no evidence of difference in the proportions of ARIs between the randomised groups (odds ratio 1.1 [0.3-4.0] for intervention relative to control).

CONCLUSION

This pilot trial suggests that conducting a future definitive RCT to assess the role of hand hygiene in the prevention of ARIs is feasible in Umrah setting amidst such a pandemic; however, outcomes from this trial are inconclusive, and such a study would need to be very large given the low rates of outcomes observed here.

TRIAL REGISTRATION

This trial was registered in the Australian New Zealand Clinical Trials Registry (ANZCTR) (ACTRN12622001287729), the full protocol can be accessed there.

MERS-CoV seroconversion amongst Malaysian Hajj pilgrims returning from the Middle East, 2016-2018: results from the MERCURIAL multiyear prospective cohort study

Prospective cohort study to investigate the potential exposure to the Middle East Respiratory Syndrome-Coronavirus (MERS-CoV) following Hajj pilgrims is still very limited. Here, we report the antibody seroconversion study results obtained from successive three years cohort studies (2016-2018) involving the Malaysian Hajj pilgrims returning from the Middle East. A cohort study of Hajj pilgrims from Malaysia enrolled 2,863 participants from 2016-2018, all of whom consented to provide paired blood samples for both pre- and post-Hajj travel to the Middle East. ELISAs and micro-neutralization assays were performed to detect the presence of MERS-CoV IgG antibodies. Sociodemographic data, symptoms experienced during Hajj, and history of exposure to camels or camel products were recorded using structured pre- and post-Hajj questionnaires. A 4-fold increase in anti-MERS-CoV IgG between paired pre-Hajj and post-Hajj serum samples in twelve participants was observed. None of the twelve ELISA-positive sera had detectable levels of virus-neutralizing antibodies. All reportedly had mild symptoms of respiratory symptoms at a certain point during the pilgrimage, implying mild or asymptomatic infections. No association between post-Hajj serum positivity and a history of exposure to camels or camel products was obtained. Findings from the study suggest that serologic conversion to MERS-CoV occurred in at least 0.6% of the Hajj pilgrims returning from the Middle East. Since all the seroconvertants had mild to no symptoms during the sampling period, it highlights the likelihood of occurrence of only low infectivity spillover infections among the Hajj pilgrims.

Macrolides for better resolution of community-acquired pneumonia: A global meta-analysis of clinical outcomes with focus on microbial aetiology

OBJECTIVES

This meta-analysis examined the effect of macrolides on resolution of community-acquired pneumonia (CAP) and interpretation of clinical benefit according to microbiology; emphasis is given to data under-reported countries (URCs).

METHODS

This meta-analysis included 47 publications published between 1994 and 2022. Publications were analysed for 30-d mortality (58 759 patients) and resolution of CAP (6465 patients). A separate meta-analysis was done for the prevalence of respiratory pathogens in URCs.

RESULTS

Mortality after 30 d was reduced by the addition of macrolides (odds ratio [OR] 0.65, 95% confidence interval [CI] 0.51-0.82). The OR for CAP resolution when macrolides were added to the treatment regimen was 1.23 (95% CI 1.00-1.52). In the CAP resolution analysis, the most prevalent pathogen was Streptococcus pneumoniae (12.68%; 95% CI 9.36-16.95%). Analysis of the pathogen epidemiology from the URCs included 12 publications. The most prevalent pathogens were S. pneumoniae (24.91%) and Klebsiella pneumoniae (12.90%).

CONCLUSION

The addition of macrolides to the treatment regimen led to 35% relative decrease of 30-d mortality and to 23% relative increase in resolution of CAP.

Travel-related respiratory symptoms and infections in travellers (2000-22): a systematic review and meta-analysis

BACKGROUND

Respiratory tract infections (RTIs) are common in travellers due to the year-round or seasonal presence of respiratory pathogen and exposure to crowded environments during the itinerary. No study has systematically examined the burden of RTI infections among travellers. The aim of this systematic review and meta-analysis is to evaluate the prevalence of RTIs and symptoms suggestive of RTIs among travellers according to risk groups and/or geographic region, and to describe the spectrum of RTIs.

METHODS

The systematic review and meta-analysis was registered in PROSPERO (CRD42022311261). We searched Medline, Embase, Scopus, Cochrane Central, Web of Science, Science Direct and preprint servers MedRxiv, BioRxiv, SSRN and IEEE Xplore on 1 February 2022. Studies reporting RTIs or symptoms suggestive of RTIs in international travellers after 1 January 2000 were eligible. Data appraisal and extraction were performed by two authors, and proportional meta-analyses were used to obtain estimates of the prevalence of respiratory symptoms and RTIs in travellers and predefined risk groups.

FINDINGS

A total of 429 articles on travellers' illness were included. Included studies reported 86 841 symptoms suggestive of RTIs and 807 632 confirmed RTIs. Seventy-eight percent of reported respiratory symptoms and 60% of RTIs with available location data were acquired at mass gatherings events. Cough was the most common symptom suggestive of respiratory infections, and the upper respiratory tract was the most common site for RTIs in travellers. The prevalence of RTIs and respiratory symptoms suggestive of RTIs were 10% [8%; 14%] and 37% [27%; 48%], respectively, among travellers. Reporting of RTIs in travellers denoted by publication output was found to correlate with global waves of new respiratory infections.

INTERPRETATION

This study demonstrates a high burden of RTIs among travellers and indicates that travellers' RTIs reflect respiratory infection outbreaks. These findings have important implications for understanding and managing RTIs among travellers.

Middle East Respiratory Syndrome Coronavirus (MERS-CoV) is Not Circulating Among Hajj Pilgrims

Since the emergence of the middle east respiratory syndrome coronavirus (MERS-CoV) 2012, the virus had caused multiple healthcare-associated outbreaks. The initial 2012 Hajj season started few weeks after the first case of MERS-CoV, but there were no reported cases among pilgrims in 2012. Since then, there had been multiple studies examining the prevalence of MERS-CoV among Hajj pilgrims. Subsequently, multiple studies utilized screening of pilgrims for MERS-CoV and > 10,000 pilgrims were screened with no identifiable cases of MERS.

Epidemiological Differences in Hajj-Acquired Airborne Infections in Pilgrims Arriving from Low and Middle-Income versus High-Income Countries: A Systematised Review

This systematised review aims to compare the epidemiological patterns of Hajj-acquired airborne infections among pilgrims from low and middle-income countries (LMIC) versus those from high-income countries (HIC). A PubMed search was carried out for all published articles before February 2023, using a combination of MeSH terms and text words. The Newcastle-Ottawa Scale (NOS) was used to assess data quality. From a total of 453 titles identified, 58 studies were included in the review (LMIC = 32, and HIC = 26). In the pooled sample, there were 27,799 pilgrims aged 2 days to 105 years (male: female = 1.3:1) from LMIC and 70,865 pilgrims aged 2 months to 95 years (male: female = 1:1) from HIC. Pilgrims from both HIC and LMIC had viral and bacterial infections, but pilgrims from HIC tended to have higher attack rates of viral infections than their LMIC counterparts. However, the attack rates of bacterial infections were variable: for instance, pilgrims from LMIC seemed to have higher rates of meningococcal infections (0.015-82% in LMIC vs. 0.002-40% in HIC) based on the study population, but not Mycobacterium tuberculosis (0.7-20.3% in LMIC vs. 38% in HIC). Targeted measures are needed to prevent the spread of airborne infections at Hajj.

Impact of a Health Education Intervention on the Incidence of Influenza-Like Illnesses (ILI) During Hajj via Smartphone Application

This study was aimed at demonstrating the impact of a health education intervention on reducing the incidence of influenza-like illnesses symptoms among Malaysian Hajj pilgrims. This study utilizes a quasi-experimental study in the evaluation of the impact of the intervention. Participants were recruited during Hajj orientation courses organized by private Hajj companies. Participants from two companies were assigned to an intervention group and control group, respectively. The intervention group received a smartphone-based health education intervention guided by the Health Belief Model (HBM), while the control group received a regular Hajj guide intervention smartphone application before departure to Hajj. Data on the incidence of influenza-like illnesses (ILI) were collected from participants from two Hajj companies before and after returning from Hajj. Data analysis was conducted using SPSS with descriptive analysis, and analytical tests were conducted at 5% significance level. A total of 102 pilgrims completed the study in both intervention and control groups. The incidence of ILI and Non-ILI symptoms were statistically significant when the intervention and control groups (p = 0.049) were compared. In conclusion, health education has an impact on reducing the incidence of ILI and non-ILI among Hajj pilgrims.

Healthcare Research in Mass Religious Gatherings and Emergency Management: A Comprehensive Narrative Review

Religious mass gatherings, especially pilgrimages of various faiths, involve overcrowding and the international movement of people, exposing individuals to significant health risks, such as the spread of infectious diseases, crowds, exposure to bad weather, physical stress, or risks due to pre-existing medical conditions. This paper aims to review the literature related to health care research on religious mass gatherings, with special reference to the role of awareness creation, training, and risk awareness for individuals during Hajj. The results indicated that the research on health risks associated with large-scale gatherings showed that some countries (which witness religious gatherings) follow effective preventive measures to reduce health risks, while some countries did not (and linked this to its poor infrastructure and the low standard of living in it, such as India). It also showed that most studies overlooked identifying the causes of infectious diseases and determining the perceptions of participants in mass gatherings. While it showed that environmental factors strongly influence the emergence of infectious diseases among individuals, the results also showed the scarcity of research that revolves around the awareness of community members, the health risks of mass gatherings, preventive measures against diseases, and the main effects on individuals' perceptions of risks. The results also showed a lack of research evidence on how pilgrims perceive risks, adopt information, and interact with their willingness to be trained in preventive measures.

Respiratory virus detection in returning travelers and pilgrims from the Middle East

BACKGROUND

Pilgrims travelling to Saudi Arabia are commonly infected with respiratory viruses. Since the Middle East Respiratory Syndrome Coronavirus (MERS-CoV) emerged in 2012, patients with acute respiratory symptoms returning from an endemic area can be suspected to be infected by this virus.

