Samir Benkouiten

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

n Abstractn n A cohort of 154 French Hajj pilgrims participating in the 2012 Hajj were systematically sampled with nasal swabs prior to returning to France, and screened for the novel HCoV-EMC coronavirus by two real-time RT-PCR assays. Despite a high rate of respiratory symptoms (83.4%), including 41.0% influenza-like illness, no case of HCoV-EMC infection was detected. Despite the fact that zoonotic transmission was suspected in the first few cases, a recent family cluster in the Kingdom of Saudi Arabia suggests that the virus might show at least limited spread from person to person, which justifies continuing epidemiological surveillance.n n

Acquisition of extended-spectrum cephalosporin- and colistin-resistant Salmonella enterica subsp. enterica serotype Newport by pilgrims during Hajj

Gatherings like the Hajj involving many people who travel from different parts of the world represent a risk for the acquisition and dissemination of infectious diseases. In this study, acquisition of multidrug-resistant (MDR) Salmonella spp. in 2013 Hajj pilgrims from Marseille, France, was investigated. In total, 267 rectal swabs were collected from 129 participants before their departure and after their return from the pilgrimage as well as during the pilgrimage from patients with diarrhoea. Samples were screened for the presence of Salmonella using quantitative real-time PCR and culture. Whole-genome sequencing was performed to characterise one of the isolates, and the mechanism leading to colistin resistance was investigated. Six post-Hajj samples and one sample collected during a diarrhoea episode in Hajj were positive for Salmonella by real-time PCR, with five Salmonella enterica belonging to several serotypes recovered by culture, whereas no pre-Hajj sample was positive. Two of the isolates belonged to the epidemic Newport serotype, were resistant to cephalosporins, gentamicin and colistin, and harboured the bla(CTX-M-2) gene and a 12-nucleotide deletion in the pmrB gene leading to colistin resistance. This study shows that pilgrims acquired Salmonella bacteria, including a novel MDR clone, during the Hajj pilgrimage. This calls for more improved public health surveillance during Hajj because Salmonella is one of the most common diarrhoea-causing bacteria worldwide. Therefore, returning pilgrims could disseminate MDR bacteria worldwide upon returning to their home countries.

Non-pharmaceutical interventions for the prevention of respiratory tract infections during Hajj pilgrimage

n Summaryn n Overcrowding during the yearly Hajj mass gatherings is associated with increased risk of spreading infectious diseases, particularly respiratory diseases. Non-pharmaceutical interventions (e.g., hand hygiene, wearing face masks, social distancing) are known to reduce the spread of respiratory viruses from person to person and are therefore recommended to pilgrims by public health agencies. The implementation of effective public health policies and recommendations involves evaluating the adherence to and effectiveness of these measures in the specific context of the Hajj. This review summarizes the evidence related to the effectiveness of non-pharmaceutical interventions in preventing the spread of respiratory infectious diseases during the Hajj. Overall, although hand hygiene compliance is high among pilgrims, face mask use and social distancing remain difficult challenges. Data about the effectiveness of these measures at the Hajj are limited, and results are contradictory, highlighting the need for future large-scale studies.n n

Acquisition of Streptococcus pneumoniae Carriage in Pilgrims During the 2012 Hajj

To investigate the nasal carriage of some respiratory bacterial pathogens that are responsible for infections associated with person-to-person transmission, we conducted a cohort survey of pilgrims departing to Mecca for the 2012 Hajj season. In this report, we demonstrate the acquisition of Streptococcus pneumoniae nasal carriage in returning Hajj pilgrims.

The inevitable Hajj cough: Surveillance data in French pilgrims, 2012-2014.

n Summaryn n Backgroundn Respiratory tract infections are the most common infection affecting Hajj pilgrims, and the ‘‘Hajj cough’’ is considered by pilgrims almost de rigueur.n n n Methodsn French pilgrims were recruited between January 2012–December 2014 and information on demographics, medical history, compliance with preventive measures and health problems during travel were collected.n n n Resultsn A total of 382 pilgrims were included with 39.3% aged ≥65 years and 55.1% suffering from a chronic disease, most frequently hypertension and diabetes. The prevalence of cough was 80.9% and a high proportion presented with associated sore throat (91.0%), rhinitis (78.7%) and hoarseness (63.0%). Myalgia was reported in 48.3% of cases and subjective fever in 47.3%. The incubation time of respiratory symptoms was 7.7 days (range 0–25 days) and 51.9% of pilgrims presenting with a cough during their stay were still symptomatic on return. Among pilgrims with a cough, 69.4% took antibiotics. The prevalence of cough was significantly higher among females than men, but age, chronic conditions and preventive measures had no significant effect.n n n Conclusionsn The Hajj cough is highly common, likely a result of crowded conditions at religious places. Pilgrims should be advised to carry symptomatic relief for the Hajj cough such as cough suppressant, soothing throat lozenges and paracetamol. Use of antibiotics should be discouraged.n n

Hajj pilgrims' knowledge about Middle East respiratory syndrome coronavirus, August to September 2013.

In preparation for Hajj 2013, 360 French pilgrims were interviewed regarding their knowledge about Middle East respiratory syndrome (MERS). Respondents were aged 20–85 years, male-female ratio was 1.05:1;64.7% were aware of the MERS situation in Saudi Arabia; 35.3% knew about the Saudi Ministry of Health recommendations for at-risk pilgrims to postpone participation in the 2013 Hajj. None of 179 at-risk individuals(49.9%) decided to cancel their Hajj participation even after advice during consultation.

