Mass religious gatherings in Middle East increase risk of MERS coronavirus spreading globally
platform has been used by numerous international agencies, including the U.S. Centers for Disease Control and Prevention (CDC), the European Center for Disease Prevention and Control, and the World Health Organization (WHO) to evaluate emerging infectious disease threats, including those during global mass gatherings such as the Olympics and the hajj.
“With millions of foreign pilgrims set to congregate in Mecca and Medina between Ramadan and the hajj, pilgrims could acquire and subsequently return to their home countries with MERS, either through direct exposure to the as-of-yet unidentified source or through contact with domestic pilgrims who may be infected,” he said.
Khan’s team found that of the 16.8 million travelers who flew on commercial flights out of Saudi Arabia, Jordan, Qatar, and the United Arab Emirates between June and November 2012 (the period starting one month before Ramadan and ending one month after the hajj) 51.6 percent had destinations in just eight countries: India (16.3 percent), Egypt (10.4 percent), Pakistan (7.8 percent), Britain (4.3 percent), Kuwait (3.6 percent), Bangladesh (3.1 percent), Iran (3.1 percent) and Bahrain (2.9 percent).
Twelve cities — Cairo, Kuwait City, London, Bahrain, Beirut, Mumbai, Dhaka, Karachi, Manila, Kozhikode (India), Istanbul, and Jakarta — each received more than 350,000 commercial air travelers between June and November 2012 from the four countries where MERS cases have been traced back to.
In contrast to SARS, where the disease was introduced into predominantly high-income countries through air travel, more than half of all air travelers departing Saudi Arabia, Jordan, Qatar, and UAE have final destinations in low or lower-middle income countries. Two-thirds of all hajj pilgrims originate from low or lower-middle income countries.
The release notes that of particular note is the degree of connectivity between the Middle East and South Asia.
Collectively, India, Pakistan, Bangladesh, Afghanistan, and Nepal represent the final destinations of nearly one-third of all international air travelers departing Saudi Arabia, Jordan, Qatar and the UAE, and the origins of roughly one in four foreign hajj pilgrims worldwide.
“Given that these countries have limited resources, they may have difficulty quickly identifying imported MERS cases, implementing rigorous infection control precautions and responding effectively to newly introduced cases,” Khan said.
Khan’s previous research suggests that if screening of air travelers for MERS is considered, it would be far more efficient and less disruptive to the world’s air traffic to screen travelers as they leave source areas in the Middle East rather than screen the same travelers as they arrive at other airports around the world. All countries receiving pilgrims and other travelers from known MERS areas, however, should mobilize their infectious disease surveillance and public health resources in ways that are commensurate with their potential for MERS introduction, he said.
Educating and preparing front-line health care providers to consider the possibility of MERS in patients is also critical, he said, since that is a necessary first step to implement effective infection control practices that could minimize the risk of spread to others. In the SARS epidemic, delays in considering the diagnosis led to delays in implementing appropriate infection control measures, which in turn enabled SARS to spread within health care institutions.
Funding for this study was provided by the Canadian Institutes of Health Research and the U.S. Centers for Disease Control and Prevention.
— Read more in Kamran Khan et al., “Potential for the International Spread of Middle East Respiratory Syndrome in Association with Mass Gatherings in Saudi Arabia,” PLoS Currents: Outbreaks (17 July 2013)