METHODS

98 patients suspected to have MERS-CoV infection from 2014 to 2019 were included in this retrospective cohort study. Upper and lower respiratory tract samples were tested by real-time RT-PCR for the detection of MERS-CoV and other respiratory viruses. Routine microbiological analyses were also performed. Patient data were retrieved from laboratory and hospital databases retrospectively.

RESULTS

All patients with suspected MERS-CoV infection travelled before their hospitalization. Most frequent symptoms were cough (94.4%) and fever (69.4%). 98 specimens were tested for MERS-CoV RNA and none of them was positive. Most frequently detected viruses were Enterovirus/Rhinovirus (40/83; 48.2%), Influenzavirus A (34/90; 37.8%) and B (11/90; 12.2%), H-CoV (229E and OC43 10/83; 12% and 7/83; 8.4%, respectively).

CONCLUSION

From 2014 to 2019, none of 98 patients returning from endemic areas was MERS-CoV infected. However, infections with other respiratory viruses were frequent, especially with Enterovirus/Rhinoviruses and Influenzaviruses.

Respiratory pathogens among ill pilgrims and the potential benefit of using point-of-care rapid molecular diagnostic tools during the Hajj

We investigated respiratory pathogens among ill Hajj pilgrims from Marseille. We also discuss the potential role of point-of-care (POC) rapid molecular diagnostic tools for this purpose. Clinical data were collected using a standardised questionnaire. Influenza A and B viruses, human rhinovirus and human coronaviruses, Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae and Klebsiella pneumoniae were investigated using real-time PCR in respiratory samples obtained during travel, at the onset of symptoms. 207 participants were included. A cough, expectoration, rhinitis and a sore throat were the most frequent respiratory symptoms, followed by loss of voice and dyspnoea. 38.7% and 25.1% of pilgrims reported a fever and influenza-like symptoms, respectively. 59.4% pilgrims received antibiotics. Rhinovirus (40.6%) was the most frequent pathogen, followed by S. aureus (35.8%) and H. influenzae (30.4%). Virus and bacteria co-infections were identified in 28.5% of participants. 25.1% pilgrims who were positive for respiratory bacteria did not receive antibiotic treatment. In the context of the Hajj pilgrimage, it is important to detect infections that can be easily managed with appropriate treatment, and those that can affect prognosis, requiring hospitalisation. POC rapid molecular diagnostic tools could be used for patient management at small Hajj medical missions and to rationalise antibiotic consumption among Hajj pilgrims.

Low Prevalence of Syndromic Respiratory Tract Infections among Returning Hajj Pilgrims Amidst the COVID-19 Pandemic: A Post-Hajj Survey

This study estimates the point prevalence of symptomatic respiratory tract infections (RTIs) among returned Hajj pilgrims and their contacts in 2021. Using the computer-assisted telephone interview (CATI) technique, domestic pilgrims were invited to participate in this cross-sectional survey two weeks after their home return from Hajj. Of 600 pilgrims approached, 79.3% agreed to participate and completed the survey. Syndromic definitions were used to clinically diagnose possible influenza-like illnesses (ILI) and COVID-19. Median with range was applied to summarise the continuous data, and frequencies and proportions were used to present the categorical variables. Simple logistic regression was carried out to assess the correlations of potential factors with the prevalence of RTIs. The majority of pilgrims (88.7%) reported receiving at least two doses of the COVID-19 vaccine before Hajj. Eleven (2.3%) pilgrims reported respiratory symptoms with the estimated prevalence of possible ILI being 0.2%, and of possible COVID-19 being 0.4%. Among those who were symptomatic, five (45.5%) reported that one or more of their close contacts had developed similar RTI symptoms after the pilgrims’ home return. The prevalence of RTIs among pilgrims who returned home after attending the Hajj 2021 was lower compared with those reported in the pre-pandemic studies; however, the risk of spread of infection among contacts following Hajj is still a concern.

Diagnostic detection of intended bacteria associated with respiratory tract infections among Kelantanese Malaysian Hajj pilgrims by a ready-to-use, thermostable multiplex PCR assay

Bacterial respiratory tract infections (RTIs) are prone to be associated with serious health problems during the annual Hajj pilgrimage and are a public health concern due to the potential of pathogens transmission across continents. This study aimed to perform a diagnostic screening of intended bacteria associated with RTIs among Malaysian Hajj pilgrims by using a newly developed PCR assay. Expectorated sputum specimens (n = 202) and sociodemographic characteristics of the returning Hajj pilgrims were collected upon arrival in Kelantan, Malaysia. Diagnostic screening of bacterial respiratory pathogens was performed using a thermostabilized multiplex PCR assay in parallel with the sputum culture. Of the six intended bacteria: Haemophilus influenzae, Klebsiella pneumoniae, Mycobacterium tuberculosis, Pseudomonas aeruginosa, Staphylococcus aureus and Streptococcus pneumoniae, the sputum specimens were found positive for H. influenzae (n = 139), K. pneumoniae (n = 20), and S. pneumoniae (n = 19) by the multiplex PCR assay. The sensitivity, specificity, positive- and negative predictive values (PPV and NPV) of this assay were 100% (95% confidence interval (CI): 97.85% to 100.00%), 92.23% (95% CI: 85.27% to 96.59%), 95.51% (95% CI: 91.61% to 97.64%) and 100.00%, respectively. The accuracy of this assay was 97.07% (95% CI: 94.31% to 98.73%). Overall, H. influenzae was found to be the predominant organism in the pilgrims’ sputa by both molecular and microbial culture methods. The multiplex PCR assay would enable a simple, faster and reliable means for the massive screening of intended bacteria compared to the sputum culture, especially during the Hajj pilgrimage.

Syndromic surveillance of respiratory-tract infections and hand hygiene practice among pilgrims attended Hajj in 2021: a cohort study

Background

The risk of transmission of viral respiratory tract infections (RTIs) is high in mass gatherings including Hajj. This cohort study estimated the incidence of symptomatic RTIs and hand hygiene compliance with its impact among Hajj pilgrims during the COVID-19 pandemic.

Methods

During the week of Hajj rituals in 2021, domestic pilgrims were recruited by phone and asked to complete a baseline questionnaire. Pilgrims were followed up after seven days using a questionnaire about the development of symptoms, and practices of hand hygiene. Syndromic definitions were used to clinically diagnose ‘possible’ influenza-like illnesses (ILI) and COVID-19 infection.

Results

A total of 510 pilgrims aged between 18 and 69 (median of 50) years completed the questionnaire, 280 (54.9%) of whom were female, and all of them (except for one) were vaccinated against COVID-19 with at least one dose. The mean (± SD) of pilgrims’ hand hygiene knowledge score (on a scale of 0 to 6) was 4.15 (± 1.22), and a higher level of knowledge was correlated with a higher frequency of handwashing using soap and water. Among those 445 pilgrims who completed the follow-up form, 21 (4.7%) developed one or more respiratory symptoms, of which sore throat and cough were the commonest (respectively 76.2% and 42.8%); ‘possible ILI’ and ‘possible COVID-19’ were present in 1.1% and 0.9% of pilgrims. Obesity was found to be a significant factor associated with the risk of developing RTIs (odds ratio = 4.45, 95% confidence interval 1.15–17.13).

Conclusions

Hajj pilgrims are still at risk of respiratory infections. Further larger and controlled investigations are needed to assess the efficacy of hand hygiene during Hajj.

High genetic diversity of human rhinovirus among pilgrims with acute respiratory tract infections during the 2019 Hajj pilgrimage season

OBJECTIVES

Acute respiratory tract infections (ARIs) due to human rhinoviruses (HRVs) are common in pilgrims during the annual Hajj pilgrimage. The objective of this study was to investigate the genetic diversity of HRV among pilgrims with respiratory symptoms during Hajj 2019.

METHODS

HRV infection was detected using multiplex real-time reverse transcription polymerase chain reaction. Cycle sequencing was performed on positive samples and the sequences were subjected to phylogenetic analysis.

RESULTS

A total of 19 HRV-positive respiratory samples were sequenced. All three serotypes of HRV were identified: HRV-A (13; 68.42%) was more common than HRV-B (2; 10.53%) and HRV-C (4; 21.05%). HRV-A species were found to be of genotypes A101, A21, A30, A57, A23, A60, and A11. HRV-B species belonged to genotypes B4 and B84, and HRV-C species were of genotypes C15, C3, and C56.

CONCLUSION

Sequencing studies of respiratory tract viruses in pilgrims are important. We provide preliminary evidence of high diversity of HRV genotypes circulating in pilgrims in a restricted area during Hajj. This requires further clinical and sequencing studies of viral pathogens in larger cohorts of overseas and local pilgrims.

Multiyear prospective cohort study to evaluate the risk potential of MERS-CoV infection among Malaysian Hajj pilgrims (MERCURIAL): a study protocol

INTRODUCTION

Middle East respiratory syndrome (MERS) is a viral respiratory infection caused by the MERS-CoV. MERS was first reported in the Kingdom of Saudi Arabia in 2012. Every year, the Hajj pilgrimage to Mecca attracts more than two million pilgrims from 184 countries, making it one of the largest annual religious mass gatherings (MGs) worldwide. MGs in confined areas with a high number of pilgrims' movements worldwide continues to elicit significant global public health concerns. MERCURIAL was designed by adopting a seroconversion surveillance approach to provide multiyear evidence of MG-associated MERS-CoV seroconversion among the Malaysian Hajj pilgrims.

METHODS AND ANALYSIS

MERCURIAL is an ongoing multiyear prospective cohort study. Every year, for the next 5 years, a cohort of 1000 Hajj pilgrims was enrolled beginning in the 2016 Hajj pilgrimage season. Pre-Hajj and post-Hajj serum samples were obtained and serologically analysed for evidence of MERS-CoV seroconversion. Sociodemographic data, underlying medical conditions, symptoms experienced during Hajj pilgrimage, and exposure to camel and untreated camel products were recorded using structured pre-Hajj and post-Hajj questionnaires. The possible risk factors associated with the seroconversion data were analysed using univariate and multivariate logistic regression. The primary outcome of this study is to better enhance our understanding of the potential threat of MERS-CoV spreading through MG beyond the Middle East.

