Potential for the international spread of middle East respiratory syndrome in association with mass gatherings in saudi arabia

Abstract

Background: A novel coronavirus (MERS-CoV) causing severe, life-threatening respiratory disease has emerged in the Middle East at a time when two international mass gatherings in Saudi Arabia are imminent. While MERS-CoV has already spread to and within other countries, these mass gatherings could further amplify and/or accelerate its international dissemination, especially since the origins and geographic source of the virus remain poorly understood.

Methods: We analyzed 2012 worldwide flight itinerary data and historic Hajj pilgrim data to predict population movements out of Saudi Arabia and the broader Middle East to help cities and countries assess their potential for MERS-CoV importation. We compared the magnitude of travel to countries with their World Bank economic status and per capita healthcare expenditures as surrogate markers of their capacity for timely detection of imported MERS-CoV and their ability to mount an effective public health response.

Results: 16.8 million travelers flew on commercial flights out of Saudi Arabia, Jordan, Qatar, and the United Arab Emirates between June and November 2012, of which 51.6% were destined for India (16.3%), Egypt (10.4%), Pakistan (7.8%), the United Kingdom (4.3%), Kuwait (3.6%), Bangladesh (3.1%), Iran (3.1%) and Bahrain (2.9%). Among the 1.74 million foreign pilgrims who performed the Hajj last year, an estimated 65.1% originated from low and lower-middle income countries.

Conclusion: MERS-CoV is an emerging pathogen with pandemic potential with its apparent epicenter in Saudi Arabia, where millions of pilgrims will imminently congregate for two international mass gatherings. Understanding global population movements out of the Middle East through the end of this year's Hajj could help direct anticipatory MERS-CoV surveillance and public health preparedness to mitigate its potential global health and economic impacts.

Country-Level Destinations of Air Travelers Departing MERS-CoV Source Countries*, Origins of Hajj Pilgrims†, and Healthcare Expenditures per Capita‡

* Final Destinations of Air Travelers Departing Saudi Arabia, Jordan, Qatar and the United Arab Emirates via Commercial Flights between June and November 2012† Estimated for 2012 ‡ Sizes of the circles are proportionate with healthcare expenditures per capita as estimated by the World Bank, 2011

City-Level Destinations of Air Travelers Departing MERS-CoV Source Countries* and Origins of Hajj Pillgrims†

* Final Destinations of Air Travelers Departing Saudi Arabia, Jordan, Qatar and the United Arab Emirates via Commercial Flights between June and November 2012 † Estimated for 2012