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  • ProMED: Hajj travel advice

    Published Date: 2012-10-11 17:24:30
    Subject: PRO> Health hazards - Saudi Arabia: updated Hajj advice
    Archive Number: 20121011.1338172

    HEALTH HAZARDS - SAUDI ARABIA: UPDATED HAJJ PILGRIMS TRAVEL ADVICE
    ************************************************** ****************
    A ProMED-mail post
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    Date: 11 Oct 2012
    Source: Eurosurveillance 2012; 17(41), 11 Oct [edited]
    This year the Hajj will take place during 24-29 October. Recent outbreaks of Ebola haemorrhagic fever in Uganda and the Democratic Republic of the Congo, cholera in Sierra Leone, and infections associated with a novel coronavirus in Saudi Arabia and Qatar required review of the health recommendations of the 2012 Hajj. Current guidelines foresee mandatory vaccination with quadrivalent meningococcal vaccine for all pilgrims, and yellow fever and poliomyelitis vaccine for pilgrims from high-risk countries. Influenza vaccine is strongly recommended. .



    The Hajj: updated health hazards and current recommendations for 2012
    ------------------------------------------------------------
    This year [2012] the Hajj will take place during [24-29 Oct 2012]. Recent outbreaks of Ebola haemorrhagic fever in Uganda and the Democratic Republic of the Congo, cholera in Sierra Leone, and infections associated with a novel coronavirus in Saudi Arabia and Qatar required review of the health recommendations of the 2012 Hajj. Current guidelines foresee mandatory vaccination with quadrivalent meningococcal vaccine for all pilgrims and yellow fever and poliomyelitis vaccine for pilgrims from high-risk countries. Influenza vaccine is strongly recommended.

    The annual Hajj is one of the greatest assemblies of humankind on earth. Each year, 3 million Muslims attend the Hajj in Mecca, Saudi Arabia. Of these, 1.8 million non-Saudi Arabians usually come from overseas countries, and 89 per cent (1.6 millions) of them arrive by air [1]. Pilgrims come from more than 180 countries worldwide, and about 45 000 pilgrims each year arrive to Saudi Arabia from the European Union [2].

    Preventive measures during the Hajj:
    Saudi Arabia provides free health care to all pilgrims during the Hajj. For the 2012 Hajj, which will take place on [24-29 Oct 2012], the country has prepared 25 hospitals, 4427 beds including 500 critical care beds and 550 emergency care beds. In addition, there are 141 health care centres in the vicinity of the Hajj area with 20 000 specialised health care workers. The planning for the Hajj relies on the coordinated efforts of 24 supervisory committees [2]. The Hajj preventive medicine committee oversees all public health and preventative matters during the Hajj. A large number of public health officers regulate ports of entry for all pilgrims to ensure compliance with the requirements of the Saudi Arabian Ministry of Health. Public health teams are located in various areas of the Hajj, including 21 mobile teams. At each of the 18 hubs at King Abdulaziz International Airport Hajj terminal in Jeddah, 2 clinical examination rooms and a large holding area are dedicated to assess arriving pilgrims, check their immunisation status, and administer the recommended prophylactic medicines [2]. The public health teams and teams at the ports of entry report back to the command centre on 9 communicable diseases using electronic and manual surveillance systems. These diseases are influenza, influenza-like illness, meningococcal disease, food poisoning, viral haemorrhagic fevers, yellow fever, cholera, poliomyelitis, and plague [2].

    Pre- and post-Hajj travel advice:
    The Hajj is a unique event with possible impact on international public health. Health care practitioners around the world must be attentive to the potential risks of disease transmission during the Hajj. They must recommend appropriate strategies for the prevention and control of communicable diseases before, during, and after the completion of the Hajj. The current international collaboration in planning vaccination campaigns, developing visa quotas, arranging rapid repatriation, and managing health hazards at the Hajj are crucial steps in this process. The Saudi Arabian Ministry of Health publishes the Hajj requirements for each Hajj season. This year's [2012] Hajj recommendations have recently been published [3].