ETHICS AND DISSEMINATION

This study has obtained ethical approval from the Medical Research and Ethics Committee (MREC), Ministry of Health Malaysia. Results from the study will be submitted for publication in peer-reviewed journals and presented in conferences and scientific meetings.

TRIAL REGISTRATION NUMBER

NMRR-15-1640-25391.

Novel Respiratory Viruses in the Context of Mass-Gathering Events: A Systematic Review to Inform Event Planning from a Health Perspective

BACKGROUND

Mass-gathering events (MGEs) occur regularly throughout the world. As people congregate at MGEs, there is an increased risk of transmission of communicable diseases. Novel respiratory viruses, such as Severe Acute Respiratory Syndrome Coronavirus-1 (SARS-CoV-1), Influenza A Virus Subtype H1N1 Strain 2009 (H1N1pdm09), Middle East Respiratory Syndrome Coronavirus (MERS-CoV), and Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), or Coronavirus Disease 2019 (COVID-19), may require specific infection prevention and control strategies to minimize the risk of transmission when planning MGEs. This literature review aimed to identify and analyze papers relating to novel respiratory viruses with pandemic potential and to inform MGE planning.

METHOD

This paper used a systematic literature review method. Various health care databases were searched using keywords relating to MGEs and novel respiratory viruses. Information was extracted from identified papers into various tables for analysis. The analysis identified infection prevention and control strategies used at MGEs to inform planning before, during, and following events.

RESULTS

In total, 27 papers met the criteria for inclusion. No papers were identified regarding SARS-CoV-1, while the remainder reported on H1N1pdm09 (n = 9), MERS-CoV (n = 15), and SARS-CoV-2 (n = 3). Various before, during, and after event mitigation strategies were identified that can be implemented for future events.

CONCLUSIONS

This literature review provided an overview of the novel respiratory virus epidemiology at MGEs alongside related public health mitigation strategies that have been implemented at these events. This paper also discusses the health security of event participants and host communities in the context of cancelling, postponing, and modifying events due to a novel respiratory virus. In particular, ways to recommence events incorporating various mitigation strategies are outlined.

International travel-related control measures to contain the COVID-19 pandemic: a rapid review

BACKGROUND

In late 2019, the first cases of coronavirus disease 2019 (COVID-19) were reported in Wuhan, China, followed by a worldwide spread. Numerous countries have implemented control measures related to international travel, including border closures, travel restrictions, screening at borders, and quarantine of travellers.

OBJECTIVES

To assess the effectiveness of international travel-related control measures during the COVID-19 pandemic on infectious disease transmission and screening-related outcomes.

SEARCH METHODS

We searched MEDLINE, Embase and COVID-19-specific databases, including the Cochrane COVID-19 Study Register and the WHO Global Database on COVID-19 Research to 13 November 2020.

SELECTION CRITERIA

We considered experimental, quasi-experimental, observational and modelling studies assessing the effects of travel-related control measures affecting human travel across international borders during the COVID-19 pandemic. In the original review, we also considered evidence on severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS). In this version we decided to focus on COVID-19 evidence only. Primary outcome categories were (i) cases avoided, (ii) cases detected, and (iii) a shift in epidemic development. Secondary outcomes were other infectious disease transmission outcomes, healthcare utilisation, resource requirements and adverse effects if identified in studies assessing at least one primary outcome.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts and subsequently full texts. For studies included in the analysis, one review author extracted data and appraised the study. At least one additional review author checked for correctness of data. To assess the risk of bias and quality of included studies, we used the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool for observational studies concerned with screening, and a bespoke tool for modelling studies. We synthesised findings narratively. One review author assessed the certainty of evidence with GRADE, and several review authors discussed these GRADE judgements.

MAIN RESULTS

Overall, we included 62 unique studies in the analysis; 49 were modelling studies and 13 were observational studies. Studies covered a variety of settings and levels of community transmission. Most studies compared travel-related control measures against a counterfactual scenario in which the measure was not implemented. However, some modelling studies described additional comparator scenarios, such as different levels of stringency of the measures (including relaxation of restrictions), or a combination of measures. Concerns with the quality of modelling studies related to potentially inappropriate assumptions about the structure and input parameters, and an inadequate assessment of model uncertainty. Concerns with risk of bias in observational studies related to the selection of travellers and the reference test, and unclear reporting of certain methodological aspects. Below we outline the results for each intervention category by illustrating the findings from selected outcomes. Travel restrictions reducing or stopping cross-border travel (31 modelling studies) The studies assessed cases avoided and shift in epidemic development. We found very low-certainty evidence for a reduction in COVID-19 cases in the community (13 studies) and cases exported or imported (9 studies). Most studies reported positive effects, with effect sizes varying widely; only a few studies showed no effect. There was very low-certainty evidence that cross-border travel controls can slow the spread of COVID-19. Most studies predicted positive effects, however, results from individual studies varied from a delay of less than one day to a delay of 85 days; very few studies predicted no effect of the measure. Screening at borders (13 modelling studies; 13 observational studies) Screening measures covered symptom/exposure-based screening or test-based screening (commonly specifying polymerase chain reaction (PCR) testing), or both, before departure or upon or within a few days of arrival. Studies assessed cases avoided, shift in epidemic development and cases detected. Studies generally predicted or observed some benefit from screening at borders, however these varied widely. For symptom/exposure-based screening, one modelling study reported that global implementation of screening measures would reduce the number of cases exported per day from another country by 82% (95% confidence interval (CI) 72% to 95%) (moderate-certainty evidence). Four modelling studies predicted delays in epidemic development, although there was wide variation in the results between the studies (very low-certainty evidence). Four modelling studies predicted that the proportion of cases detected would range from 1% to 53% (very low-certainty evidence). Nine observational studies observed the detected proportion to range from 0% to 100% (very low-certainty evidence), although all but one study observed this proportion to be less than 54%. For test-based screening, one modelling study provided very low-certainty evidence for the number of cases avoided. It reported that testing travellers reduced imported or exported cases as well as secondary cases. Five observational studies observed that the proportion of cases detected varied from 58% to 90% (very low-certainty evidence). Quarantine (12 modelling studies) The studies assessed cases avoided, shift in epidemic development and cases detected. All studies suggested some benefit of quarantine, however the magnitude of the effect ranged from small to large across the different outcomes (very low- to low-certainty evidence). Three modelling studies predicted that the reduction in the number of cases in the community ranged from 450 to over 64,000 fewer cases (very low-certainty evidence). The variation in effect was possibly related to the duration of quarantine and compliance. Quarantine and screening at borders (7 modelling studies; 4 observational studies) The studies assessed shift in epidemic development and cases detected. Most studies predicted positive effects for the combined measures with varying magnitudes (very low- to low-certainty evidence). Four observational studies observed that the proportion of cases detected for quarantine and screening at borders ranged from 68% to 92% (low-certainty evidence). The variation may depend on how the measures were combined, including the length of the quarantine period and days when the test was conducted in quarantine.

AUTHORS' CONCLUSIONS

With much of the evidence derived from modelling studies, notably for travel restrictions reducing or stopping cross-border travel and quarantine of travellers, there is a lack of 'real-world' evidence. The certainty of the evidence for most travel-related control measures and outcomes is very low and the true effects are likely to be substantially different from those reported here. Broadly, travel restrictions may limit the spread of disease across national borders. Symptom/exposure-based screening measures at borders on their own are likely not effective; PCR testing at borders as a screening measure likely detects more cases than symptom/exposure-based screening at borders, although if performed only upon arrival this will likely also miss a meaningful proportion of cases. Quarantine, based on a sufficiently long quarantine period and high compliance is likely to largely avoid further transmission from travellers. Combining quarantine with PCR testing at borders will likely improve effectiveness. Many studies suggest that effects depend on factors, such as levels of community transmission, travel volumes and duration, other public health measures in place, and the exact specification and timing of the measure. Future research should be better reported, employ a range of designs beyond modelling and assess potential benefits and harms of the travel-related control measures from a societal perspective.

Prevalence of Influenza Among Hajj Pilgrims: A Systematic Review and Meta-Analysis

OBJECTIVES

Respiratory transmission, especially in mass gatherings, is considered one of the main ways of influenza transmission. The Hajj ceremony, as one of the largest gatherings worldwide, can increase the distribution of influenza infection. Thus, the present study aimed to evaluate the incidence of influenza among Hajj pilgrims.

METHODS

In this present systematic review and meta-analysis, all English studies published by 2019 were extracted from several databases such as the Web of Science, PubMed, Scopus, Cochrane Library, Science Direct, and Google Scholar. Finally, the data were extracted using a pre-prepared checklist and then analyzed by fixed and random effects model tests in the meta-analysis, Cochran, meta-regression, and Begg's test.

RESULTS

Eighteen studies with a sample size of 62 431 were entered into the meta-analysis process. The overall prevalence of influenza, in addition to the prevalence of types A, B, and C influenza, was estimated at 5.9 (95% CI: 4.3-8.0), 3.6 (95% CI: 2.6-4.9), 2.9 (95% CI: 2.8-3.1), and 0.9% (95% CI: 0.5-1.5), respectively.

CONCLUSIONS

In general, influenza remains widespread regardless of vaccinating pilgrims and following health protocols. Therefore, it is recommended that comprehensive management and educational approaches be used to reduce the prevalence of influenza and its adverse consequences among the pilgrims.

The Emergence, Persistence, and Dissemination of Antimicrobial-Resistant Bacteria in Environmental Hajj Settings and Implications for Public Health

The emergence of antimicrobial resistance is causing the loss of what was once considered the miracle cure. The transmission of antimicrobial resistance during mass gathering is a potential threat in addition to other infectious diseases. Here, we review the English language literature on the rate and the acquisition of antimicrobial resistance during the Hajj. There is a variable incidence of methicillin-resistant Staphylococcus aureus, Escherichia coli, and Enterobacteriaceae. There had been no report of multi-drug-resistant Mycobacterium tuberculosis. Continued surveillance of antimicrobial resistance coupled with public health measures are needed to decrease the rate of emergence of resistance.

