Alert, not alarmed: Advice for Australian pilgrims

SHOULD Australian Muslims planning to attend the Umrah or Hajj pilgrimages in Saudi Arabia this year be concerned about the Middle East respiratory syndrome coronavirus (MERS-CoV)?

To borrow a well-worn phrase, Travelvax Australia believes they should be alert, not alarmed.
Before explaining why, a little about MERS-CoV...

What is MERS-CoV?
Coronaviruses (so named for the crown-like spikes on their surface) are one of the viruses that cause the common cold. However, MERS-CoV is different from any other coronavirus previously found in people.
You may have heard it referred to as 'SARS-like'. That's a reference to the outbreak of Severe Acute Respiratory Syndrome (SARS) just over a decade ago, which infected 8273 people and killed 775 in 37 countries. Like the SARS virus, MERS-CoV is most similar to the coronaviruses found in bats.
Since it was first diagnosed, MERS-CoV has caused severe illness and pneumonia among virtually all of the 61 people infected to date, according to WHO figures. Around half of them (34) have died – mainly older people who had one or more pre-existing chronic illnesses.

First, why pilgrims should not scrap plans
There are 2 main reasons why we believe Australian Muslims should not call off their pilgrimage to the Hajj (October 13-18) or to Umrah, known as the 'lesser pilgrimage', this year.
– So far, MERS-CoV's capacity to spread from person to person has been very limited. Most of those who have developed severe illness or have died from the infection were older people who had one or more pre-existing chronic diseases that made the impact of the virus more severe.
– At this stage, neither Australian nor international health agencies have recommended that pilgrims cancel plans to attend the Hajj or Umrah.
This may change: Pilgrims should watch this space for updates. In fact, the potential for the virus to mutate and become more efficient at passing from one person to another is still unknown. This is the reason the WHO and other international and national health authorities are watching the outbreak closely as investigations into the virus' origins continue.

And, why they should take precautions...
However, anyone travelling to Saudi Arabia or to anywhere else in the Middle East in coming months, should be aware of, and prepared for, any potential health issues – including MERS-CoV.
Many of the pilgrims attending the Hajj are older Muslims. Depending on their general health, they may be more susceptible to a severe respiratory illness.
Airborne respiratory and infectious diseases are not uncommon in aircraft, in crowded airport terminals, hotel lobbies, and public transport – anywhere people congregate in large numbers. (Thirteen of the 17 measles cases detected in Australia this year were 'imported' by travellers returning from overseas trips, or linked to an infected passenger.)
But, these infections are often highly contagious and are commonplace during mass gatherings like the Hajj and Umrah, where pilgrims from all over the world congregate, eat and pray shoulder-to-shoulder for days – sometimes weeks – at a time.
In fact, outdoor public events don't get any bigger than the Hajj; it's a world's largest annual gathering, attracting an average 3 million Muslim faithful from across the globe to Mecca and other holy sites in Saudi Arabia each year. The peak times for Umrah pilgrimages are the last 10 days of Ramadan, the month-long period of fasting which begins on July 9, as well as the days before, during and after the Hajj itself.

Pilgrims are at higher risk of illness
Medical Director of Travelvax Australia, Dr Eddy Bajrovic said that besides vaccinating against influenza and pneumococcal disease, pilgrims can protect themselves from respiratory and other illnesses with regular, thorough hand-washing – especially after using the toilet and before eating.
"Whereas all air passengers are at risk of flu and other respiratory illnesses in flight and in airports, pilgrims are at higher risk every day," Dr Bajrovic said.
"It's the reason why we strongly recommend flu vaccination for all pilgrims, as well as pneumococcal vaccination for those over the age of 65, smokers or people with chronic health conditions.
"But, as we've been stressing for several weeks now, not all infectious diseases can be prevented by vaccines and the importance of hand washing during travel can't be overstated.
"If soap and water are not available, travellers should use an alcohol-based hand sanitiser that contains at least 60% alcohol to disinfect their hands."

