key: cord-268105-617qcgpe
authors: Refaey, Samir; Amin, Marwa Mohamed; Roguski, Katherine; Azziz‐Baumgartner, Eduardo; Uyeki, Timothy M.; Labib, Manal; Kandeel, Amr
title: Cross‐sectional survey and surveillance for influenza viruses and MERS‐CoV among Egyptian pilgrims returning from Hajj during 2012‐2015
date: 2016-11-11
journal: Influenza Other Respir Viruses
DOI: 10.1111/irv.12429
sha: 
doc_id: 268105
cord_uid: 617qcgpe

BACKGROUND: Approximately 80 000 Egyptians participate in Hajj pilgrimage annually. The purpose of this study was to estimate influenza virus and MERS‐CoV prevalence among Egyptian pilgrims returning from Hajj. STUDY: A cross‐sectional survey among 3 364 returning Egyptian pilgrims from 2012 to 2015 was conducted. Nasopharyngeal (NP) and oropharyngeal (OP) swabs were collected from all participants. Sputum specimens were collected from participants with respiratory symptoms and productive cough at the time of their interview. Specimens were tested for influenza viruses, and a convenience sample of NP/OP specimens was tested for MERS‐CoV. Thirty percent of participants met the case definition for influenza‐like illness (ILI), 14% tested positive for influenza viruses, and none tested positive for MERS‐CoV. Self‐reported influenza vaccination was 20%. CONCLUSIONS: High prevalence of reported ILI during pilgrimage and confirmed influenza virus on return from pilgrimage suggest a continued need for influenza prevention strategies for Egyptian Hajj pilgrims. An evaluation of the Ministry of Health and Population's current risk communication campaigns to increase influenza vaccine use among pilgrims may help identify strategies to improve vaccine coverage.

pre-departure vaccination against influenza A(H1N1)pmd09 for all pilgrims during the 2009 season. 9 Since then, the MOHP has required seasonal influenza vaccination for all pilgrims as part of the Saudi visa application process. Although the requirement is not always enforced, seasonal influenza vaccine is available at local health offices for all Egyptian pilgrims throughout most of year. The MOHP has additionally conducted an annual survey among pilgrims returning from Hajj to explore the risk of influenza virus transmission to the broader community. Following the emergence of MERS-CoV in Saudi Arabia, the MOHP expanded the survey to test for MERS-CoV.

A cross-sectional survey was conducted at Cairo International Airport among Egyptians returning from Hajj during the week following the end of Hajj each year from 2012 to 2015 (Table 1) . Cairo airport was selected for this survey as it is the main point of entry into Egypt for returning Hajj pilgrims. 9 Cairo airport receives 7-8 flights during working hours (9Am-9 pm) from Saudi Arabia, accounting for approximately 1500-2000 pilgrims per day.

A team from the MOHP sought to enroll a convenience sample of approximately 10% of pilgrims from each flight returning from Hajj and congregating at the airport carousels, regardless of age, sex, and illness status. After providing verbal consent, participants were asked about demographic information, respiratory symptoms, and whether they received vaccines as part of their Hajj visa application process. Both nasopharyngeal (NP) and oropharyngeal (OP) swabs were collected from all participants regardless of the presence of respiratory symptoms. Sputum specimens were collected from participants who presented with respiratory symptoms and a productive cough at the time of their interview.

Travelers who reported a history of subjective fever (a proxy for measured fever) and cough with symptom onset in the previous 10 days were categorized as having influenza-like illness (ILI). 10 For minors, consent and survey responses were provided by accompanying parents. Specimens positive for influenza A were subsequently tested for influenza A virus subtypes. Sputum specimens and a convenience sample of NP/OP specimens were tested for MERS-CoV according to WHO guidelines. 11 The proportion of samples testing positive for influenza virus from participants was compared to those collected from ILI casepatients through the national surveillance system during the same time period.

T A B L E 1 The distribution of Egyptian pilgrims surveyed by season according to gender, age group, presence of influenza-like illness (ILI), vaccination status and influenza laboratory test result 

<5 y 0 (0) 1 (0.1) 2 (0.2) 6 (0.6) 9 (0.3) 5-<15 y 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 15-<50

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Cross-sectional survey and surveillance for influenza viruses and MERS-CoV among Egyptian pilgrims returning from Hajj during 2012-2015