Pattern of Respiratory Viruses among Pilgrims during 2019 Hajj Season Who Sought Healthcare Due to Severe Respiratory Symptoms

The aim of our study was to define the spectrum of viral infections in pilgrims with acute respiratory tract illnesses presenting to healthcare facilities around the holy places in Makkah, Saudi Arabia during the 2019 Hajj pilgrimage. During the five days of Hajj, a total of 185 pilgrims were enrolled in the study. Nasopharyngeal swabs (NPSs) of 126/185 patients (68.11%) tested positive for one or more respiratory viruses by PCR. Among the 126 pilgrims whose NPS were PCR positive: (a) there were 93/126 (74%) with a single virus infection, (b) 33/126 (26%) with coinfection with more than one virus (up to four viruses): of these, 25/33 cases had coinfection with two viruses; 6/33 were infected with three viruses, while the remaining 2/33 patients had infection with four viruses. Human rhinovirus (HRV) was the most common detected viruses with 53 cases (42.06%), followed by 27 (21.43%) cases of influenza A (H1N1), and 23 (18.25%) cases of influenza A other than H1N1. Twenty-five cases of CoV-229E (19.84%) were detected more than other coronavirus members (5 CoV-OC43 (3.97%), 4 CoV-HKU1 (3.17%), and 1 CoV-NL63 (0.79%)). PIV-3 was detected in 8 cases (6.35%). A single case (0.79%) of PIV-1 and PIV-4 were found. HMPV represented 5 (3.97%), RSV and influenza B 4 (3.17%) for each, and Parechovirus 1 (0.79%). Enterovirus, Bocavirus, and M. pneumoniae were not detected. Whether identification of viral nucleic acid represents nasopharyngeal carriage or specific causal etiology of RTI remains to be defined. Large controlled cohort studies (pre-Hajj, during Hajj, and post-Hajj) are required to define the carriage rates and the specific etiology and causal roles of specific individual viruses or combination of viruses in the pathogenesis of respiratory tract infections in pilgrims participating in the annual Hajj. Studies of the specific microbial etiology of respiratory track infections (RTIs) at mass gathering religious events remain a priority, especially in light of the novel SARS-CoV-2 pandemic.

Streptococcus pneumoniae carriage and antibiotic susceptibility among Indonesian pilgrims during the Hajj pilgrimage in 2015

The Hajj is an annual pilgrimage to Mecca and one of the largest gathering of people in the world. Most Indonesian pilgrims are senior adults and elderly adults, who are more prone to acquire infections during the Hajj ritual. The aims of this study are to investigate the dynamics of Streptococcus pneumoniae colonization and to investigate antibiotic susceptibility of pneumococcal strains in Indonesian pilgrims. This was a prospective multi-site longitudinal study in Indonesian hajj pilgrims aged >18 years old in the year 2015. Nasopharyngeal swabs were collected from the same subject before departure and upon arrival at the airport. S. pneumoniae was identified using conventional and molecular approach, while antibiotic susceptibility was determined using a disk diffusion method. Among 813 Hajj pilgrims who were enrolled from five sites in this study, the prevalence of S. pneumoniae carriage rates before- and after-the Hajj were 8.6% (95% CI 6.7–10.5%) and 8.2% (95% CI 6.4–10.1%), (p value: 0.844) respectively. Serotype 16F, 6A/6B, 3, 18, and 23F were the five most prevalent serotypes before Hajj, whereas serotypes 3, 34, 13, 4, and 23F were the most prevalent serotypes after Hajj. Serotype 3 was identified as most acquired serotype during Hajj in Indonesian pilgrim. There was an increase in the percentage of isolates susceptible to co-trimoxazole after Hajj (42.9% versus 57.4%). The study provided an overview of the change of dynamics of S. pneumoniae serotype acquisition in Indonesian Hajj Pilgrims. Along with data of vaccination serotypes coverage and antimicrobial susceptibility, these findings may contribute to recommendation of vaccination and treatment policies in the future.

Assessment of Preventative Measures Practice among Umrah Pilgrims in Saudi Arabia, 1440H-2019

:Background: Annually, approximately 10 million pilgrims travel to the Kingdom of Saudi Arabia (KSA) for Umrah from more than 180 countries. This event presents major challenges for the Kingdom's public health sector, which strives to decrease the burden of infectious diseases and to adequately control their spread both in KSA and pilgrims home nations. The aims of the study were to assess preventative measures practice, including vaccination history and health education, among Umrah pilgrims in Saudi Arabia. Methods: A cross sectional survey was administered to pilgrims from February to April 2019 at the departure lounge at King Abdul Aziz International airport, Jeddah city. The questionnaire comprised questions on sociodemographic information (age, gender, marital status, level of education, history of vaccinations and chronic illnesses), whether the pilgrim had received any health education and orientation prior to coming to Saudi Arabia or on their arrival, and their experiences with preventative practices. Results: Pilgrims (n = 1012) of 41 nationalities completed the survey. Chronic diseases were reported among pilgrims (n = 387, 38.2%) with cardiovascular diseases being the most reported morbidity (n = 164, 42.3%). The majority of pilgrims had been immunized prior to travel to Saudi Arabia (n = 770, 76%). The most commonly reported immunizations were influenza (n = 514, 51%), meningitis (n = 418, 41%), and Hepatitis B virus vaccinations (n = 310, 31%). However, 242 (24%) had not received any vaccinations prior to travel, including meningitis vaccine and poliomyelitis vaccine, which are mandatory by Saudi Arabian health authorities for pilgrims coming from polio active countries. Nearly a third of pilgrims (n = 305; 30.1%) never wore a face mask in crowded areas during Umrah in 2019. In contrast, similar numbers said they always wore a face mask (n = 351, 34.6%) in crowded areas, while 63.2% reported lack of availability of face masks during Umrah. The majority of participants had received some form of health education on preventative measures, including hygiene aspects (n = 799, 78.9%), mostly in their home countries (n = 450, 44.4%). A positive association was found between receiving health education and practicing of preventative measures, such as wearing face masks in crowded areas (p = 0.04), and other health practice scores (p = 0.02). Conclusion: Although the experiences of the preventative measures among pilgrims in terms of health education, vaccinations, and hygienic practices were at times positive, this study identified several issues. These included the following preventative measures: immunizations, particularly meningitis and poliomyelitis vaccine, and using face masks in crowded areas. The recent COVID-19 pandemic highlights the need for further studies that focus on development of accessible health education in a form that engages pilgrims to promote comprehensive preventative measures during Umrah and Hajj and other religious pilgrimages.

Natural immunity to influenza A and B among Saudi blood donors in Al Madinah Al Munawarah, Saudi Arabia

Objectives:

To investigate the seroprevalence of influenza viruses (A and B) among blood donors in Kingdom of Saudi Arabia.

Methods:

The present investigation was conducted between April 2019 and July 2019. Participants were healthy adults recruited from the central blood bank Al Madinah Al Munawarah, Kingdom of Saudi Arabia. Immunoglobulin G (IgG) levels against influenza A and B were measured in serum samples using ELISA.

Results:

The results showed that 29.2% of the sample had significant concentrations of influenza A IgG antibody, whereas 38.6% had significant concentrations of influenza B IgG antibody. A strong correlation was found between the levels of influenza A and influenza B antibodies (r=0.708, p<0.001). The number of individuals identified as negative for influenza A IgG antibody increased with age (p<0.01). In addition, no correlations were identified between influenza A IgG and influenza B IgG and body mass index (BMI), (p>0.05). Finally, linear regression analysis showed that the level of influenza A antibody can be predicted by age (p<0.05) and body mass index (BMI) (p<0.05).

Conclusion:

Approximately one-third of Saudi Arabian adults presented significant levels of influenza A and B antibodies in our study. Demographic factors, including age and BMI, might contribute to influenza A antibody levels.

Hand Hygiene Knowledge and Practices among Domestic Hajj Pilgrims: Implications for Future Mass Gatherings Amidst COVID-19

This study examined Hajj pilgrims' knowledge and reported practice of hand hygiene. In Hajj 2019, a cross-sectional survey was undertaken in Mina, Makkah, Saudi Arabia, of domestic Saudi pilgrims aged ≥18 years by using a self-administered Arabic questionnaire that captured data on pilgrims' socio-demographics, hand hygiene knowledge, and reported practices of hand cleaning following certain actions. A total of 348 respondents aged 18 to 63 (median 32) years completed the survey, of whom 200 (57.5%) were female. The mean (±standard deviation (SD)) hand hygiene knowledge score was 6.7 (±SD 1.9). Two hundred and seventy one (77.9%) and 286 (82.2%) of respondents correctly identified that hand hygiene can prevent respiratory and gastrointestinal infections respectively, but 146 (42%) were not aware that it prevents hand-foot-mouth disease. Eighty-eight (25.3%) respondents erroneously reported that hand hygiene prevents HIV. Washing hands with water and soap was the most preferred method practiced before a meal (67.5% (235/348)), after a meal (80.2% (279/348)), after toilet action (81.6% (284/348)), when hands were visibly soiled (86.2% (300/348)), and after waste disposal (61.5% (214/348)). Hajj pilgrims demonstrated a good knowledge and practice of hand hygiene, but there are gaps that are vital to control outbreaks such as COVID-19.

Travel-related control measures to contain the COVID-19 pandemic: a rapid review

BACKGROUND

In late 2019, first cases of coronavirus disease 2019, or COVID-19, caused by the novel coronavirus SARS-CoV-2, were reported in Wuhan, China. Subsequently COVID-19 spread rapidly around the world. To contain the ensuing pandemic, numerous countries have implemented control measures related to international travel, including border closures, partial travel restrictions, entry or exit screening, and quarantine of travellers.

OBJECTIVES

To assess the effectiveness of travel-related control measures during the COVID-19 pandemic on infectious disease and screening-related outcomes.

SEARCH METHODS

We searched MEDLINE, Embase and COVID-19-specific databases, including the WHO Global Database on COVID-19 Research, the Cochrane COVID-19 Study Register, and the CDC COVID-19 Research Database on 26 June 2020. We also conducted backward-citation searches with existing reviews.

