key: cord-0008130-egi4diog
authors: Gautret, Philippe; Benkouiten, Samir; Salaheddine, Imane; Parola, Philippe; Brouqui, Philippe
title: Preventive measures against MERS-CoV for Hajj pilgrims
date: 2013-09-23
journal: Lancet Infect Dis
DOI: 10.1016/s1473-3099(13)70259-7
sha: 7899c49f31d697c6fc8af1cdc7bf1a169a432131
doc_id: 8130
cord_uid: egi4diog

nan

Assiri and colleagues 1 provide a clinical synopsis of 47 cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection identifi ed between September, 2012, and June, 2013, in Saudi Arabia. Of note is the high rate of underlying comorbidity in patients with MERS (table). Since the fi rst cases were reported in April, 2012, from Jordan, most cases have been reported from Saudi Arabia where the Hajj, the largest religious mass gathering, takes place annually. Given the predicted population movements out of Saudi Arabia, potential for worldwide spread of MERS-CoV exists according to Kahn and colleagues. 2 By contrast, Breban and colleagues 3 calculated that the risk of MERS-CoV to have pandemic potential does not exceed 5%, but they did not take into account the eff ect of Hajj mass gathering in their scenario.

The Saudi Ministry of Health (MoH) recommends that elderly people (older than 65 years), people with chronic diseases (eg, heart disease, kidney disease, useless. Their detailed and sophisticated microbiological work showed that the genes encoding VIM-2 are most often borne by a specifi c integron, In559, which also contains genes conferring resistance to trimethoprim and aminoglycosides.

The reported rise in prevalence of VIM-2 strains, from less than 5% in 2002-04, to nearly 30% in 2008-10 is large, even though the rates are questionable because the method of strain collection used was not a representative sampling scheme. Nevertheless, this spread of resistance probably led to increased use of colistin, the last available antibiotic to which P aeruginosa are susceptible. In turn, this rise in colistin use unsurprisingly resulted in the emergence in 2010 of strains resistant to all available drugs-a situation that could not be much worse.

But what about the patients? What were the risk factors for acquiring an epidemic strain? Edelstein and colleagues compared patients infected with VIM-2-positive P aeruginosa with those infected with P aeruginosa insusceptible to carbapenems probably by other variable mechanisms of resistance, which are not described. The results did not clearly point to specifi c risks for acquisition of the epidemic strain. The more frequent use of broad-spectrum antibiotics in patients infected with VIM-2-producing strains suggests that such patients were exposed to high-risk procedures or to highrisk units for prolonged periods. In this regard, Edelstein and colleagues' report largely confi rms what was already known. Specifi c control measures are not suggested.

What is the real burden of diseases associated with these VIM-2 strains? Mortality in the patients infected with VIM-2-producing strains was 29%, but probably varied greatly between those only colonised with the bacteria and those with severe invasive infections. Was mortality lower in patients infected with non-VIM-2-producing P aeruginosa strains? To what extent mortality was attributable to resistance was not addressed by the authors. More sophisticated epidemiological methods would have been needed to provide an answer. Thus we cannot assess the true clinical consequences of this epidemic.

Although increasingly precise data for bacterial resistance are accumulating, progress is needed in the measurement of the clinical eff ects of resistance. At a time when the G8 has issued a statement 2 about their concerns about antimicrobial resistance, clinical epidemiologists have to provide decision makers with quantitative estimates of the resulting medical and economic burdens of disease and eff ects on public health so that appropriate responses can be made. This is the second major warning from Timothy Walsh's group-3 years ago, they reported 3 the dissemination of NDM-1, another potent enzyme that hydrolyses carbapenems. Let's take global action before a third and maybe even worse report of antibiotic resistance. 4 However, we reported rapid acquisition of other respiratory viruses in pilgrims during their stay in Saudi Arabia-most notably, rhinovirus-emphasising the potential of these infections to spread in the pilgrims' home countries on their return. 5 The 2013 mandatory meningococcal vaccination campaign for Hajj was started on Aug 19, at our institution. Early results of the first week show that pilgrims preparing for Hajj this year were younger and less likely to present with comorbidity than in 2012; however, 48% had at least one disorder for which the Saudi MoH recommends to postpone the performance of the Hajj. Although our results cannot be extrapolated to all Hajj pilgrims, they clearly show that a substantial proportion of European pilgrims departing from southern France are unlikely to heed the recommendations set out by the Saudi MoH.

Public health agencies are unanimous in recommending that pilgrims apply personal protective measures against respiratory infection (wearing of face masks, cough etiquette, hand hygiene, use of disposable tissues, and avoiding contact with sick people). Such measures have already been highly accepted by pilgrims. 6 The presence of MERS-CoV neutralising anti bodies in dromedary camels in Oman and the Canary Islands might provide a clue as to a potential source for human infection, although the presence of MERS-CoV in camels has not been established. 7 We recently investigated the willingness of French pilgrims to consume raw camel milk if offered during their stay in Saudi Arabia; 41% said that they would drink it if offered. 8 Given that camel milk consumption in the Middle East is associated with several zoonotic infections, we recommend that Hajj pilgrims be cautioned against consuming unpasteurised dairy products. Following recent isolation of MERS-CoV from the faeces of a bat in Saudi Arabia, we recommend people avoid contact with both farm and wild animals. 9 *Philippe Gautret 

Epidemiological, demographic, and clinical characteristics of 47 cases of Middle East respiratory syndrome coronavirus disease from Saudi Arabia: a descriptive study

Potential for the international spread of Middle East respiratory syndrome in association with mass gatherings in Saudi Arabia

Interhuman transmissibility of Middle East respiratory syndrome coronavirus: estimation of pandemic risk

Lack of nasal carriage of novel corona virus (HCoV-EMC) in French Hajj pilgrims returning from the Hajj 2012, despite a high rate of respiratory symptoms

Circulation of respiratory viruses among pilgrims during the 2012 Hajj pilgrimage

Hajj pilgrims' knowledge about acute respiratory infections

Middle East respiratory syndrome coronavirus neutralising serum antibodies in dromedary camels: a comparative serological study

Camel milkassociated infection risk perception and knowledge in French Hajj pilgrims

Middle East respiratory syndrome coronavirus in bats, Saudi Arabia