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How great is the risk of Middle East respiratory syndrome coronavirus to the global population Expert Rev Anti Infect Ther 11 10 979 981 2013 Ziad A Memish Author for correspondence WHO Collaborating Center for Mass Gathering Medicine Ministry of Health Al Faisal University Riyadh 11176 Kingdom of Saudi Arabia Tel 966 11 2124052 Fax 966 11 2125052 zmemish Alimuddin Zumla Division of Infection and Immunity University College London London and University College London Hospitals NHS Foundation Trust London UK Jaffar A Al Tawfiq Specialty Internal Medicine Saudi Aramco Medical Services Organization Dhahran Kingdom of Saudi Arabia The potential for respiratory tract infections during mass gatherings is related to the presence of a large number of people from different parts of the world in congested and crowded areas Since the initial discovery of the Middle East respiratory syndrome coronavirus MERS CoV there has been global concern about its threat to global health security and its pandemic potential The virus was initially recovered from a patient from the Kingdom of Saudi Arabia KSA in September 2012 1 2 The virus was originally designated human coronavirus Erasmus Medical Center 2 and was later called MERS CoV 3 As of 30 August 2013 there were a total of 104 cases with 49 47 death 101 The majority of these cases occurred in KSA where 82 cases with 41 50 deaths 101 In Saudi Arabia there were two periods of disease activ ity 4 The initial period was from June 2012 to 1 April 2013 and during that period nine cases were reported mainly in the central and western part of the country These cases occurred sporadi cally and included two family clusters This reporting period was also signifi cant for the lack of any transmission in health care setting The second reporting period in Saudi Arabia was from 1 April 2013 to 14 July 2013 4 This period showed a cluster of 23 cases and these cases were linked to an outbreak in a health care facility in the eastern part of the country Al Hasa 5 In addition to Saudi Arabia 2 4 7 additional cases were reported from other countries such as Qatar 1 Jordan 8 102 the UK 9 10 Germany 11 France 12 Tunisia 103 UAE 13 and Italy 104 MERS CoV infection so far has three pattern of transmission The first pattern is the occurrence of sporadic cases in different Middle East countries The second pat tern is nosocomial transmission within health care facilities to health care work ers and other patients 4 and the third pattern is the occurrence of transmission as a family cluster 5 6 8 10 14 15 The severity of reported cases of MERS CoV ranges from mild disease to fulminant respiratory infection 4 5 Less severe disease was described within fam ily contacts and hospital clusters 5 6 15 The clinical spectrum of MERS CoV infections also includes asymptomatic and subclinical cases 16 Asymptomatic and or subclinical MERS CoV cases are important since these cases may contrib ute to the transmission of MERS CoV to close contacts within the community or the hospital setting cases 16 In addi tion the presence of these mild cases would inversely affect the reported high case fatality rates The potential for respiratory tract infections during mass gatherings is related to the presence of a large number of people from different parts of the world in congested and crowded areas especially during the annual Muslim pilgrimage the Hajj 17 18 Thus the occurrence of the first cases MERS CoV a few months before the 2012 Hajj sea son was a concern for international com munities 19 At that time there was no human to human transmission and there Editorial www expert 10 1586 14787210 2013 836965 C211 2013 Informa UK Ltd ISSN 1478 7210 979 Expert Review of Anti infective Therapy Downloaded from by University of North Dakota on 10 27 14 For personal use only were no travel restrictions to areas where cases were reported 19 The KSA has a unique policy to manage health risks associated with the annual pilgrimage through the preparation