SELECTION CRITERIA

We considered experimental, quasi-experimental, observational and modelling studies assessing the effects of travel-related control measures affecting human travel across national borders during the COVID-19 pandemic. We also included studies concerned with severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) as indirect evidence. Primary outcomes were cases avoided, cases detected and a shift in epidemic development due to the measures. Secondary outcomes were other infectious disease transmission outcomes, healthcare utilisation, resource requirements and adverse effects if identified in studies assessing at least one primary outcome.

DATA COLLECTION AND ANALYSIS

One review author screened titles and abstracts; all excluded abstracts were screened in duplicate. Two review authors independently screened full texts. One review author extracted data, assessed risk of bias and appraised study quality. At least one additional review author checked for correctness of all data reported in the 'Risk of bias' assessment, quality appraisal and data synthesis. For assessing the risk of bias and quality of included studies, we used the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool for observational studies concerned with screening, ROBINS-I for observational ecological studies and a bespoke tool for modelling studies. We synthesised findings narratively. One review author assessed certainty of evidence with GRADE, and the review author team discussed ratings.

MAIN RESULTS

We included 40 records reporting on 36 unique studies. We found 17 modelling studies, 7 observational screening studies and one observational ecological study on COVID-19, four modelling and six observational studies on SARS, and one modelling study on SARS and MERS, covering a variety of settings and epidemic stages. Most studies compared travel-related control measures against a counterfactual scenario in which the intervention measure was not implemented. However, some modelling studies described additional comparator scenarios, such as different levels of travel restrictions, or a combination of measures. There were concerns with the quality of many modelling studies and the risk of bias of observational studies. Many modelling studies used potentially inappropriate assumptions about the structure and input parameters of models, and failed to adequately assess uncertainty. Concerns with observational screening studies commonly related to the reference test and the flow of the screening process. Studies on COVID-19 Travel restrictions reducing cross-border travel Eleven studies employed models to simulate a reduction in travel volume; one observational ecological study assessed travel restrictions in response to the COVID-19 pandemic. Very low-certainty evidence from modelling studies suggests that when implemented at the beginning of the outbreak, cross-border travel restrictions may lead to a reduction in the number of new cases of between 26% to 90% (4 studies), the number of deaths (1 study), the time to outbreak of between 2 and 26 days (2 studies), the risk of outbreak of between 1% to 37% (2 studies), and the effective reproduction number (1 modelling and 1 observational ecological study). Low-certainty evidence from modelling studies suggests a reduction in the number of imported or exported cases of between 70% to 81% (5 studies), and in the growth acceleration of epidemic progression (1 study). Screening at borders with or without quarantine Evidence from three modelling studies of entry and exit symptom screening without quarantine suggests delays in the time to outbreak of between 1 to 183 days (very low-certainty evidence) and a detection rate of infected travellers of between 10% to 53% (low-certainty evidence). Six observational studies of entry and exit screening were conducted in specific settings such as evacuation flights and cruise ship outbreaks. Screening approaches varied but followed a similar structure, involving symptom screening of all individuals at departure or upon arrival, followed by quarantine, and different procedures for observation and PCR testing over a period of at least 14 days. The proportion of cases detected ranged from 0% to 91% (depending on the screening approach), and the positive predictive value ranged from 0% to 100% (very low-certainty evidence). The outcomes, however, should be interpreted in relation to both the screening approach used and the prevalence of infection among the travellers screened; for example, symptom-based screening alone generally performed worse than a combination of symptom-based and PCR screening with subsequent observation during quarantine. Quarantine of travellers Evidence from one modelling study simulating a 14-day quarantine suggests a reduction in the number of cases seeded by imported cases; larger reductions were seen with increasing levels of quarantine compliance ranging from 277 to 19 cases with rates of compliance modelled between 70% to 100% (very low-certainty evidence).

AUTHORS' CONCLUSIONS

With much of the evidence deriving from modelling studies, notably for travel restrictions reducing cross-border travel and quarantine of travellers, there is a lack of 'real-life' evidence for many of these measures. The certainty of the evidence for most travel-related control measures is very low and the true effects may be substantially different from those reported here. Nevertheless, some travel-related control measures during the COVID-19 pandemic may have a positive impact on infectious disease outcomes. Broadly, travel restrictions may limit the spread of disease across national borders. Entry and exit symptom screening measures on their own are not likely to be effective in detecting a meaningful proportion of cases to prevent seeding new cases within the protected region; combined with subsequent quarantine, observation and PCR testing, the effectiveness is likely to improve. There was insufficient evidence to draw firm conclusions about the effectiveness of travel-related quarantine on its own. Some of the included studies suggest that effects are likely to depend on factors such as the stage of the epidemic, the interconnectedness of countries, local measures undertaken to contain community transmission, and the extent of implementation and adherence.

Health Education Intervention as an Effective Means for Prevention of Respiratory Infections Among Hajj Pilgrims: A Review

The prevalence of respiratory illness has continued to surge among Hajj pilgrims from different countries despite having some practices of preventive measures. Respiratory illnesses during Hajj could be due to many reasons and many factors that promote disease spread. These factors include overcrowding, cigarette smoking, and direct contact with infectious agents particularly viruses promote the spread of respiratory infections. However, due to the longer duration of the pilgrimage, there are high chances of pilgrims contracting various respiratory illnesses due to exposure to respiratory pathogens. Hajj pilgrims' knowledge, attitudes, and practices toward respiratory tract infections are used as the determinant of the effectiveness of the health education interventions. Knowledge and application of basic hygiene principles, use of face masks, following cough etiquettes, engaging in social distancing, and engaging in other measures are highly important. In this paper, we reviewed the various effective intervention strategies implemented to help prevent respiratory tract infections during Hajj.

Diagnostic tools for bacterial infections in travellers: Current and future options

International travel has increased dramatically over the past 50 years, and travel destinations have diversified. Although physicians are more familiar with the panel of aetiological agents responsible for illnesses of returning travellers, thanks to regular epidemiological studies, the spectrum of pathogens potentially encountered in various travel destinations is nevertheless increasing. In addition, the wide array of approaches currently available and addressed in this paper could render the procedures for microbiological analyses increasingly complex. As the time to result is crucial to adequately manage patients, modern approaches have been developed to shorten diagnosis delays. The syndromic approach, which consists of simultaneously testing a wide panel of microorganisms, substantially increases the diagnostic yield with significant time savings, particularly when coupled with point-of-care laboratories. The tools commonly used for this purpose are immunochromatographic tests, mainly targeting bacterial antigens, and multiplex real-time PCR. The emergence of next-generation sequencing technologies, which enable random amplification of genetic material of any microbe present in a clinical specimen, provides further exciting perspectives in the diagnosis of infectious diseases.

Meningococcal and pneumococcal carriage in Hajj pilgrims: findings of a randomized controlled trial

BACKGROUND

Intense congestion during the Hajj pilgrimage amplifies the risk of meningococcal carriage and disease, and there have been many meningococcal outbreaks reported amongst pilgrims. Thus, a strict vaccination policy is enforced by the host country and either polysaccharide or conjugate quadrivalent meningococcal vaccines are mandatory. However, unlike conjugate vaccines, the polysaccharide vaccine is not thought to reduce pharyngeal carriage of meningococci.

METHODS

A single-blinded, randomized, controlled trial amongst pilgrims from Saudi Arabia and Australia during the Hajj seasons of 2016-2017 was conducted to compare MenACWY-Conjugate vaccine with MenACWY-Polysaccharide vaccine, to determine if the conjugate vaccine is more effective in reducing asymptomatic carriage of meningococci, and whether the effect may be long-standing. Oropharyngeal swabs were obtained pre-, immediately post- and 6-11 months following completion of Hajj and tested for the presence of meningococci.

RESULTS

Amongst 2000 individuals approached, only 1146 participants aged 18-91 (mean 37.6) years agreed to participate and were randomized to receive either the polysaccharide (n = 561) or the conjugate (n = 561) vaccine, 60.8% were male, and 93.5% were from Saudi Arabia. Amongst oropharyngeal swabs obtained before Hajj, only two (0.2%) tested positive for Neisseria meningitidis. Similarly, meningococci were identified in only one sample at each of the post-Hajj and late follow-up visits. None of the carriage isolates were amongst the serogroups covered by the vaccines. A post hoc analysis of the third swabs revealed that 22.4% of all participants (50/223) were positive for Streptococcus pneumoniae nucleic acid.

CONCLUSION

The low overall carriage rate of meningococci found amongst Hajj pilgrims in 2016 and 2017 demonstrates a successful vaccination policy, but neither supports nor refutes the superiority of meningococcal conjugate ACWY vaccine over the polysaccharide vaccine against carriage. Although an association could not be established in this study, molecular epidemiology would help to establish the role of Hajj in facilitating transmission of pneumococci and inform vaccination policy.

Middle East respiratory syndrome coronavirus (MERS-CoV) - Surveillance and testing in North England from 2012 to 2019

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MERS is an emerging infectious disease with high consequences.

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PHE Manchester receives a high number of MERS surveillance samples.

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Sputum samples are the optimum samples for diagnosing respiratory viruses.

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Multiple samples per patient result in a 100% diagnostic yield and a confirmed end-diagnosis.

Background

Middle East respiratory syndrome coronavirus (MERS-CoV) emerged in Saudi Arabia in 2012 and caused an epidemic in the Middle East. Public Health England (PHE) Manchester is one of the two PHE centres in the UK that perform testing for MERS-CoV. The results of the PHE Manchester MERS surveillance from 2012 to 2019 are presented in this report.

Methods

Retrospective data were collected for returning travellers from the Middle East fitting the PHE MERS case definition. Respiratory samples were tested for respiratory viruses and MERS-CoV using an in-house RT-PCR assay.

Results

Four hundred and twenty-six (426) samples from 264 patients were tested for MERS Co-V and respiratory viruses. No MERS-CoV infections were identified by PCR. Fifty-six percent of samples were PCR positive for viral or bacterial pathogen with Influenza A as the predominant virus (44%). Sixty-two percent of all patients had a pathogen identified with the highest positivity from sputum samples. Patients with multiple samples demonstrated a 100% diagnostic yield.

