International travel and health

World - travel advice on MERS-CoV for pilgrimages

World Health Organization travel advice on MERS-CoV for pilgrimages

3 June 2014

I. Introduction

As of May 2014, more than 635 cases of Middle East respiratory syndrome coronavirus (MERS-CoV) have been reported to WHO.

The virus appears to be circulating widely throughout the Arabian Peninsula and most MERS cases have been reported by the Kingdom of Saudi Arabia. While most cases have occurred among residents, some cases have occurred among visitors. Based on currently available information, the overall risk for visitors to acquire MERS infection appears to be low.

The currently known epidemiological patterns indicate some infections occur in communities. Cases detected in the community may arise from contact with infected animals or unprocessed products from infected animals, from person-to-person spread in the community, or from acquisition in the healthcare setting by individuals who remained living in the community. Studies are underway to determine the relative contribution of all of these, but the studies are not yet complete. Other infections have occurred in hospitals, primarily when hospitalization of an infected patient, coupled with suboptimal infection control and prevention practices, has led to hospital transmission and outbreaks. Finally, infection among families has been seen and may reflect either person to person transmission or possibly exposure to a common source. At this time, the understanding of how MERS is transmitted is not complete, and we await the results of the studies in progress. There is no information at this time to suggest that widespread transmission is occurring in communities.

Since April 2014, there was an increased number of cases, notably in the Kingdom of Saudi Arabia and in the United Arab Emirates in both communities and health care setting. The latest information on MERS-CoV can be found here:

II. Effective communication of risk information

It is important for countries to use all practical and effective means possible to communicate information on a range of issues before, during and after Umra and Hajj to all key groups, including the following:

  • travellers to Umra and Hajj, particularly vulnerable groups within this population;
  • public health officials;
  • health care staff responsible for the care of ill pilgrims;
  • transportation and tourism industries; and
  • the general public.

2.1. Actions for countries to take in preparation for Umra and Hajj

  • Countries should advise travellers that persons with pre-existing major medical conditions (e.g. chronic diseases such as diabetes, chronic lung disease, immunodeficiency) are more likely to develop severe infection for MERS if they are exposed to the virus. Pilgrims should be advised to consult a health care provider before travelling to review the risk and assess whether making the pilgrimage is advisable.
  • Countries should advise travellers and travel organizations on general travel health precautions1, which will lower the risk of infection in general, including influenza and traveller’s diarrhoea. Specific emphasis should be placed on:
    • hand hygiene2 and respiratory hygiene (covering mouth and nose when coughing or sneezing, washing hands after contact with respiratory secretions, and keeping a distance of one metre with other persons when having acute febrile respiratory symptoms);
    • adhering to good food-safety practices, such as avoiding undercooked meat or food prepared under unsanitary conditions, and properly washing fruits and vegetables before eating them;
    • maintaining good personal hygiene;
  • Countries should make health related advice available to all travellers departing for Umra or Hajj by working with the travel and tourism sectors and placing such materials at strategic locations (eg. travel agent offices or points of departure in airports). Different kinds of communication, such as health alerts on board of planes and ships, and banners, pamphlets and radio announcements at international points of entry, can also be used to reach travellers. Travel advice should include current information on MERS-CoV and guidance on how to avoid illness while travelling.
  • Countries should distribute current WHO guidelines, or their national equivalents, on surveillance3, infection prevention and control measures4 and clinical management5 of MERS-CoV to health care practitioners and health care facilities.
  • Countries should ensure that they have access to adequate laboratory services for testing for MERS-CoV and that information on how to obtain laboratory services and clinical referral is known to health care providers and facilities.
  • Countries should advise travellers to delay their travel if they develop a significant acute respiratory illness with fever and cough.
  • Countries should provide medical staff accompanying pilgrims with up to date information and guidance on MERS-CoV, ensuring that:
    • they are alert to the early signs of a developing respiratory infection and pneumonia:
    • they know who is considered to be in a high-risk group;
    • they know what to do when a suspected case is identified;
    • they are aware of simple health measures to reduce transmission.

2.2. Actions to take during Umra or Hajj

  • Countries should advise travellers that if they develop a significant acute respiratory illness with fever and cough (severe enough to interfere with usual daily activities) during Umra or Hajj,they should:
    • report to the medical staff accompanying the group or to the local health services;
    • cover their mouth and nose when coughing or sneezing, wash hands afterwards, or if this is not possible, cough or sneeze into upper sleeves of their clothing;
    • avoid attending crowded places and preferably isolate themselves until the end of the respiratory symptoms and, if isolation is not possible, use a tissue for covering nose and mouth or a surgical mask when in crowded places6.
  • Countries should advise travellers to avoid close contact with camels, visit farms and consume unpasteurized camel milk, urine or improperly cooked meat.

2.3. Actions to take after Umra or Hajj

  • Countries should advise returning travellers that if they develop a significant acute respiratory illness with fever and cough (severe enough to interfere with usual daily activities) during the two weeks after their return, they should:
    • seek medical attention, informing health attendants of their recent travel for Umra or Hajj;
    • immediately notify their local health authority;
    • take precautions when coughing or sneezing (see 2.2. above);
    • minimize their contact with others to keep from infecting them.
  • Countries should alert health practitioners and facilities to test returning travellers with a clinical presentation that suggests the diagnosis of MERS-CoV to be tested for MERS-CoV and to implement infection prevention and control measures. Confirmed cases of MERS-CoV must be reported to WHO. Clinicians should also be alerted to the possibility of atypical presentations in patients who are immunocompromised.

III. Measures at borders and for conveyances

  • WHO does not recommend the application of any travel or trade restrictions or entry screening.
  • WHO encourages countries to provide information on MERS and this travel advice to transport operators and ground staff, and about self-reporting of illness by travellers.
  • As provided by the IHR, countries should ensure that;
    • routine measures are in place at point of entry for assessing ill travellers detected on board conveyances (such as planes and ships) and at entry;
    • procedures and means are in place for communicating information on ill travellers between conveyance and points of entry as well as between points of entry and national health authorities;
    • safe transportation of symptomatic travellers to hospitals or designated facilities for clinical assessment and treatment is organized.
  • If a sick traveller is on board a plane, a passenger locator form7 can be used. This form is useful for collecting contact information for passengers, which can be used for follow-up if necessary.

1 International Travel and Health http://www.who.int/ith/en/index.html.
2 World Health Organization., WHO Patient Safety. WHO guidelines on hand hygiene in health care. Geneva, World Health Organization, 2009 http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf .
3 Interim surveillance recommendations for human infection with Middle East respiratory syndrome coronavirus http://www.who.int/csr/disease/coronavirus_infections/InterimRevisedSurveillanceRecommendations_nCoVinfection_27Jun13.pdf.
4 Infection prevention and control of epidemic-and pandemic prone acute respiratory infections in health care. WHO guidelines (2014) http://www.who.int/csr/bioriskreduction/infection_control/publication/en/.
5 Interim guidance for clinical management of severe acute respiratory infections when novel coronavirus is suspected: What to do and what not to do http://www.who.int/csr/disease/coronavirus_infections/InterimGuidance_ClinicalManagement_NovelCoronavirus_11Feb13u.pdf.
6 See: rapid advice note on home care for patients with Middle East respiratory syndrome coronavirus (MERS-CoV) infection presenting with mild symptoms and management of contacts at: http://www.who.int/csr/disease/coronavirus_infections/MERS_home_care.pdf?ua=1
7 See a model passenger locator form at: http://www.who.int/ihr/ports_airports/locator_card/en/index.html

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