and annual revision of the recommendations and health requirements for the annual Umrah and Hajj As MERS CoV emerged in 2012 prior to Hajj an update to the Hajj requirements was published in Eurosurveillance 20 The recommendations included explicit measures to reduce the risk of transmission of viral respiratory infections including MERS CoV infection These recommendations include the practice of proper hand hygiene protective behaviors and cough etiquette 20 The 2012 Hajj season which took place from 10 to 31 October 2012 was uneventful without any MERS CoV cases being reported During that season four mil lion pilgrims from 187 countries performed the annual Hajj None should 300 pilgrims with respiratory symptoms was tested positive for MERS CoV infections 21 In addition the testing of 154 French pilgrims returning from the 2012 annual Hajj showed that 83 4 had respiratory symptoms 22 None of the pilgrims were positive for MERS CoV by real time PCR 22 This year 2013 the annual Hajj is taking place in October 1 20 and thus with the increased number of cases of MERS CoV there was a concern of the potential risk of the transmission of MERS CoV The KSA released the 2013 Hajj requirement 105 The Saudi Ministry of Health recommends that people aged over 65 years and those with chronic diseases e g heart disease kidney disease respiratory disease and dia betes and pilgrims with immune deficiency congenital and acquired malignant and terminal illnesses pregnant women and children aged under 12 years planning to come for Hajj and Umrah this year to postpone the performance of the Hajj and Umrah 105 The Saudi Ministry of Health also recom mends that all pilgrims should comply with common public health recommendations to prevent the spread of respiratory infectious disease such as hand hygiene use of disposable tis sues when coughing or sneezing avoid direct contact with the persons who is coughing sneezing or vomiting 105 The second meeting of the WHO Emergency Committee convened by the Director General under the International Health Regulations 2005 106 was held on Wednesday 17 July 2013 The unanimous decision of the Committee was that with the information now available and using a risk assessment approach the conditions for a Public Health Emergency of International Concern have not at presently been met 107 Two mass gatherings events attracting over 15 million pilgrims have occurred in Saudi Arabia over the past 12 months the annual Hajj in October 2012 19 and the recently completed July 2013 Ramadaan Umrah season No MERS CoV cases have been reported from these events These observations support the findings in a recent modeling paper published in Lancet that examined the risk of MERS CoV on mass gathering 23 24 Breban and colleagues estimated MERS CoV R0 to be 0 69 compared to the R0 for pre pandemic severe acute respiratory syndrome coronavirus of 0 80 23 concluding that MERS CoV in its current status quo is unlikely to cause a pandemic 23 Watchfulsurveilanceand vigilance will continue despite the minimal risk of global spread Financial announcement of the Coronavirus Study Group J Virol 87 14 7790 7792 2013 4 Assiri A Al Tawfiq JA Al Rabeeah AA et al Epidemiological demographic and clinical characteristics of 47 cases of Middle East respiratory syndrome coronavirus disease from Saudi Arabia a descriptive study Lancet Infect Dis 13 9 752 761 2013 5 Assiri A McGeer A Perl TM et al KSA MERS CoV Investigation Team Hospital outbreak of Middle East respiratory syndrome coronavirus N Engl J Med 369 5 407 416 2013 6 Memish ZA Zumla AI Al Hakeem RF Al Rabeeah AA Stephens GM Family cluster of Middle East respiratory syndrome coronavirus infections N Engl J Med 368 26 2487 2494 2013 7 Al Ahdal MN Al Qahtani AA Rubino S Coronavirus respiratory illness in Saudi Arabia J Infect Dev Ctries 6 10 692 694 2012 8 Hijawi B Abdallat M Sayaydeh A et al Novel coronavirus infections in Jordan April 2012 epidemiological findings from a retrospective investigation East Mediterr Health J 19 Suppl 1 S12 