    Recent outbreaks of Ebola haemorrhagic fever in Uganda and the Democratic Republic of the Congo (DRC), cholera in Sierra Leone, and infections associated with a novel coronavirus in Saudi Arabia and Qatar required review of the health recommendations of the 2012 Hajj. We present here the changes and additions made in the recommendations for these diseases. For completeness, we also summarise the existing recommendations [3,4].

    Meningococcal disease
    The risk of the occurrence of meningococcal outbreaks is a real concern during the Hajj seasons. This risk is related to the high carriage rates, with one study from Mecca reporting carriage rate as high as 80 per cent [5]. Due to the previous occurrence of meningococcal outbreaks, the bivalent A and C meningococcal vaccine became a requirement for the attendance of the Hajj in 1986. Two large outbreaks caused by meningococcal serogroup W135 in 2000 and 2001 [6-8] resulted in an extension of the previous requirement to include serogroups Y and W135, and the quadrivalent (A, C, Y, W135) meningococcal polysaccharide vaccine was included as a requirement for a Hajj visa in May 2001 [9]. In addition, visitors arriving from countries in the African meningitis belt receive chemoprophylaxis with ciprofloxacin tablets (500 mg) at the port of entry to lower the rate of meningococcal carriage. It is estimated that about 400 000 to 460 000 pilgrims receive the recommended doses at the port of entry in Saudi Arabia. Compliance with meningococcal vaccination among arriving international pilgrims exceeded 97 per cent in 2011 [1].

    Yellow fever
    In accordance with the International Health Regulations 2005, all travellers arriving from countries identified by the World Health Organization (WHO) as areas at risk of yellow fever must present a valid yellow fever vaccination certificate showing that the person was vaccinated at least 10 days previously and not more than 10 years before arrival at the border. In the absence of such a certificate, the individual will be placed under strict surveillance for 6 days from the date of vaccination or the last date of potential exposure to infection, whichever is earlier. Health offices at entry points will be responsible for notifying the appropriate director general of health affairs in the region or governorate about the temporary place of residence of the visitor. Aircraft, ships, and other means of transportation arriving from countries affected by yellow fever are requested to submit a certificate indicating that it applied disinfection in accordance with methods recommended by WHO.

    Risks of respiratory tract infections
    Acute upper respiratory tract infections (URTIs) are the most common disease during Hajj. There are many factors promoting the spread of respiratory pathogens, including close contact among pilgrims, shared sleeping tents, and dense air pollution [2]. The pathogens causing URTIs among pilgrims are respiratory syncytial virus (RSV), parainfluenza virus, influenza virus and adenovirus [10]. The rates of different types of respiratory virus infections are as follows: influenza (9.8 per cent), parainfluenza (7.4 per cent), adenovirus (5.4 per cent) and RSV (1.4 per cent) [11]. Because of overcrowding and the fact that many Muslims come from countries where tuberculosis (TB) is endemic, pulmonary tuberculosis was a leading cause of hospitalisation in patients with community-acquired pneumonia [12]. The estimated risk of tuberculosis acquisition during the Hajj is thought to be around 10 per cent, based on the use of pre-visit and post-visit QuantiFERON TB assay test [13]. In another community-based survey of the epidemiology of tuberculosis in Saudi Arabia, positive tests using purified tuberculin antigens were more frequent in Saudi Arabians living in the Holy cities hosting pilgrims compared to other cities in Saudi Arabia [14]. The development of strategies to reduce the transmission of TB during the Hajj is a challenge for which no evidence-based approved measures are available to date. The Saudi Arabian Ministry of Health continues to recommend wearing face masks in crowded places and changing them frequently to minimise transmission of respiratory infections. Controlling tuberculosis transmission in mass gatherings is an area that needs urgent research studies. [14].

    Novel coronavirus infection
    Of particular interest is the recent report of 2 cases of acute respiratory failure associated with a novel coronavirus. Both patients were previously healthy adults. The cases occurred a few months before the 2012 Muslim Hajj season. The 1st case of infection with the novel coronavirus was identified in a Saudi Arabian national, who died in June 2012 [15,16]. The 2nd case was a patient from Qatar who was transferred to a hospital in London, United Kingdom in early September 2012 [17]. Available data to date do not support human-to-human transmission of this novel coronavirus, and zoonotic transmission is highly suspected. In the 2nd case of this novel coronavirus infection, none of the 64 close contacts developed severe disease, 13 of them (20 percent) reported mild respiratory symptoms, and the novel coronavirus was not detected in 10 symptomatic contacts who were tested [17].

