Eurosurveillance: Hajj Health Hazards & Recommendations

 

 

Credit Wikipedia

# 6627

 

 

While no new cases of the novel coronavirus have been detected beyond the first two from Saudi Arabia & Qatar, Singapore had a brief scare yesterday when a woman - recently arrived from Kuwait - was hospitalized with a respiratory infection (see Woman tests negative for SARS-related bug).

 

This comes on the heels of a similar case last week in Hong Kong (also negative), and 5 people isolated in Denmark (again, negative) two weeks earlier.

 

Although there are no signs that this coronavirus is being spread from person-to-person, memories of the SARS epidemic of 2003 have prompted enhanced surveillance for anyone traveling from the Middle East showing respiratory symptoms. 

 

Out of an abundance of caution, these cases are quickly isolated and tested - even though health officials know most will turn out to have something far less exotic than this new coronavirus. 

 

With the Hajj only 10 days away - and influenza and other viruses in circulation – we shouldn’t be surprised to see this drill repeated around the world as pilgrims return home from Mecca at the end of the month.

 

Which brings us to this Rapid Communications from the ECDC journal Eurosurveillance, posted yesterday.  I’ve only included excerpts, follow the link to read it in its entirety.

 

 

Eurosurveillance, Volume 17, Issue 41, 11 October 2012

Rapid communications

The Hajj: updated health hazards and current recommendations for 2012

J A Al-Tawfiq¹, Z A Memish

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This year the Hajj will take place during 24–29 October. Recent outbreaks of Ebola haemorrhagic fever in Uganda and the Democratic Republic of the Congo, cholera in Sierra Leone, and infections associated with a novel coronavirus in Saudi Arabia and Qatar required review of the health recommendations of the 2012 Hajj. Current guidelines foresee mandatory vaccination with quadrivalent meningococcal vaccine for all pilgrims, and yellow fever and poliomyelitis vaccine for pilgrims from high-risk countries. Influenza vaccine is strongly recommended.

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The annual Hajj is one of the greatest assemblies of humankind on earth. Each year, three million Muslims attend the Hajj in Mecca, Saudi Arabia. Of these, 1.8 million non-Saudi Arabians usually come from overseas countries and 89% (1.6 millions) of them arrive by air [1]. Pilgrims come from more than 180 countries worldwide and about 45,000 pilgrims each year arrive to Saudi Arabia from the European Union [2].

<SNIP>

Pre- and post-Hajj travel advice

The Hajj is a unique event with possible impact on international public health. Healthcare practitioners around the world must be attentive to the potential risks of disease transmission during the Hajj. They must recommend appropriate strategies for the prevention and control of communicable diseases before, during and after the completion of the Hajj. The current international collaboration in planning vaccination campaigns, developing visa quotas, arranging rapid repatriation, and managing health hazards at the Hajj are crucial steps in this process. The Saudi Arabian Ministry of Health publishes the Hajj requirements for each Hajj season. This year’s Hajj recommendations have recently been published [3].

Recent outbreaks of Ebola haemorrhagic fever in Uganda and the Democratic Republic of the Congo (DRC), cholera in Sierra Leone, and infections associated with a novel coronavirus in Saudi Arabia and Qatar required review of the health recommendations of the 2012 Hajj. We present here the changes and additions made in the recommendations for these diseases. For completeness, we also summarise the existing recommendations [3,4].

(Continue . . . )

 

 

Whenever there is a mass gathering (or migration) of people, public health officials must plan on how to deal with, and hopefully contain, any disease outbreaks.

 

Earlier this year the ECDC, along with local public health officials, geared up for three very high profile and well attended public events; The London Olympics and Para-Olympics Games, and the UEFA EURO 2012 football championship.

 

You can see their preparations in How The ECDC Will Spend Your Summer Vacation.

 

Similarly, as this report details, Saudi Arabia is taking serious steps to prevent disease outbreaks. 

 

Every year there are multiple mass gatherings which could conceivably facilitate disease transmission; including the Super bowl, Mardi Gras, and Carnival in Rio, and the Hajj.

And the granddaddy of all human migrations takes place every winter across Asia, with the celebration of the Lunar New Year. More than 2 billion passenger journeys – mostly by crowded train – are made in China alone over a six week period.

 

The good news is, that while mass gatherings and migrations provide greater opportunities for disease outbreaks, history has shown that serious outbreaks rarely occur.

 

Still, public health authorities must anticipate and prepare for the worst, even though it probably won’t happen. This is hardly wasted energy.

 

After all, we’ll never know the number of outbreaks that have been prevented by proactive measures over the years.

 

The old saying is true, `When public health works, nothing happens’.

 

For more on health planning for mass gatherings, you may wish to revisit:

 

Lancet: Mass Gatherings And Health

The Impact Of Mass Gatherings & Travel On Flu Epidemics

The Lunar New Year And Flu

»» Read More

How The ECDC Will Spend Your Summer Vacation

 

 

# 6374

 

This summer there will be three high profile, well-attended public events in Europe; The London Olympics and Para-Olympics Games, and the UEFA EURO 2012 football championship (which is being hosted by Poland and the Ukraine).