Conclusions

Although no cases of MERS were identified, the majority of patients had Influenza infection for which oseltamivir treatment was indicated and isolation warranted. Sputum samples were the most useful in diagnosing respiratory viruses with a 100% diagnostic yield from patients with multiple samples.

The dynamics and interactions of respiratory pathogen carriage among French pilgrims during the 2018 Hajj

We conducted this study to describe the dynamics of the acquisition of respiratory pathogens, their potential interactions and risk factors for possible lower respiratory tract infection symptoms (LRTI) among French pilgrims during the 2018 Hajj. Each participant underwent four successive systematic nasopharyngeal swabs before and during their stay in Saudi Arabia. Carriage of the main respiratory pathogens was assessed by PCR. 121 pilgrims were included and 93.4% reported respiratory symptoms during the study period. The acquisition of rhinovirus, coronaviruses and Staphylococcus aureus occurred soon after arrival in Saudi Arabia and rates decreased gradually after days 5 and 6. In contrast, Streptococcus pneumoniae and Klebsiella pneumoniae carriage increased progressively until the end of the stay in Saudi Arabia. Haemophilus influenzae and Moraxella catarrhalis carriage increased starting around days 12 and 13, following an initial clearance. Influenza viruses were rarely isolated. We observed an independent positive mutual association between S. aureus and rhinovirus carriage and between H. influenzae and M. catarrhalis carriage. Dual carriage of H. influenzae and M. catarrhalis was strongly associated with S. pneumoniae carriage (OR = 6.22). Finally, our model showed that M. catarrhalis carriage was negatively associated with K. pneumoniae carriage. Chronic respiratory disease was associated with symptoms of LRTI. K. pneumoniae, M. catarrhalis-S. aureus and H. influenzae-rhinovirus dual carriage was associated with LRTI symptoms. Our data suggest that RTIs at the Hajj are a result of complex interactions between a number of respiratory viruses and bacteria.

Respiratory tract infections among French Hajj pilgrims from 2014 to 2017

Respiratory tract infections (RTIs) are common among Hajj pilgrims, but risk factors for RTIs and respiratory pathogen acquisition during the Hajj are not clearly identified. Based on previous studies, most frequent pathogens acquired by Hajj pilgrims were investigated: rhinovirus, human coronaviruses, influenza viruses, Streptococcus pneumoniae, Staphylococcus aureus, Klebsiella pneumoniae and Haemophilus influenzae. 485 pilgrims were included. 82.1% presented with RTIs. Respiratory chronic diseases were associated with cough, Influenza-like illness (ILI) and the acquisition of H. influenzae. Vaccination against invasive pneumococcal diseases (IPD) and influenza was associated with a decrease in the acquisition of S. pneumoniae and prevalence of ILI (aRR = 0.53, 95%CI [0.39-0.73] and aRR = 0.69, 95%CI [0.52-0.92] respectively). Individuals carrying rhinovirus and H. influenzae-S. pneumoniae together were respectively twice and five times more likely to have respiratory symptoms. Individual with H. influenzae-K. pneumoniae carriage were twice (p = 0.04) as likely to develop a cough. The use of disposable handkerchiefs was associated with a decrease in the acquisition of S. aureus (aRR = 0.75, 95%CI [0.57-0.97]). Results could be used to identify pilgrims at increased risk of RTIs and acquisition of respiratory pathogens. Results also confirm the effectiveness of influenza and IPD vaccinations in reducing ILI symptoms and acquisition of S. pneumoniae carriage respectively.

Influenza vaccine effectiveness among Hajj pilgrims: a test-negative case-control analysis of data from different Hajj years

Background: Influenza is a common respiratory infection at Hajj. Thus, influenza vaccine is recommended for Hajj pilgrims but data on its effectiveness from a large sample are unavailable. This analysis aims to assess the effectiveness of the trivalent seasonal influenza vaccine (TIV) among Hajj pilgrims.Patients and methods: A 'test-negative' case-control analysis using data from individual studies was conducted. Included studies involved participants from Saudi Arabia, India, Australia and the United Kingdom who attended Hajj in Makkah, Saudi Arabia in different years between 2005 and 2015. Pilgrims who developed symptoms of respiratory infection during Hajj were included in these studies. Participants' vaccination histories were recorded and respiratory samples were collected to test for influenza by PCR. Vaccine effectiveness (VE) was calculated after adjusting for potential confounders.Results: A total of 1,569 pilgrims were included in this analysis. Influenza vaccine uptake was 52.2% and the attack rate of influenza was 8.2%. The estimated overall VE was 43.4% (95% CI 11.4% to 63.9%, P = 0.01). VE against a specific subtype of influenza was not significant.Conclusion: The current analysis has shown that TIV is moderately effective among Hajj pilgrims, but the vaccine uptake has been suboptimal. Power was much reduced when testing for influenza subtypes.

Uptake of Recommended Vaccines and Its Associated Factors Among Malaysian Pilgrims During Hajj and Umrah 2018

This study aimed to assess the uptake of recommended vaccines and to identify the factors associated with the vaccines' uptake among Malaysian Hajj and Umrah pilgrims. A cross-sectional survey among Malaysian Hajj and Umrah pilgrims in 2018. The uptake of the recommended vaccines was surveyed through an anonymous self-administered questionnaire to pilgrims attending a pre-departure Hajj/Umrah orientation course. Descriptive statistics were used for elaborating the demographic characteristics and vaccines uptake of the respondents. Multiple logistic regression was used for predicting the factors associated with the vaccines' uptake. A total of 1,274 pilgrims participated in the study with a mean age (standard deviation) of 42.42 (15.6). A total of 833 (65.4%) participants were females and 232 of the participants (18.2%) had at least more than one chronic disease. The uptake of influenza and pneumococcal vaccines were 28.6% (364/1,274) and 25.4% (324/1,274), respectively. Among the 527 pilgrims who were "at increased risk" of infections, 168 (31.9%) and 184 (34.9%) received influenza and pneumococcal vaccines, respectively. Gender, marital status and occupation were the common predictors associated with vaccines uptake. The vaccination uptake among Malaysian Hajj and Umrah pilgrims is low and declining from previous years. Educating the pilgrims toward vaccine uptake is essential and exploring the barriers for vaccination.

Antibacterial evaluation of activated carbon cloth with Ag+ impregnated with ZnO nanoparticles

Purpose

Staphylococcus aureus (S. aureus), Klebsiella pneumoniae (K. pneumoniae) and Streptococcus pneumoniae (S. pneumoniae) are among the pathogens detected during Hajj pilgrimage known to cause pneumonia. This study aims to evaluate the antibacterial activity of activated carbon cloth (ACC) with Ag+ impregnated with zinc oxide nanoparticles (ZnO NPs) against these pathogens.

Design/methodology/approach

ZnO NPs were impregnated into ACC-Ag+ via layer-by-layer (LbL) self-assembly. Scanning electron microscope (SEM) was used to observe the fine surface morphological details of the ACC-Ag+-ZnO sheets. Antibacterial activity of the ACC-Ag+-ZnO sheets was evaluated using the disk-diffusion susceptibility assay. Allergy patch test was done to evaluate allergic reactions of the ACC-Ag+-ZnO sheets on human skin.

Findings

SEM micrographs showed successful impregnation of ZnO NPs into the ACC-Ag+ sheets. Disk-diffusion susceptibility assay results of ACC-Ag+-ZnO sheets against S. aureus, K. pneumoniae and S. pneumoniae showed good antibacterial activity; with 1.82 ± 0.13 mm zone of inhibition for S. pneumoniae, at a ZnO concentration of 0.78 mg mL-1. No signs of human skin irritation were observed throughout the allergy patch test.

Originality/value

Results indicate that ACC-Ag+-ZnO sheets could potentially be embedded within surgical face masks (pilgrims’ preferred) to reduce the risks involved with the transmission of respiratory tract infections during and after mass gatherings (e.g. Hajj/Umrah, Olympics).

Acquisition of respiratory and gastrointestinal pathogens among health care workers during the 2015 Hajj season

BACKGROUND

Data on the risk of transmission of infection to health care workers (HCWs) serving ill pilgrims during the Hajj is scarce.

METHODS

Two cohorts of HCWs, the first serving Hajj pilgrims in Mecca and the second serving patients in Al-Ahsa, were investigated for respiratory and gastrointestinal symptoms and pathogen carriage using multiplex polymerase chain reaction before and after the 2015 Hajj.

RESULTS

A total of 211 HCWs were enrolled of whom 92 were exposed to pilgrims (Mecca cohort), whereas 119 were not exposed (Al-Ahsa cohort). Symptoms were observed only in HCWs from the Mecca cohort, with 29.3% experiencing respiratory symptoms during the Hajj period or in the subsequent days and 3.3% having gastrointestinal symptoms. Acquisition rates of at least 1 respiratory virus were 14.7% in the Mecca cohort and 3.4% in the Al-Ahsa cohort (P = .003). Acquisition rates of at least 1 respiratory bacterium were 11.8% and 18.6% in the Mecca and Al-Ahsa cohorts, respectively (P = .09). Gastrointestinal pathogens were rarely isolated in both cohorts of HCWs and acquisition of pathogens after the Hajj was documented in only a few individuals.

CONCLUSIONS

HCWs providing care for pilgrims both acquire pathogens and present symptoms (especially respiratory symptoms) more frequently than those not working during Hajj.

The Hajj 2019 Vaccine Requirements and Possible New Challenges

Each year millions of pilgrims perform the annual Hajj from more than 180 countries around the world. This is one of the largest mass gathering events and may result in the occurrence and spread of infectious diseases. As such, there are mandatory vaccinations for the pilgrims such as meningococcal vaccines. The 2019 annual Hajj will take place during August 8-13, 2019. Thus, we review the recommended and mandated vaccinations for the 2019 Hajj and Umrah. The mandatory vaccines required to secure the visa include the quadrivalent meningococcal vaccine for all pilgrims, while yellow fever, and poliomyelitis vaccines are required for pilgrims coming from countries endemic or with disease activity. The recommended vaccines are influenza, pneumococcal, in addition to full compliance with basic vaccines for all pilgrims against diphtheria, tetanus, pertussis, polio, measles, and mumps. It is imperative to continue surveillance for the spread of antimicrobial resistance and occurrence of all infectious diseases causing outbreaks across the globe in the last year, like Zika virus, MDR-Typhoid, Nipah, Ebola, cholera, chikungunya and Middle East Respiratory Syndrome Coronavirus.