    WHO does not recommend any travel restrictions to or from Saudi Arabia. The current case definitions from WHO [18] and from the Saudi Arabian Ministry of Health can be found on the WHO website (http://www.who.int/csr/disease/coron.../en/index.html) and in Table 1, respectively. The practice of good hand hygiene and cough etiquette was associated with less respiratory illness among United States travellers to the 2009 Hajj [19]. It is recommended that pilgrims continue to practice proper hand hygiene, protective behaviours and cough etiquette to further decrease the occurrence of respiratory diseases. [see Table 1. Severe respiratory disease associated with novel coronavirus: case definition by the Saudi Arabian Ministry of Health at above given URL link.]

    Foodborne diseases and cholera
    Diarrhoeal illnesses during mass gathering including Hajj are a potential health hazard. Many factors may contribute to this problem including: inadequate standards of food hygiene, shortage of water, the presence asymptomatic carriers of pathogenic bacteria, and the preparation of large numbers of meals poorly stored by pilgrims. There are only few studies describing the incidence and aetiology of traveller's diarrhoea during the Hajj. In one study, diarrhoea was the 3rd most common cause (6.7 per cent) of hospitalisation [20]. Another study describes an outbreak of diarrhoeal illness in a small number of soldiers during the Hajj season [21]. As a precautionary measure, the Saudi Arabian Ministry of Health strongly enforces that pilgrims are not allowed to bring fresh food into Saudi Arabia. Only properly canned or sealed food or food stored in containers with easy access for inspection is allowed in small quantities, sufficient for one person for the duration of their trip.

    Cholera is another risk during the Hajj, especially in light of the continued occurrence of outbreaks in different countries. As of 20 Sep 2012, a total of 19 283 cases, including 276 (1.4 per cent) deaths have been reported in the ongoing cholera outbreak in Sierra Leone since the beginning of the year [2012] [22]. The highest numbers of cases occurred in the western area of the country, where the capital city of Freetown is located. In addition, the WHO reported a sharp increase in the number of cholera cases in July [2012] in the DRC and many other countries [23]. The Ministry of Health of Saudi Arabia has updated its public health staff at all ports of entry for pilgrims, to be observant of all pilgrims coming from areas where cholera has been reported by WHO, and to maintain a high level of vigilance for any signs and symptoms of diarrhoea, and to continue surveillance at their camps and initiate quarantine and contact tracing once a case is suspected. Emphasis is being placed on early detection of cases and timely provision of treatment at all Hajj premises, once pilgrims have passed the ports of entry while incubating the disease.

    Poliomyelitis
    Poliomyelitis is still predominant in certain countries around the world. The attendance of visitors from these countries to the Hajj may pose a health risk for other visitors. All travellers arriving from polio-endemic countries and re-established transmission countries, namely Afghanistan, Angola, Chad, the DRC, Nigeria and Pakistan, regardless of age and vaccination status, should receive one dose of oral poliovirus vaccine (OPV). Proof of OPV vaccination at least 6 weeks prior departure is required to apply for entry visa for Saudi Arabia. These travellers will also receive one dose of OPV at border points on arrival in Saudi Arabia. The same requirements are valid for travellers from recently endemic countries at high risk of reimportation of poliovirus, i.e. India (Table 2).

    Polio cases secondary to wild poliovirus importation or to circulating vaccine-derived poliovirus in the past 12 months have been reported in the following countries: China, Central African Republic, Cote d'Ivoire, Kenya, Mali, Niger, Somalia and Yemen [4]. All visitors aged under 15 years travelling to Saudi Arabia from these countries should be vaccinated against poliomyelitis with the OPV or inactivated poliovirus vaccine (IPV). Proof of OPV or IPV vaccination 6 weeks prior to application is required for entry visa. Irrespective of previous immunisation history, all visitors under 15 years arriving in Saudi Arabia will also receive one dose of OPV at border points (Table 2).

