An outbreak of the Middle East respiratory syndrome coronavirus (MERS-CoV), first reported in 2012, has affected nine countries to date. WHO is coordinating the global response to this emerging virus according to the International Health Regulations (IHR 2005). This paper provides guidance to national authorities of countries from which pilgrims will be travelling in the coming months for Umra and Hajj for the prevention, detection and management of imported cases of MERS-CoV. At this time, the risk to an individual pilgrim of contracting MERS-CoV is considered very low.
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;
- public transportation and tourism industries and the general public.
Actions to take before Umra or Hajj
Countries should advise pilgrims that pre-existing major medical conditions (e.g. chronic diseases such as diabetes, chronic lung disease, immunodeficiency) can increase the likelihood of illness, including MERS-CoV infection, during travel; thus, pilgrims should consult a health care provider before travelling to review the risk and assess whether making the pilgrimage is advisable.
Countries should make information known to departing pilgrims and travel organizations on general travel health precautions,1which will lower the risk of infection in general, including illnesses such as influenza and traveller’s diarrhoea. Specific emphasis should be placed on:
- washing hands often with soap and water. When hands are not visibly dirty, a hand rub can be used;
- 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;
avoiding unnecessary contact with farm, domestic, and wild animals.
- Health advisories should be made available to all departing travellers to 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 planes and ships, and banners, pamphlets and radio announcements at international points of entry, can also be used to reach travellers.
- travel advisories should include current information on MERS-CoV and guidance on how to avoid illness while travelling.
- Current WHO guidelines, or their national equivalents, on surveillance,2 infection prevention and control measures3 and clinical management4of MERS-CoV should be distributed to health care practitioners and health care facilities.
- Countries should ensure that there are adequate laboratory services for testing for MERS-CoV and that information on laboratory services and clinical referral mechanisms is known to health care providers and facilities.
- Medical staff accompanying pilgrims should be up to date on MERS-CoV information and guidance, including how to recognize early signs and symptoms of infection, who is considered to be in a high-risk group, and what to do when a suspected case is identified, as well as on simple health measures to reduce transmission.
Actions to take during Umra or Hajj
Travellers who develop a significant acute respiratory illness with fever and cough (severe enough to interfere with usual daily activities) should be advised to:
- minimize their contact with others to keep from infecting them;
- cover their mouth and nose with a tissue when coughing or sneezing and discard the tissue in the trash after use and wash hands afterwards, or, if this is not possible, to cough or sneeze into upper sleeves of their clothing, but not their hands;
- report to the medical staff accompanying the group or to the local health services.
Actions to take after Umra or Hajj
Returning pilgrims should be advised 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 and immediately notify their local health authority.
Persons who have had close contact with a pilgrim or traveller with a significant acute respiratory illness with fever and cough (severe enough to interfere with usual daily activities) and who themselves develop such an illness should be advised to report to local health authorities to be monitored for MERS-CoV.
Practitioners and facilities should be alerted to the possibility of MERS-CoV infection in returning pilgrims with acute respiratory illness, especially those with fever and cough and pulmonary parenchymal disease (e.g. pneumonia or the acute respiratory distress syndrome). If clinical presentation suggests the diagnosis of MERS-CoV, laboratory testing,5,6 in accordance with WHO’s case definition7 should be done and infection prevention and control measures implemented. 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 raise awareness of this travel advice to reduce the risk of MERS-CoV infection among pilgrims and those associated with their travel, including transport operators and ground staff, and about self-reporting of illness by travellers.
As required by the IHR, countries should ensure that routine measures are in place for assessing ill travellers detected on board conveyances (such as planes and ships) and at points of entry, as well as measures for safe transportation of symptomatic travellers to hospitals or designated facilities for clinical assessment and treatment.
If a sick traveller is on board a plane, a passenger locator form8 can be used. This form is useful for collecting contact information for passengers, which can be used for follow-up if necessary.