M.Div, Psy.D, D. Min

an International Threat

By James D. Blair

A cousin of the deadly severe acute respiratory syndrome (SARS CoV), which killed the citizens of Toronto, Canada and wrecked economic havoc on the region (2003), slowly made its way out of the deserts of Saudi Arabia in the form of The Middle East Respiratory Syndrome (MERS CoV) in 2012.

There have been several recent articles concerning the potential of MERS corona-virus spreading globally from Saudi Arabia. One of the challenges confronting the World Health Organization (WHO) is mass religious gatherings that will bring approximately three million pilgrims to Mecca from the 13th to 18th of October for the Hajj, on the heels of Umra, which started on the 9th of July and will finish on the 7th of August.

WHO decision-makers will be under pressure to deal with the Hajj population returning to their home countries. To date, there have been over ninety cases reported of MERS, with a mortality rate of almost 50%, and we are a week away from the end of Umra, which means there have potentially been 1.5 million pilgrims who have come and gone over the last month. Onset of MERS is asymptomatic and this makes it difficult to spot early. Unlike what we saw during the SARS epidemic, in which 800 died worldwide (a large fraction in Canada), there does not seem to be any protocol or guidance on how to deal with symptomatic travelers as they enter this country.

The only serious guidance we could see was for travelers to be careful and report any respiratory infections to local medical facilities. A thorough research project on this issue, conducted by Khan, shows the potential for disease to spread through air travel. According to Khan’s study, hundreds of thousands of visitors originating from the Middle East are traveling into major U.S. cities between the months of June and November. To Americans, it seems there is a significant difference between how international travel was being screened during the early stages of SARS, and where we are today.

We closely follow MERS CoV through RSOE Emergency and Disaster Information Service (EDIS) and see that MERS is detected in many parts of the world. Concerns over UMRA and Hajj are well-founded. It is important to keep in mind that a substantial portion (27%) of KSA’s total population is non-Saudi expatriates who live and work in the Kingdom.

There has been a consistent spread of MERS across the globe during 2014 and what appears to be a substantial increase in the Kingdom of Saudi Arabia (KSA). On February 21st, 2015 WHO reported the global number at nearly 1,000. The U.S. Centers for Disease Control and Prevention (CDC) reports the following countries have lab-confirmed MERS cases: countries in or near the Arabian Peninsula with cases in the United Arab Emirates (UAE), Qatar, Oman, Jordan, Kuwait, the UK, France, Tunisia, Italy, Malaysia, Greece, Egypt, Philippines, U.S.A., Netherlands, Algeria, Austria, Turkey, China, South Korea, and Pakistan. The cases in South Korea are increasing every day and are placing the government at risk of having to make huge decisions as schools and many social organizations create healthcare and economic chaos.

Hajj is a holy pilgrimage to Mecca located in KSA. For Muslims, it is a once in a lifetime religious obligation. There are 1.6 billion Muslims in the world; limitations on capacity in the Holy City of Mecca dictate the number of the devout who may satisfy their Hajj duty. That does not mean that millions may do so. This year, 2015, it is anticipated that 3 million pilgrims will participate in the Hajj. The inclusive event dates change from year to year. This year it falls on September 21st through 26th. Part of the pilgrimage is centered in a huge structure made of three levels that accommodate 200,000 pilgrims at one time. In the center of this edifice is a sacred stone around which the pilgrims must circle seven times. All pictures taken of the event show pilgrims’ dress and white garments in a densely congested environment in extremely hot temperatures, which contributes to the spread of dangerous disease.

A careful reading of Doctor Kamran Khan’s research paper: “Potential for the International Spread of Middle East Respiratory Syndrome in Association with Mass Gatherings in Saudi Arabia”, July 17, 2013, will give the reader a unique insight into the dynamics of such an event.

The specter of millions of pilgrims’ exposed to the geographic center of a deadly evolving novel viral disease can be something to lose sleep over. Closely competing with that is the sight of these pilgrims boarding commercial and private aircraft on the way back to hundreds of densely populated destinations around the globe.

We continue to see very loose guidance from WHO and CDC. The thing that has us scratching our heads is guidance couched in words like “should” and the statement: “At this time, CDC does not recommend that travelers change their plans because of MERS.”

This Paper offers no private or professional advice. The reader is encouraged to use good judgment when applying the information contained and to seek advice from appropriate qualified domain professionals. The author shall in no event be held liable for any loss or other damages, including but not limited to special, incidental, consequential, or other damages. The reader is responsible for any subjective decisions made as to the content and or its use. JB

About the Author

James D. Blair
James D. BlairA Fifty-plus year career in progressive levels of responsibility within the Private, Public and Military Healthcare Sectors. Chief Executive Officer at military hospitals ranging from Combat Field, Combat Evacuation, Community, Medical Centers, and Major Healthcare System. Chief of Staff, 7th Medical Command and USAREUR Deputy Chief Surgeon - Medical Support Services (Safety and Security Readiness), Senior Healthcare Consultant for US Army Surgeon General, Chief, Education and Training, Office of Army Surgeon General. Vice-President HCA Middle East, Ltd. Health and Human Services Finance Commission Deputy Director, Operations, State of South Carolina, Independent Contractor, JCI. Fifteen years of preparing healthcare organizations to meet their expected role in the nation's strategy for first, CBRNE and later all-hazards preparedness for Homeland Security protection. Author of two books on Hospital and Healthcare all-hazards protection and numerous articles on several expert domains dealing with hospital administration. .

Published by Dr. Robert O' Block in Inside Homeland Security June 2015.