    Table 2. Saudi Arabian health requirements and recommendations for entry visas for the Hajj seasons in 2012

    Ebola outbreaks
    Two large outbreaks of Ebola have been reported by the Ministries of Health of Uganda and the DRC. In Uganda, a total of 24 probable and confirmed cases were reported during the outbreak. Eleven of these 24 cases have been laboratory-confirmed by the Uganda Virus Research Institute in Entebbe. A total of 17 deaths were reported in this outbreak. The last confirmed case was admitted on [3 Aug 2012] and discharged from hospital on [24 Aug 2012] [24,25]. This is twice the maximum incubation period (21 days) for Ebola proposed by the WHO during Ebola outbreak response operations. In the DRC, 46 cases (14 laboratory-confirmed, 32 probable) of Ebola haemorrhagic fever were reported until [15 Sep 2012]. Of these, 19 have been fatal (6 confirmed, 13 probable). The cases occurred in 2 health zones of Isiro and Viadana in Haut-Uele district in Province Orientale. In addition, 26 suspected cases have been reported and are being investigated.

    The 2 Ebola outbreaks are not epidemiologically linked and have been caused by 2 different Ebola subtypes: Ebola subtype Sudan in Uganda, and Ebola subtype Bundibugyo in DRC. To avoid global spread of the disease, the Saudi Arabian Ministry of Health decided to exclude pilgrims from these 2 countries for this Hajj season. This restriction is based on the careful review and deliberation of the national committee on communicable disease prevention who felt that it cannot be excluded that new cases may emerge, and on the fact that the risk of disease transmission is thought to be high with potential catastrophic consequences if occurring during the Hajj, as the disease has a high mortality rate, and no therapeutic interventions are available.

    [Reported by: J A Al-Tawfiq /1, Z A Memish /2
    1. Saudi Aramco Medical Services Organization, Dhahran, Kingdom of Saudi Arabia
    2. Public Health Directorate, Ministry of Health, Riyadh, Director WHO Collaborating Center for Mass Gathering Medicine, Professor, College of Medicine, Alfaisal University, Riyadh, Kingdom of Saudi Arabia]

