key: cord-0752615-o8lb6jeb authors: Pavli, Androula; Smeti, Paraskevi; Papadima, Kalliopi; Andreopoulou, Anastasia; Hadjianastasiou, Sofia; Triantafillou, Eleni; Vakali, Annita; Kefaloudi, Chrysovalantou; Pervanidou, Danai; Gogos, Charalambos; Maltezou, Helena C title: A cluster of COVID-19 in pilgrims to Israel date: 2020-06-25 journal: J Travel Med DOI: 10.1093/jtm/taaa102 sha: 303a81654b1a88a9017e412066875c401be9e214 doc_id: 752615 cord_uid: o8lb6jeb This report describes a cluster of SARS-CoV-2 infections in pilgrims returning from Israel to Greece. Out of 53 pilgrims, 48 (90.5%) were tested positive for SARS-CoV-2; of them, 41 (85.4%) developed symptoms consistent with COVID-19, and 7 (14.6%) remained asymptomatic. These cases suggest a high risk of COVID-19 infection for pilgrims traveling during the pandemic. Although at that time the prevalence of the disease was low in the origin and destination countries, crowded exposure to other pilgrims from many other countries led to this cluster. Increasing awareness about the risks in pilgrims is important and particularly for elderly pilgrims and those with underlying conditions. Mass gatherings with high intensity social contacts have been a well-recognized risk factor for the transmission of infectious diseases, including SARS-CoV-2, as shown by recent reports in returning pilgrims. [1] [2] [3] [4] Therefore, and in the interests of global safety, many mass gatherings have been suspended as a response to the pandemic. 5 The aim of this report is to describe a cluster of SARS- crew member). Guidelines were provided to all close contacts (group of pilgrims, tour guides, all passengers and crew members) for a 14-day self-quarantine following their last exposure, self-monitoring for fever and/or respiratory symptoms, and for contacting the National Public Health Organization's hotline for further advice in case of symptoms onset. In addition, the travel agent was informed in order to notify travel agencies in Israel and Egypt to take relevant public health measures. All 53 pilgrims were tested for SARS-CoV-2 by RT-PCR 7 days after their arrival upon notification of the two COVID-19 cases. Of them, 48 (90.5%) were tested positive. Table 1 shows the characteristics of the 48 positive cases. others had an uneventful recovery. Self-isolation and health monitoring for 14 days was recommended to the five pilgrims who were tested negative; repeat tests were also negative. It is worth mentioning that a Greek tour bus driver of the pilgrim group in Israel was also infected. 6 Containment measures including contact tracing and isolation implemented at that time seemed to be effective to prevent disease spread in the local community. Considering the low possibility of local transmission at destinations and also at the country of origin due to low prevalence in origin and destination countries, it is possible that the pilgrims were infected during religious rituals by other SARS-CoV-2 infected travelers from countries where local transmission was already established. 1 Based on the results of our study, these cases suggested a high risk of SARS-CoV-2 infection for pilgrims traveling during the pandemic. A large proportion of these pilgrims were 65 years of age and older with underlying conditions. This explains their high complication rate and case fatality rate. 7 The high attack rate among this group of pilgrims, is probably related to potential risk behaviors during pilgrimage, such as exposure to crowded conditions with pilgrims from different countries and also engagement in common activities, including religious rituals and also recreational activities for a long period of time. 1 A similar outbreak was reported among South Korean nationals who were tested positive for SARS-CoV-2 infection after they visited the West Bank from February 9 to 14 as a group of 77 members; however, no evidence was found of connection leading to transmission between the two groups. 8 Mass gatherings, including pilgrimage, are a risk factor for rapid spread of respiratory infections which is the most common disease among pilgrims. Crowded conditions and intensity of social contacts during their engagement in religious rituals may lead to propagation and amplification of this novel respiratory virus SARS-CoV-2. 1 As the pandemic continues, there will be an increasing number of pilgrims returning back home. SARS-CoV-2 may be seeded in and transmitted out of holy places by visitors. Therefore, it is strongly recommended that the home countries should be prepared to receive such cases, and therefore to implement appropriate public health measures. 9 Public health authorities should increase awareness in pilgrims about the risks and the need for personal protection. Pilgrims should be advised adherence to hygiene recommendations, to avoid close contact with sick people and to report and seek healthcare if they become symptomatic after pilgrimage. 10 Travel health professionals must be aware of the risks posed by returned pilgrims. Preventive measures before departure and on the field should be reinforced during pre-travel consultation. Postponement may be recommended in particular for elderly pilgrims and those with chronic and underlying conditions. Mass gatherings medicine: public health issues arising from mass gathering religious and sporting events Pilgrimage and COVID-19: the risk among returnees from Muslim countries Spread of novel coronavirus by returning pilgrims from Iran to Pakistan A single mass gathering resulted in massive transmission of COVID-19 infections in Malaysia with further international spread The cancellation of mass gatherings decision making in the time of COVID-19 Risk factors for SARS-CoV-2 among patients in the Oxford Royal College of General Practitioners Research and Surveillance Centre Primary Care Network: a cross-sectional study We thank Athanasios Minitsios and Panagiota Isari from the Department of Travel Medicine of the National Public Health Organization for their administrative and data management support.