Travel advice on MERS-CoV for pilgrimages
1 June 2017
As of 31 May 2017, more than 1950 laboratory-confirmed cases of human infection with Middle East respiratory syndrome coronavirus (MERS-CoV) have been reported to WHO, including at least 693 deaths. Overall, approximately 65% of cases of MERS are male and the median age of cases is 52 years old (range 9 months–109 years). Males above the age of 60 with underlying conditions are at a higher risk of infection and severe disease, including death.
Since 2012, 27 countries have reported cases of MERS1. The majority of cases (approximately 80%) have been reported from the Kingdom of Saudi Arabia (KSA).
MERS-CoV is a zoonotic virus, which has entered the human population in the Arabian Peninsula on multiple occasions from direct or indirect contact with infected dromedary camels or possibly camel-related products (e.g. raw camel milk). Several studies have shown that MERS-CoV-specific antibodies are widespread in dromedary camel populations in the Middle East and Africa. The evidence from animal seroepidemiologic surveys suggests that MERS-CoV has been circulating in camels for decades. The reason why human cases were first detected only in 2012 is unknown, and the specific exposures resulting in and modes of transmission from animals to humans have not been fully elucidated.
However, the evidence linking MERS-CoV transmission between camels to humans has steadily been increasing and is now irrefutable. A significant amount of knowledge of MERS-CoV has accumulated in the last two years and includes human and animal serologic surveys from Middle East and African countries and one case control study from KSA, which has confirmed that direct and indirect contact with dromedary camels are risk factors for infection.
Human-to-human transmission has been observed in health care settings and to a limited extent in households. Failures in infection prevention and control in health care settings have resulted in sometimes large numbers of secondary cases, as seen in Saudi Arabia, the United Arab Emirates, Jordan and in the Republic of Korea. To date, there is no evidence of sustained human-to-human transmission anywhere in the world. The latest information on MERS-CoV can be found at:
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 people with pre-existing major medical conditions (e.g. diabetes, chronic lung disease, chronic renal disease, immunodeficiency etc.) are more likely to develop a severe form of MERS if they are exposed to the MERS-CoV virus. Pilgrims should be advised to consult a health care provider before travelling to review the risks and assess whether making the pilgrimage is advisable.
Countries should advise travellers and travel organizations on general travel health precautions2, which will lower the risk of infection in general, including influenza and traveller’s diarrhoea. Specific emphasis should be placed on:
- hand hygiene 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 (e.g. 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 travelling3.
Countries should distribute current WHO guidelines, or their national equivalents, on surveillance4, laboratory5, case management and infection prevention and control6 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 places.
Countries should advise travellers to avoid close contact with dromedary 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 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-CoV, including this travel advice, to transport operators and ground staff.
As provided by the International Health Regulations (2005) (IHR), countries should ensure that:
- routine measures are in place at points of entry for assessing ill travellers detected on board conveyances (such as planes and ships);
- procedures and means are in place for communicating information on ill travellers between conveyances 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;
- capacity is in place to implement measures for responding to Events that may constitute a public health emergency of international concern.
If a sick traveller is on board a ship/ a plane, and in accordance to articles 37 and 38 of IHR, the model of Maritime declaration of health (Annex 8 of IHR)/ the health part of the aircraft general declaration (Annex 9 of IHR) shall be used, when required by a State Party. Also, a passenger locator form7 can be used in the event of a sick traveller detected on board a plane. This form is useful for collecting contact information for passengers, and can be used for follow-up if necessary. Travellers should also be encouraged to self-report if they feel ill.
1 Algeria, Austria, Bahrain, China, Egypt, France, Germany, Greece, Iran, Italy, Jordan, Kuwait, Lebanon, Malaysia, Netherlands, Oman, Philippines, Qatar, Republic of Korea, Saudi Arabia, Thailand, Tunisia, Turkey, United Arab Emirates, United Kingdom, United States of America and Yemen.
2 WHO, International Travel and Health, available at http://www.who.int/ith/en/.
3 See MERS-CoV Information resources at http://www.emro.who.int/health-topics/mers-cov/information-resources.html and http://who.int/emergencies/mers-cov/en/.
4 See http://www.who.int/csr/disease/coronavirus_infections/technical-guidance-surveillance/en/.
5 See http://www.who.int/csr/disease/coronavirus_infections/technical-guidance-laboratory/en/.
6 See http://www.who.int/csr/disease/coronavirus_infections/technical-guidance-infection/en/.
7 A sample public health passenger locator can be found at http://www.who.int/ihr/ports_airports/locator_card/en/index.html.