Epidemiology of respiratory viruses in Saudi Arabia: toward a complete picture

Acute lower respiratory tract infection is a major health problem that affects more than 15% of the total population of Saudi Arabia each year. Epidemiological studies conducted over the last three decades have indicated that viruses are responsible for the majority of these infections. The epidemiology of respiratory viruses in Saudi Arabia is proposed to be affected mainly by the presence and mobility of large numbers of foreign workers and the gathering of millions of Muslims in Mecca during the Hajj and Umrah seasons. Knowledge concerning the epidemiology, circulation pattern, and evolutionary kinetics of respiratory viruses in Saudi Arabia are scant, with the available literature being inconsistent. This review summarizes the available data on the epidemiology and evolution of respiratory viruses. The demographic features associated with Middle East respiratory syndrome-related coronavirus infections are specifically analyzed for a better understanding of the epidemiology of this virus. The data support the view that continuous entry and exit of pilgrims and foreign workers with different ethnicities and socioeconomic backgrounds in Saudi Arabia is the most likely vehicle for global dissemination of respiratory viruses and for the emergence of new viruses (or virus variants) capable of greater dissemination.

Acquisition of respiratory viruses and presence of respiratory symptoms in French pilgrims during the 2016 Hajj: A prospective cohort study

BACKGROUND

Viral respiratory tract infections are frequent among Hajj pilgrims. However, it is still not known whether viruses are responsible for the symptoms observed in sick pilgrims or whether they only colonize sick and asymptomatic pilgrims.

PATIENTS AND METHODS

A prospective cohort study was conducted among French Hajj pilgrims in 2016. Medical follow-up and systematic nasal swabbing were performed pre- and post-Hajj. Additional samples were obtained per-Hajj, at symptom onset in ill pilgrims. Viruses were identified using the BioFire FilmArray^® Respiratory multiplex qualitative PCR panel.

RESULTS

109 pilgrims were included. 83.5% presented respiratory symptoms during Hajj and 39.5% were still symptomatic on return. 5.5% of pre-Hajj, 95.2% of per-Hajj (at symptom onset) and 46.5% of post-Hajj samples tested positive (p < 0.0001). Acquisition rates of rhinovirus/enterovirus, coronavirus 229E and influenza A virus were respectively 38.6%, 19.8% and 2.0%. Although rhinovirus/enterovirus, coronavirus 229E and influenza A clearance were respectively 70.6%, 71.4% and 100% on return, overall virus carriage proportion on return was 75.0% in pilgrims with influenza-like illness and 44.0% in those who have never experienced this symptoms or resolved it (OR = 4.05, 95% CI [1.02-16.02]).

CONCLUSIONS

Viruses likely play some role in the pathogenesis of the respiratory tract infections at the Hajj. Point of care-rapid multiplex PCR assays are valuable diagnosis tools in this context when used at respiratory symptom onset or soon after.

An Overview of the Most Significant Zoonotic Viral Pathogens Transmitted from Animal to Human in Saudi Arabia

Currently, there has been an increasing socioeconomic impact of zoonotic pathogens transmitted from animals to humans worldwide. Recently, in the Arabian Peninsula, including in Saudi Arabia, epidemiological data indicated an actual increase in the number of emerging and/or reemerging cases of several viral zoonotic diseases. Data presented in this review are very relevant because Saudi Arabia is considered the largest country in the Peninsula. We believe that zoonotic pathogens in Saudi Arabia remain an important public health problem; however, more than 10 million Muslim pilgrims from around 184 Islamic countries arrive yearly at Makkah for the Hajj season and/or for the Umrah. Therefore, for health reasons, several countries recommend vaccinations for various zoonotic diseases among preventive protocols that should be complied with before traveling to Saudi Arabia. However, there is a shortage of epidemiological data focusing on the emerging and reemerging of zoonotic pathogens transmitted from animal to humans in different densely populated cities and/or localities in Saudi Arabia. Therefore, further efforts might be needed to control the increasing impacts of zoonotic viral disease. Also, there is a need for a high collaboration to enhance the detection and determination of the prevalence, diagnosis, control, and prevention as well as intervention and reduction in outbreaks of these diseases in Saudi Arabia, particularly those from other countries. Persons in the health field including physicians and veterinarians, pet owners, pet store owners, exporters, border guards, and people involved in businesses related to animal products have adopted various preventive strategies. Some of these measures might pave the way to highly successful prevention and control results on the different transmission routes of these viral zoonotic diseases from or to Saudi Arabia. Moreover, the prevention of these viral pathogens depends on socioeconomic impacts, available data, improved diagnosis, and highly effective therapeutics or prophylaxis.

MERS-CoV, influenza and other respiratory viruses among symptomatic pilgrims during 2014 Hajj season

More than two million Muslims visit Makkah, Saudi Arabia, annually to perform the religious rituals of Hajj where the risk of spreading respiratory infections is very common. The aim here was to screen symptomatic pilgrims for Middle East respiratory syndrome coronavirus (MERS-CoV) and other viral etiologies. Thus, 132 nasopharyngeal samples were collected from pilgrims presenting with acute respiratory symptoms at the healthcare facilities in the holy sites during the 5 days of the 2014 Hajj season. Samples were tested using real-time reverse transcription polymerase chain reactions and microarray. Demographic data including age, sex, and country of origin were obtained for all participants. While we did not detect MERS-CoV in any of the samples, several other viruses were detected in 50.8% of the cases. Among the detected viruses, 64.2% of the cases were due to a single-virus infection and 35.8% were due to the coinfections with up to four viruses. The most common respiratory virus was influenza A, followed by non-MERS human coronaviruses, rhinoviruses, and influenza B. Together, we found that it was not MERS-CoV but other respiratory viruses that caused acute respiratory symptoms among pilgrims. The observed high prevalence of influenza viruses underscores the need for more effective surveillance during the Hajj and adoption of stringent vaccination requirements from all pilgrims.

What Have We Learned About Middle East Respiratory Syndrome Coronavirus Emergence in Humans? A Systematic Literature Review

BACKGROUND

Middle East respiratory syndrome coronavirus (MERS-CoV) was first identified in humans in 2012. A systematic literature review was conducted to synthesize current knowledge and identify critical knowledge gaps.

MATERIALS AND METHODS

We conducted a systematic review on MERS-CoV using PRISMA guidelines. We identified 407 relevant, peer-reviewed publications and selected 208 of these based on their contributions to four key areas: virology; clinical characteristics, outcomes, therapeutic and preventive options; epidemiology and transmission; and animal interface and the search for natural hosts of MERS-CoV.

RESULTS

Dipeptidyl peptidase 4 (DPP4/CD26) was identified as the human receptor for MERS-CoV, and a variety of molecular and serological assays developed. Dromedary camels remain the only documented zoonotic source of human infection, but MERS-like CoVs have been detected in bat species globally, as well as in dromedary camels throughout the Middle East and Africa. However, despite evidence of camel-to-human MERS-CoV transmission and cases apparently related to camel contact, the source of many primary cases remains unknown. There have been sustained health care-associated human outbreaks in Saudi Arabia and South Korea, the latter originating from one traveler returning from the Middle East. Transmission mechanisms are poorly understood; for health care, this may include environmental contamination. Various potential therapeutics have been identified, but not yet evaluated in human clinical trials. At least one candidate vaccine has progressed to Phase I trials.

CONCLUSIONS

There has been substantial MERS-CoV research since 2012, but significant knowledge gaps persist, especially in epidemiology and natural history of the infection. There have been few rigorous studies of baseline prevalence, transmission, and spectrum of disease. Terms such as "camel exposure" and the epidemiological relationships of cases should be clearly defined and standardized. We strongly recommend a shared and accessible registry or database. Coronaviruses will likely continue to emerge, arguing for a unified "One Health" approach.

Asymptomatic Middle East Respiratory Syndrome Coronavirus (MERS-CoV) infection: Extent and implications for infection control: A systematic review

Background

The Middle East Respiratory Syndrome Coronavirus (MERS-CoV) emerged in 2012 and attracted an international attention as the virus caused multiple healthcare associated outbreaks. There are reports of the role of asymptomatic individuals in the transmission of MERS-CoV, however, the exact role is not known.

Method

The MEDLINE/PubMed and Scopus databases were searched for relevant papers published till August 2018 describing asymptomatic MERS-CoV infection.

Results

A total of 10 papers were retrieved and included in the final analysis and review. The extent of asymptomatic MERS infection had increased with change in the policy of testing asymptomatic contacts. In early cases in April 2012–October 2013, 12.5% were asymptomatic among 144 PCR laboratory-confirmed MERS-CoV cases while in 2014 the proportion rose to 25.1% among 255 confirmed cases. The proportion of asymptomatic cases reported among pediatric confirmed MERS-CoV cases were higher (41.9%–81.8%). Overall, the detection rate of MERS infection among asymptomatic contacts was 1-3.9% in studies included in this review. Asymptomatic individuals were less likely to have underlying condition compared to fatal cases. Of particular interest is that most of the identified pediatric cases were asymptomatic with no clear explanation.

Conclusions

The proportion of asymptomatic MERS cases were detected with increasing frequency as the disease progressed overtime. Those patients were less likely to have comorbid disease and may contribute to the transmission of the virus.

Clinical respiratory infections and pneumonia during the Hajj pilgrimage: A systematic review

Background

The Islamic Hajj pilgrimage to Mecca is one of the world's largest annual mass gatherings. Inevitable overcrowding during the pilgrims' stay greatly increases the risk of acquiring and spreading infectious diseases, especially respiratory diseases.