 

Hundreds of thousands of visitors will converge on multiple venues over the summer, coming from all parts of Europe and around the world.  And as with any large gathering of people, there are serious public health concerns.

 

Over the past few months we’ve seen some hyperbolic media stories suggesting that these games could help launch the next pandemic, but past experience with other big travel events, like the Hajj, the Carnival in rio, The World Cup,  or our own Super Bowl suggests that is unlikely.

 

It is true that some disease outbreaks have been exacerbated by the gathering of large crowds. 

 

This past year a number of people were exposed to measles at the Super Bowl in Indianapolis, leading to a limited outbreak of the disease (mostly among the unvaccinated).

 

Perhaps most famously, the city of Philadelphia went ahead with plans to hold a Liberty Loan parade in September of 1918, which was attended by 200,000 people.

 

Although the flu pandemic had already begun, the city fathers were apparently heartened by the low number of cases that had been reported in Philadelphia. Other cities, like St. Louis, banned public gatherings, closed movie theatres, and even limited church gatherings.

 

What happened next is best demonstrated by the following graph, which depicts an explosion of pandemic flu cases beginning just days after the parade.

The chart above, taken from the PNAS journal article entitled Public Health Interventions and Pandemic Intensity During the 1918 Influenza Pandemic , shows the excess mortality in two American cities.

 

The tall spike represents Philadelphia, while the lower curve represents St. Louis.

 

Over the next three weeks, at least 6,081 deaths from influenza and 2,651 deaths from pneumonia were registered in Pennsylvania, most occurring in Philadelphia (CDC source).

 

So the potential is there, assuming that a novel pathogen to which there is limited immunity is introduced to the crowds.

 

The good news is, that while mass gatherings provide greater opportunities for disease outbreaks, history has shown that serious outbreaks like that which followed the 1918 Philadelphia parade are a rarity.

 

Still, there is enough concern that a good deal of planning has gone into the surveillance and prevention of disease spread at these summer events. Earlier this year in Lancet: Mass Gatherings And Health, we looked at a 6-part series on public health measures during mass gathering events.

 

 

The ECDC has published a report today outlining some of the steps they are taking to try to prevent disease outbreaks during these mass gathering events.

 

Watching the summer games

08 Jun 2012

Two large mass gathering events involving millions of EU citizens and worldwide visitors are being hosted this summer in the EU: the UEFA EURO 2012 football championship and London 2012 Olympic and Paralympic Games.

 

ECDC is enhancing its surveillance activities this summer, watching for any infectious disease health events that could present a public health threat during these sport events. As of today, a summary of relevant health events will be included in the weekly Communicable Disease Threat Report (CDTR), published on this website.

 

ECDC is working with the hosting country competent bodies of Poland, the United Kingdom and the Ukraine to provide international surveillance activities in order to support their public health actions.

 

Global mass gathering events can present challenges for public health because of their scale and the possible additional demands made of the public health services. To tackle these challenges, surveillance systems can be enhanced to target specific diseases or syndromes and to support timely response actions to reduce their impact and risk of spread.

 

Based on its founding regulation, one of the core functions of ECDC is undertaking daily 24/7 epidemic intelligence. This term encompasses activities related to early identification of potential health threats, as well as their verification, assessment and investigation, in order to recommend adequate public health control measures. Epidemic intelligence sources of information vary from health data routinely collected through standardised surveillance systems to unstructured official and unofficial reports of any origin.

 

What will ECDC be doing during these mass gathering events?

During the months of June-September 2012, ECDC is undertaking enhanced event-based surveillance as part of its routine epidemic intelligence activities. It has adapted media screening tools and its procedures to assist detecting timely infectious disease threats which may be relevant for these events, and the hosting and participating countries. The use of social media and blog fora as a mechanism of timely identification of disease threats is being explored in this context.

 

ECDC is working very closely with the hosting countries and international partners such as the World Health Organisation, including having liaison officers to facilitate daily communication with ECDC. A daily bulletin containing information on events relevant from a public health perspective will be provided to public health authorities of Member States and the event-hosting countries.

 

A summary of relevant infectious disease threats will be included in the weekly CDTR published on this website.

 

What kind of infectious diseases is ECDC looking for?

Large gatherings of people may be subject to increased public health risks, including non-communicable diseases. Based on experience from previous such mass gatherings, it is unlikely that infectious diseases will be a major problem at these two events.

 

The greatest risk for visitors to these mass gatherings is likely to be related to food and waterborne diseases, such as food poisoning due to inappropriately handled food items or inadequate hand hygiene practices. At the same time, in the context of outbreaks of measles and other vaccine preventable diseases in Europe, unvaccinated and non-immune people may be at increased risk of infection.

 

In addition to food- and water-borne diseases and vaccine preventable diseases, ECDC will be monitoring for a wide range of infectious diseases and syndromes through available data sources and networks, as it does on a daily basis, in order to detect unusual events or outbreaks.