S18 2013 9 Evidence of person to person transmission within a family cluster of novel coronavirus infections United Kingdom February 2013 Euro Surveill 18 11 20427 2013 10 Bermingham A Chand MA Brown CS et al Severe respiratory illness caused by a novel coronavirus in a patient transferred to the United Kingdom from the Middle East September 2012 Euro Surveill 17 40 20290 2012 11 Buchholz U Muller MA Nitsche A et al Contact investigation of a case of human novel coronavirus infection treated in a German hospital October November 2012 Euro Surveill 18 8 pii 20406 2013 12 Mailles A Blanckaert K Chaud P et al First cases of Middle East Respiratory Syndrome Coronavirus MERS CoV infections in France investigations and implications for the prevention of human to human transmission France May 2013 Euro Surveill 18 24 pii 20502 2013 Editorial Memish Zumla Al Tawfiq 980 Expert Rev Anti Infect Ther 11 10 2013 Expert Review of Anti infective Therapy Downloaded from by University of North Dakota on 10 27 14 For personal use only 13 Drosten C Seilmaier M Corman VM et al Clinical features and virological analysis of a case of Middle East respiratory syndrome coronavirus infection Lancet Infect Dis 13 9 745 751 2013 14 AlBarrak AM Stephens GM Hewson R Memish ZA Recovery from severe novel coronavirus infection Saudi Med J 33 1265 1269 2012 15 Health Protection Agency HPA UK Novel Coronavirus Investigation team Evidence of person to person transmission within a family cluster of novel coronavirus infections United Kingdom February 2013 Euro Surveill 18 20427 2013 16 Memish ZA Zumla AI Assiri A Middle East respiratory syndrome coronavirus infections in health care workers N Engl J Med 369 9 884 886 2013 17 Tawfiq JA Memish ZA Mass gatherings and infectious diseases prevention detection and control Infect Dis Clin North Am 26 725 737 2012 18 Ahmed QA Arabi YM Memish ZA Health risks at the Hajj Lancet 367 1008 1015 2006 19 Al Tawfiq JA Smallwood CA Arbuthnott KG Malik MS Barbeschi M Memish ZA Emerging respiratory and novel coronavirus 2012 infections and mass gatherings East Mediterr Health J 19 Suppl 1 S48 S54 2013 20 Al Tawfiq JA Memish ZA The Hajj updated health hazards and current recommendations for 2012 Euro Surveill 17 41 20295 2012 21 Novel coronavirus Eastern Mediterranean 03 Saudi comment 12 February 2013 ProMed 2013 archive number 20130212 1540011 22 Gautret P Charrel R Belhouchat K et al Lack of nasal carriage of novel corona virus HCoV EMC in French Hajj pilgrims returning from the Hajj 2012 despite a high rate of respiratory symptoms Clin Microbiol Infect 19 7 E315 E317 2013 23 Breban R Riou J Fontanet A Interhuman transmissibility of Middle East respiratory syndrome coronavirus estimation of pandemic risk Lancet 382 9893 694 699 2013 24 Bauch CT Oraby T Assessing the pandemic potential of MERS CoV Lancet doi 10 1016 S0140 6736 13 61504 4 2013 Epub ahead of print Websites 101 CDC Middle East Respiratory Syndrome MERS www cdc gov coronavirus MERS index html 102 Severe respiratory disease of unknown origin Jordan outbreak in ICU Communicable Disease Threats Report week 18 29 April May 2013 2013 www ecdc europa eu en publications Publications CDTR 20online 20version 204 20May 202012 pdf 103 Novel coronavirus infection update as of 22 May 2013 World Health Organization Geneva www who int csr don 2013 05 22 ncov en Accessed 12 August 2013 104 ProMed www promedmail org promedprint php id 1750425 Accessed 12 August 2013 105 World Health Organization Weekly epidemiological record www who int wer 2013 wer8832 pdf 106 World Health Organization International Health Regulations 2005 www who int ihr 9789241596664 en Accessed 14 August 2013 107 WHO Statement on the Second Meeting of the IHR Emergency Committee concerning MERS CoV www who int mediacentre news statements 2013 mers cov 20130717 en Accessed 14 August 2013 How great is the risk of MERS CoV Editorial www expert 981 Expert Review of Anti infective Therapy Downloaded from by University of North Dakota on 10 27 14 For personal use only