    References
    1. Al-Tawfiq JA and Memish ZA. Mass gatherings and infectious diseases: prevention, detection and control. Infect Dis Clin North Am. 2012;26(3):725-37.
    2. Memish ZA. The Hajj: communicable and non-communicable health hazards and current guidance for pilgrims. Euro Surveill. 2010;15(39):pii=19671. Available from: http://www.eurosurveillance.org/View...rticleId=19671
    3. Memish ZA, Al Rabeeah AA. Health conditions for travellers to Saudi Arabia for the Umra and Hajj pilgrimage to Mecca: Requirements for 2012 (1433). J Infect Public Health 2012; 5(2):113-5.
    4. WHO. Health conditions for travellers to Saudi Arabia for the pilgrimage to Mecca (Hajj). Wkly Epidemiol Rec. 2012;87(30):277-80.
    5. al-Gahtani YM, el Bushra HE, al-Qarawi SM, al-Zubaidi AA, Fontaine RE. Epidemiolological investigation of an outbreak of meningococcal meningitis in makkah (Mecca), Saudi Arabia, 1992. Epidemiol Infect. 1995;115(3): 399-409.
    6. Memish ZA, Venkatesh S, Ahmed QA. Travel epidemiology: the Saudi perspective. Int J Antimicrob Agents. 2003;21(2): 96-101.
    7. Mayer LW, Reeves MW, Al-Hamdan N, Sacchi CT, Taha MK, Ajello GW, et al. Outbreak of W135 meningococcal disease in 2000: not emergence of a new W135 strain but clonal expansion within the electrophoretic type-37 complex. J Infect Dis. 2002;185(11):1596-1605.
    8. Issack MI, Ragavoodoo C. Hajj-related Neisseria meningitidis serogroup W135 in Mauritius. Emerg Infect Dis. 2002;8(3):332-4.
    9. Borrow R. Meningococcal disease and prevention at the Hajj. Travel Med Infect Dis. 2009(4):219-25.
    10. Balkhy HH, Memish ZA, Bafaqeer S, Almuneef MA. Influenza a common viral infection among Hajj pilgrims: time for routine surveillance and vaccination. J Travel Med. 2004;11(2):82-6.
    11. Alborzi A, Aelami MH, Ziyaeyan M, Jamalidoust M, Moeini M, Pourabbas B, et al. Viral etiology of acute respiratory infections among Iranian Hajj pilgrims, 2006. J Travel Med. 2009;16(4):239-42.
    12. Alzeer A, Mashlah A, Fakim N, Al-Sugair N, Al-Hedaithy M, Al-Majed S, et al. Tuberculosis is the commonest cause of pneumonia requiring hospitalization during Hajj (pilgrimage to Makkah). J Infect. 1998;36(3):303-6.
    13. Wilder-Smith A, Foo W, Earnest A, Paton NI. High risk of Mycobacterium tuberculosis infection during the Hajj pilgrimage. Trop Med Int Health. 2005;10(4):336-9.
    14. al-Kassimi FA, Abdullah AK, al-Hajjaj MS, al-Orainey IO, Bamgboye EA, Chowdhury MN. Nationwide community survey of tuberculosis epidemiology in Saudi Arabia. Tuber Lung Dis 1993;74(4):254-60.
    15. ProMED-mail. Novel coronavirus - Saudi Arabia: human isolate. Archive Number: 20120920.1302733. 20 Sep 2012. Available from: http://www.promedmail.org/?p=2400:1000
    16. Corman VM, Eckerle I, Bleicker T, Zaki A, Landt O, Eschbach-Bludau M, et al. Detection of a novel human coronavirus by real-time reverse-transcription polymerase chain reaction. Euro Surveill. 2012;17(39):pii=20285. Available from: http://www.eurosurveillance.org/View...rticleId=20285
    17. Pebody RG, Chand MA, Thomas HL, Green HK, Boddington NL, Carvalho C, et al. The United Kingdom public health response to an imported laboratory confirmed case of a novel coronavirus in September 2012. Euro Surveill. 2012;17(40):pii=20292. Available from:
    18. Revised interim case definition - novel coronavirus. Geneva: World Health Organization; 29 Sept 2012. Available from: http://www.who.int/csr/disease/coron.../en/index.html
    19. Balaban V, Stauffer WM, Hammad A, Afgarshe M, Abd-Alla M, Ahmed Q, et al. Protective practices and respiratory illness among US travelers to the 2009 Hajj. J Travel Med. 2012;19(3):163-8.
    20. Al-Ghamdi SM, Akbar HO, Qari YA, Fathaldin OA, Al-Rashed RS. Pattern of admission to hospitals during muslim pilgrimage (Hajj). Saudi Med J 2003;24(10):1073-6.
    21. Al-Joudi AS. An outbreak of foodborne diarrheal illness among soldiers in mina during hajj: the role of consumer food handling behaviors. J Family Community Med. 2007;14(1):29-33.
    22. WHO/UNICEF Sierra Leone. Cholera situation in Sierra Leone, 21 Sep, 2012. Available from: http://www.afro.who.int/index.php?op...nload&gid=7868
    23. Cholera: situation in the WHO African Region, 22 August 2012. World Health Organization Regional Office for Africa. [Accessed 4 Oct 2012]. Available from: http://www.who.int/hac/crises/choler...august2012.pdf
    24. 2012: Ebola hemorrhagic fever outbreak in Democratic Republic of Congo. Outbreak postings. Atlanta: CDC. [Accessed 4 Oct 2012]. Available from: http://www.cdc.gov/ncidod/dvrd/spb/o...ebola-drc-2012
    25. 2012: Ebola hemorrhagic fever outbreak in Uganda. Outbreak postings. Atlanta: CDC. [Accessed 4 Oct 2012]. Available from: http://www.cdc.gov/ncidod/dvrd/spb/o...ebola-drc-2012

    --
    communicated by:
    ProMED-mail <promed@promedmail.org>

    [The Hajj is the largest annual mass gathering in the world, and the Saudi Arabian Ministry of Health has developed the expertise of dealing with public health issues during mass gatherings. These updated recommendations take into consideration the ongoing public health events since the publication of the initial recommendations (Health conditions for travellers to Saudi Arabia for the pilgrimage to Mecca (Hajj) WHO WER, 2012, 7(20):277-288, available at: http://www.who.int/wer/2012/wer8730.pdf). Notable differences include the addition of a section on foodborne disease and cholera and mention of the novel coronavirus and the Ebola outbreaks.