 

The organisers of these mass gatherings have published public messages about how to stay healthy in order to best enjoy these events. Preventative measures that people can take themselves and can contribute to keeping others healthy include things such as: washing hands regularly, ensure relevant vaccinations are up to date, practice safe sex, stay out of the sun, and stay at home if you feel unwell. For those seeking travel or health advice, specific information for EURO 2012 and London 2012 can be found below.

ECDC Rapid risk assessment on measles

WHO European Region on health planning for large events

 

 

Assuming that no large outbreaks of illness or disease occurs, it will be due primarily to the advance work done by local and regional public health officials in planning for these events.

 

The old saying is true, `When public health works, nothing happens’.

»» Read More

Lancet: Mass Gatherings And Health

 

 

# 6079

 

Whenever there is a mass gathering (or migration) of people, the thoughts of public health officials inevitably turn to the prospect of having to deal with, and hopefully contain, outbreaks of disease.

 

With the upcoming Summer Olympics in London this year, it is not surprising that the The Lancet has devoted considerable space to a six-part series covering many of the public health issues that come with managing mass gatherings.

 

Concerns go well beyond infectious diseases like measles, influenza, and norovirus, and also involve terrorist attacks, crushing injuries from unruly crowds, food borne illnesses, and sanitation.

 

These articles are (unfortunately) behind a pay wall, but summaries are available (free registration req.), as is a short audio presentation where John McConnell discusses the background to the series.

 

 

Mass Gatherings Health

Published January 16, 2012

Executive summary

A six-part series describes the scope of the emerging specialty of mass-gatherings health. Mass gatherings are events such as religious occasions, music festivals, or sports events that attract enough people to exceed the capacity of routine health and public safety measures. Managing such events requires providing for all eventualities from infectious disease outbreaks to security against terrorist attacks. Thus mass gatherings health is a topic that goes beyond the scope of typical public health provision.

(Continue . . .)

 

This issue pops up nearly every year, and with good reason. Epidemiologists remember well the lessons of 1918,  where it was demonstrated that influenza epidemics can surge in the wake of large gatherings.

 

During the fall wave of the Spanish Flu most cities instituted strict public health ordinances; they closed schools, movie houses, pool rooms, restaurants . . even churches.

 

Those cities that took these measures generally saw much lower levels of death and illness.

 

But Philadelphia went ahead with a massive Liberty Loan parade on September 28th of that year, apparently heartened by the low number of flu cases reported in Pennsylvania to that point.

 

Days after Philadelphia’s Liberty Loan parade in September 1918, which was attended by 200,000 people, hundreds of cases of influenza were reported. [Credit: Naval Historical Center]

What happened next is best demonstrated by the following graph, which depicts an explosion of pandemic flu cases beginning just days after the parade.

 

The chart above, taken from the PNAS journal article entitled Public Health Interventions and Pandemic Intensity During the 1918 Influenza Pandemic , shows the excess mortality in two American cities.

 

The tall spike represents Philadelphia, while the lower curve represents St. Louis.

 

Over the next three weeks, at least 6,081 deaths from influenza and 2,651 deaths from pneumonia were registered in Pennsylvania, most occurring in Philadelphia (CDC source).

 

So it is little wonder that we saw some amount of angst during the lead up to the 2010 World Cup games over the concern that it might enhance the spread of the 2009 H1N1 pandemic virus (see Russia Urges Sports Fans Not To Travel To World Cup Game).

 

Each year there are multiple mass gatherings which could conceivably facilitate disease transmission; including the Super bowl, Mardi Gras, and Carnival in Rio, and the Hajj.

 

But the granddaddy of all human migrations takes place each winter across Asia, with the celebration of the Lunar New Year.  It is expected that more than 2 billion passenger journeys – mostly by crowded train –will be made in China alone over this six week period.

 

This year, the lunar New Year will fall on January 23rd, but the festivities span several weeks.

 

In many Asian cultures it is a long held tradition that people return home to attend a reunion dinner with their families on the eve of the lunar New Year. They stay a few days, then return to the cities from whence they came.

 

All of which provides opportunities pathogens to hitch rides to remote areas of the world where they may not have arrived yet, and for viruses to be carried from rural areas back to the cities.

 

Due to the potential for disease transmission (including mosquito borne illnesses, food poisoning, flu, etc.) during this very busy holiday period, the CDC posts some travel advice each year to those planning a trip to Asia.

 

Good Luck. Good Health. Good Cheer. Happy Lunar New Year!

 

The good news is, that while mass gatherings provide greater opportunities for disease outbreaks, history has shown that serious outbreaks like that which followed the 1918 Philadelphia parade are a rarity.

 

Still, public health authorities must anticipate and prepare for the worst, even though it probably won’t occur. This is hardly wasted energy.

 

After all, we’ll never know the number of outbreaks that have been prevented by proactive measures over the years.

 

The old saying is true, `When public health works, nothing happens’.

»» Read More