Monitor your health – before and after travel
Travelvax also recommends not touching your mouth, nose, or eyes without first cleaning your hands, and avoiding close contact with people who are coughing or sneezing, or are showing obvious signs of illness.
Dr Bajrovic said the medical facilities provided for pilgrims visiting Saudi Arabia are first class and the presence of MERS-CoV is certain to mean even closer scrutiny of pilgrims' health.
"However, I would advise Australian Muslims to also monitor their own health closely, and seek medical attention if they develop a fever and cough or shortness of breath," he said.
"It is also important for pilgrims of any age to seek medical advice without delay if they experience these symptoms within 14 days of returning home. It's important that they advise their doctor of their travel history, too."

Other disease risks for Umrah and Hajj
MERS-CoV is not the only infectious disease that should concern pilgrims.
Diseases such as meningococcal meningitishepatitis A and hepatitis Btyphoid, and the routine vaccine-preventable diseases are all associated with mass gatherings.
To obtain a visa for both the Hajj and Umrah, Saudi Arabia requires pilgrims to be vaccinated against meningococcal meningitis. Pilgrims must prove they've been protected with a quadrivalent vaccine (one that protects against 4 strains of the disease ­ A, C, Y, and W135). The vaccine must have been administered no less than 10 days, but no more than 3 years, before arrival in Saudi Arabia.
Proof of polio vaccination is required for pilgrims from polio-endemic countries, which does not include Australia. However, a booster is recommended.
– Choose safe food and water: Diarrhoea is common during Haj and Umrah. Pilgrims should eat only food that is cooked and served piping hot, and drink only beverages from sealed containers. Don't drink tap water, avoid ice in drinks, and use bottled water for brushing teeth. 
– Avoid insect bites: Mosquitoes, ticks, fleas, and sand flies can spread a number of diseases in Saudi Arabia, most notably mosquito-borne malaria and dengue fever. Malaria occurs in some areas bordering Yemen, but is not present in the cities of Jeddah, Mecca, Medina, Riyadh, and Ta'if. However, dengue fever occurs in urban areas, most notably in Jeddah. As of June 9, 252 new cases had been reported and activity was increasing, according to a local news report. Pilgrims should take measures to avoid daytime-biting mosquitoes and sand flies by using a personal insect repellent containing an effective active ingredient, such as DEET, Picaridin, IR3535, or oil of lemon eucalyptus, as well as covering up with long sleeved tops, long pants, and shoes and socks when mosquitoes are most active.
– Avoid animals: Although rabies can be found in dogs, bats, and other mammals in Saudi Arabia, it is not a major risk to most short-stay travellers, including pilgrims. Vaccination is generally recommended for longer stays or remote-area travel.
– Avoid densely congested areas (and know where emergency exits are located): The Saudi government has spent more than $25 billion to help thin crowds and minimise the risk of stampedes, which have injured or killed hundreds at previous Hajj events. Authorities have also expanded the times when rituals can be performed, so pilgrims can expect fewer crowds during non-peak hours.
– Be wary of heat and sun exposure: Temperatures in Mecca can easily exceed 37oC in the summer and early autumn. Heat exhaustion and heatstroke are not uncommon. Pilgrims should drink plenty of bottled water, wear sunscreen, and rest in the shade whenever possible. Pilgrims who are fasting for Ramadan and cannot drink water during daylight hours should rehydrate thoroughly before dawn and after dusk. Some rituals can be performed at night to avoid daytime heat. Travellers who develop the symptoms of heat stress – profuse sweating, chills, headache, dizziness or confusion, and nausea – should move out of the sun and seek medical care. Read more about heat stress.
– Use licensed barbers: Men are required to shave their heads after performing the Hajj (many men also shave their heads after Umrah). Because unsterile blades can transmit blood-borne diseases like hepatitis B and C, and HIV, male pilgrims should only use officially designated centres, where licensed barbers use disposable, single-use blades. While not mandatory, the Saudi Ministry of Health recommends hepatitis B vaccination for men.

For obligation-free advice on the health risks associated with international travel, call Travelvax Australia's travel health advisory service on 1300 360 164 (toll-free from landlines). You can also book an appointment to obtain tailored advice, vaccines and other medication that may be recommended for your trip at a Travelvax clinic near you.