  • #2
    Re: ProMED: Hajj travel advice

    Published Date: 2012-10-21 19:39:32
    Subject: PRO/AH/EDR> Ebola virus disease - Congo DR (20): Hajj travel restriction
    Archive Number: 20121021.1356422

    EBOLA VIRUS DISEASE - DEMOCRATIC REPUBLIC OF CONGO (20): HAJJ TRAVEL RESTRICTION
    ************************************************** ******************************
    A ProMED-mail post
    ProMED is the largest publicly-available surveillance system conducting global reporting of infectious diseases outbreaks. Subscribe today.

    ProMED-mail is a program of the
    International Society for Infectious Diseases
    The International Society for Infectious Diseases (ISID) brings together a network of individuals from around the world.


    Date: Tue 16 Oct 2012
    Source: Radio Okapi [in French, trans. & edited by Mod.CP]
    La Mecque, lieu de pélerinage des musulmans en Arabie Saoudite Photo Droits tiers Les musulmans vivant en RDC ne participeront pas au pèlerinage à la Mecque cette année. Le gouvernement saoudien a pris cette décision pour éviter toute contamination aux virus d’Ebola et de choléra qui sévit dans plusieurs régions du pays.



    Muslims living in the Democratic Republic of Congo (DRC) will not participate in the pilgrimage to Mecca this year [2012]. The Saudi government has taken this decision to avoid transmission of Ebola virus disease and cholera, which exist in many parts of the country. The President and Legal Representative of the Islamic Community in the DRC (Comico), Sheikh Abdallah Mangala, confirmed this information on Tue 16 Oct 2012.

    Sheikh Abdullah Mangala stated that the Saudi government was acting "to protect the lives of other pilgrims in deciding that the Muslims who live in the DRC should not participate in the pilgrimage this year [2012]. This is a responsible decision by the Saudi government in view of the fact that over 2 million people will be visiting Saudi Arabia. Islam itself requires that you should not expose yourself to harm," the sheik said while calling for Muslims in the DRC to pray for their country. "However, we implore the almighty to give the Congolese government officials strength and wisdom to eradicate this epidemic and enable pilgrims from the DRC to visit Mecca next year [2013].

    However, the World Health Organisation (WHO) says it has not recommended any restriction of movement to or from the DRC to neighbouring countries as a consequence of these epidemics. The Resident Representative of the WHO, Doctor Leodegat Bazira, told Radio Okapi on Tue 16 Oct 2012 that the Ebola virus disease epidemic in the eastern part of the DRC was stabilising. "As of 14 Oct 2012, there have been 75 cases with 36 fatalities. If we look at the number of deaths recorded during the course of the epidemic, we consider that the rate of detection of cases is not increasing, and the number of deaths has stabilised at 36. This stabilization is the result of the implementation of interventions such as the establishment of isolation facilities and surveillance activities."

    The Ebola virus disease outbreak was declared in the DRC in August 2012. It has occurred mainly at Isiro in Orientale province. The Department of Health has recommended preventive measures to avoid spread of the disease. "The sooner preventive measures are applied, the faster the spread of disease will be stopped," said Minister Felix Kabange in August 2012, urging the Congolese population to avoid touching any animal found dead in the forest or consuming its meat. "You should also avoid touching the blood, vomit or urine of any patient suffering from a viral haemorrhagic fever, or a deceased person," he added.

    In the case of cholera, the Ministry of Health and WHO have recorded more than 19 000 cases between January and June 2012. The most affected provinces are: Ecuador, Bas-Congo, South Kivu and Orientale.

    --
    Communicated by:
    ProMED-mail <promed@promedmail.org>

    [The restriction on pilgrimage to Mecca on the basis of the occurrence of a small number of Ebola virus disease cases in Orientale province seems an over-reaction. Perhaps the recent death of a Saudi patient as the result of infection by a previously uncharacterised coronavirus has alarmed the Saudi medical authorities. - Mod.CP]

    (Our thread on the Ebola outbreak in DRC is here: http://www.flutrackers.com/forum/sho...d.php?t=191192 - alert)

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