Method

The MEDLINE/PubMed and Scopus databases were searched for all relevant papers published prior to February 2018 that evaluated the prevalence of clinical symptoms of respiratory infections, including pneumonia, among Hajj pilgrims, as well as their influenza and pneumococcal vaccination status.

Results

A total of 61 papers were included in the review. Both cohort- and hospital-based studies provide complementary data, and both are therefore necessary to provide a complete picture of the total burden of respiratory diseases during the Hajj. Respiratory symptoms have been common among Hajj pilgrims over the last 15 years. In cohorts of pilgrims, cough ranged from 1.9% to 91.5%. However, the prevalence rates of the most common symptoms (cough, sore throat, and subjective fever) of influenza-like illness (ILI) varied widely across the included studies. These studies have shown variable results, with overall rates of ILI ranging from 8% to 78.2%. These differences might result from differences in study design, study period, and rates of vaccination against seasonal influenza that ranged from 1.1% to 100% among study participants. Moreover, the definition of ILI was inconsistent across studies. In hospitalized Hajj pilgrims, the prevalence of pneumonia, that remains a major concern in critically ill patients, ranged from 0.2% to 54.8%.

Conclusions

Large multinational follow-up studies are recommended for clinic-based syndromic surveillance, in conjunction with microbiological surveillance. Matched cohorts ensure better comparability across studies. However, study design and data collection procedures should be standardized to facilitate reporting and to achieve comparability between studies. Furthermore, the definition of ILI, and of most common symptoms used to define respiratory infections (e.g., upper respiratory tract infection), need to be precisely defined and consistently used. Future studies need to address potential effect of influenza and pneumococcal vaccine in the context of the Hajj pilgrimage.

Bacterial respiratory carriage in French Hajj pilgrims and the effect of pneumococcal vaccine and other individual preventive measures: A prospective cohort survey

Background

Viral respiratory tract infections are known to be common in Hajj pilgrims while the role of bacteria is less studied.

Methods

Clinical follow-up, adherence to preventive measures and PCR-based pharyngeal bacterial carriage pre- and post-Hajj, were assessed in a cohort of 119 French Hajj pilgrims.

Results

55% had an indication for pneumococcal vaccination. Occurrence of respiratory symptoms was 76.5%, with cough (70.6%) and sore throat (44.5%) being the most frequent; fever was reported by 38.7% pilgrims and 42.0% took antibiotics. Respiratory symptoms, fever and antibiotic intake were significantly more frequent in pilgrims with indication for vaccination against pneumococcal infection. The prevalence of S. pneumoniae carriage (1.8% pre-, 9.8% post-Hajj), H. influenzae carriage (0.9%, 45.4%) and K. pneumoniae (2.8%, 9.8%) significantly increased post-Hajj. Pilgrims vaccinated with conjugate pneumococcal vaccine were seven time less likely to present S. pneumoniae carriage post-Hajj compared to those not vaccinated (3.2% vs. 18.0%, OR = 0.15; 95% CI [0.03–0.74], p = 0.02).

Conclusions

Pilgrims at risk for pneumococcal disease are more likely to suffer from febrile respiratory symptoms at the Hajj despite being immunized against pneumococcal disease and despite lowered S. pneumoniae carriage and should be targeted for reinforced prevention against respiratory infections.

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

BACKGROUND

The Islamic Hajj pilgrimage is the largest annual mass gathering in the world. The overcrowding of people promotes the acquisition, spread and transmission of respiratory pathogens, including Streptococcus pneumoniae.

METHODS

We conducted a methodological review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The objective was to summarize the available data regarding the prevalence of pneumococcal carriage among Hajj pilgrims and about carriage acquisition and circulation of S. pneumoniae among pilgrims before and after participating in the Hajj according to their vaccination status.

RESULTS

Eight articles met eligibility criteria for pneumococcal carriage and impact of pneumococcal vaccination on carriage. Seven of them showed a significant increase in nasopharyngeal carriage of pneumococci following the pilgrimage, with acquisition rates ranging from 18 to 36%. Serotypes 3, 19F and 34 are the most common. A significant increase in antibiotic resistant strains was observed following participation in the Hajj. A lower prevalence was found in pilgrims treated with antibiotics, those who used a hand sanitizer, or those who washed their hands more frequently than usual. An increased carriage of pneumococcal serotypes included in pneumococcal vaccines (10-valent pneumococcal conjugate vaccine (PCV10), 13-valent pneumococcal conjugate vaccine (PCV13), 23-valent pneumococcal polysaccharide vaccine (PPV23)) was observed following participation in the Hajj. To date, no study has shown a significant reduction in pneumococcal carriage among pilgrims after vaccination with PPV23 or PCV. In fact, no significant difference was currently observed in the prevalence ratio of pneumococcal carriage between vaccinated and unvaccinated pilgrims.

CONCLUSION

The studies analyzed in this review showed an increased carriage of pneumococcus in post-Hajj pilgrims compared to pre-Hajj pilgrims, including vaccine serotypes. Further studies are needed to investigate the possible relationships between carriage, disease and vaccine in pilgrims.

Infectious Diseases and Mass Gatherings

Purpose of Review

Mass gatherings (MGs) are characterized by a high concentration of people at a specific time and location. Infectious diseases are of particular concern at MGs. The aim of this review was to summarize findings in the field of infectious diseases with a variety of pathogens associated with international MGs in the last 5 years.

Recent Findings

In the context of Hajj, one of the largest religious MGs at Mecca, Saudi Arabia, respiratory tract infections are the leading cause of infectious diseases in pilgrims with a prevalence of 50–93%. The most commonly acquired respiratory viruses were human rhinovirus, followed by human coronaviruses and influenza A virus, in decreasing order. Haemophilus influenzae, Staphylococcus aureus, and Streptococcus pneumoniae were the predominant bacteria. The prevalence of Hajj-related diarrhea ranged from 1.1 to 23.3% and etiologies included Salmonella spp., and Escherichia coli, with evidence of acquisition of antimicrobial-resistant bacteria. In other MGs such as Muslim, Christian, and Hindu religious events, sports events, and large-scale open-air festivals, outbreaks have been reported less frequently. The most common outbreaks at these events involved diseases preventable by vaccination, notably measles and influenza. Gastrointestinal infections caused by a variety of pathogens were also recorded.

Summary

Because social distancing and contact avoidance are difficult measures to implement in the context of many MGs, individual preventive measures including vaccination, use of face mask, disposable handkerchief and hand hygiene may be recommended. Nevertheless, the effectiveness of these measures has been poorly investigated in the context of MGs.

High frequency of Haemophilus influenzae associated with respiratory tract infections among Malaysian Hajj pilgrims

BACKGROUND

Overcrowding during the annual Hajj pilgrimage has been known to increase the risk of infectious diseases transmission. Despite the high prevalence of respiratory illness among Malaysian Hajj pilgrims, knowledge about the etiologic pathogens is yet very limited. Thus, this study aimed to determine the spectrum of bacterial respiratory pathogens among the Hajj pilgrims returning to Malaysia in year 2016.

METHODS

Expectorated sputum specimens were collected from the Hajj pilgrims with symptomatic respiratory tract infections (RTIs). Subsequently, the bacterial pathogens were identified using the standard bacteriological culture method and Vitek II system.

RESULTS

This study indicated that 255 (87.33%) out of 292 cultured sputa were positive with at least one potential pathogenic bacteria. Out of 345 total bacterial isolates, 60% (n=207) were Haemophilus influenzae, which was associated with both single bacterium infection (132/173, 76.3%) and multiple bacterial infections (75/82, 91.5%). The other bacterial isolates included; Klebsiella pneumoniae (n=37, 10.7%), Moraxella catarrhalis (n=27, 7.8%), Haemophilus parainfluenzae (n=25, 7.2%), Streptococcus group G (n=18, 5.2%), Klebsiella spesies (n=16, 4.6%), Streptococcus pneumoniae (n=11, 3.2%) and few other organisms.

CONCLUSION

High frequency of H. influenzae was isolated from Malaysian Hajj pilgrims, especially those with respiratory symptoms. Further study should evaluate the actual pathogenicity of the organism and the interactions between the respiratory microbiota towards developing effective prevention strategies of RTIs among the local pilgrims.

Clinical management of respiratory syndrome in patients hospitalized for suspected Middle East respiratory syndrome coronavirus infection in the Paris area from 2013 to 2016

Background

Patients with suspected Middle East respiratory syndrome coronavirus (MERS-CoV) infection should be hospitalized in isolation wards to avoid transmission. This suspicion can also lead to medical confusion and inappropriate management of acute respiratory syndrome due to causes other than MERS-CoV.

Methods

We studied the characteristics and outcome of patients hospitalized for suspected MERS-CoV infection in the isolation wards of two referral infectious disease departments in the Paris area between January 2013 and December 2016.

Results

Of 93 adult patients (49 male (52.6%), median age 63.4 years) hospitalized, 82 out of 93 adult patients had returned from Saudi Arabia, and 74 of them were pilgrims (Hajj). Chest X-ray findings were abnormal in 72 (77%) patients. The 93 patients were negative for MERS-CoV RT-PCR, and 70 (75.2%) patients had documented infection, 47 (50.5%) viral, 22 (23.6%) bacterial and one Plasmodium falciparum malaria. Microbiological analysis identified Rhinovirus (27.9%), Influenza virus (26.8%), Legionella pneumophila (7.5%), Streptococcus pneumoniae (7.5%), and non-MERS-coronavirus (6.4%). Antibiotics were initiated in 81 (87%) cases, with two antibiotics in 63 patients (67.7%). The median duration of hospitalization and isolation was 3 days (1–33) and 24 h (8–92), respectively. Time of isolation decreased over time (P < 0.01). Two patients (2%) died.

Conclusion

The management of patients with possible MERS-CoV infection requires medical facilities with trained personnel, and rapid access to virological results. Empirical treatment with neuraminidase inhibitors and an association of antibiotics effective against S. pneumoniae and L. pneumophila are the cornerstones of the management of patients hospitalized for suspected MERS-CoV infection.

Electronic supplementary material

The online version of this article (10.1186/s12879-018-3223-5) contains supplementary material, which is available to authorized users.