Occurrence of Tropheryma whipplei during diarrhea in Hajj pilgrims: A PCR analysis of paired rectal swabs

BACKGROUNDnTropheryma whipplei was recently associated with gastroenteritis in children. We hypothesize that T. whipplei may be a contributing microbe in travellers diarrhea.nnnMETHODnThe presence of T. whipplei was investigated by PCR on rectal swab samples of Hajj pilgrims before and after travelling to the Kingdom of Saudi Arabia (KSA). Additionally a rectal swab was performed at the time of diarrhea for some pilgrims.nnnRESULTSnA total of 129 pilgrims underwent rectal swab samples before departure and on return. All pilgrims were negative for T. whipplei before travel. One pilgrim (0.8%) was positive on return but did not reported diarrhea. A total of 30 pilgrims (23.3%) experienced diarrhea during the stay in the KSA. Nine pilgrims with diarrhea underwent the additional rectal swab during their diarrhea episode, two of them were positive for T. whipplei.nnnCONCLUSIONSnThis work suggests that T. whipplei may be associated with adult travellers diarrhea, by finding T. whipplei DNA individuals negative before and after the episode of diarrhea. Further study addressing this issue in larger cohorts of Hajj pilgrims with systematic sampling at the time of diarrheal episode may help to understand the potential role of T. whipplei in travellers diarrhea.

Diarrhea at the Hajj and Umrah.

This systematic review aims to summarize the incidence and etiology of diarrheal illness among pilgrims attending the Hajj and Umrah. Gastroenteritis and diarrhea have been potential threats during previous Hajj pilgrimages. The last cases of Hajj related cholera were reported in 1989. Currently, respiratory tract infections account for the majority of health problems during the Hajj. This shift in epidemiology reflects the improvement of sanitary conditions in Saudi Arabia in general, and at religious sites in particular. Nevertheless, gastrointestinal diseases, food-poisoning outbreaks, and diarrhea continue to occur among pilgrims. Available studies about diarrhea among Hajj pilgrims indicate a mean prevalence of 2% with the highest prevalence of 23% among a group of French pilgrims in 2013. There is an obvious lack of information about the etiology of diarrheal disease at the Hajj. Further studies addressing this issue in hospitalized patients as well as prospective cohort studies would be of interest. During the Hajj, hand washing is regularly carried out by pilgrims under a ritual purification, often called ablution. We recommend implementation of effective hand hygiene practices focusing on the regular use of alcohol-based hand rubs, as they require less time than traditional hand washing, act more rapidly, and contribute to sustained improvement in compliance associated with decreased infection rates.

Mass Gatherings and the Spread of Respiratory Infections. Lessons from the Hajj.

The mass gathering of people is a potential source for developing, propagating, and disseminating infectious diseases on a global scale. Of the illnesses associated with mass gatherings, respiratory tract infections are the most common, the most easily transmitted, and the most likely to be spread widely beyond the site of the meeting by attendees returning home. Many factors contribute to the spread of these infections during mass gatherings, including crowding, the health of the attendees, and the type and location of meetings. The annual Hajj in the Kingdom of Saudi Arabia is the largest recurring single mass gathering in the world. Every year more than 10 million pilgrims attend the annual Hajj and Umrah. Attendees assemble in confined areas for several days. People with a wide range of age, health, susceptibility to illness, and hygiene sophistication come in close contact, creating an enormous public health challenge. Controlling respiratory infections at the Hajj requires surveillance, rapid diagnostic testing, and containment strategies. Although the Hajj is without equal, other mass gatherings can generate similar hazards. The geographic colocalization of the Zika virus epidemic and the 2016 Summer Olympic Games in Brazil is a current example of great concern. The potential of international mass gatherings for local and global calamity calls for greater global attention and research.

Does Tropheryma whipplei contribute to travelers' diarrhea?: A PCR analysis of paired stool samples in French travelers to Senegal.

BACKGROUNDnTropheryma whipplei was recently associated with acute infections as gastroenteritis in children. We hypothesize that T. whipplei may be a contributing microbe in travelers diarrhea.nnnMETHODnThe presence of T. whipplei was investigated by using a specific PCR on stool samples of travelers to Senegal before and after traveling, independently of the occurrence of diarrhea.nnnRESULTSnA total of 59 travelers returned both stool samples before and after travel and 16 (27%) experienced diarrhea during travel. Fifty-three patients (89.8%) were negative for T. whipplei before and after travel. Two patients (3.4%) were negative before and positive after travel. Two patients (3.4%) were positive before travel and negative after travel. Finally, two patients (3.4%) were positive before and after travel. There were no carriage differences of T. whipplei, visiting Senegal or staying in France. We found no significant association of T. whipplei carriage and travel-associated diarrhea but this may have been impacted by the use of doxycycline.nnnCONCLUSIONSnThis is the first report of T. whipplei carriage acquired during travel to tropical area. Further study addressing this issue in larger cohorts of travelers to Senegal, including individuals visiting friends and relatives in their country of origin and the protective role of doxycycline malaria chemoprophylaxis may help to understand the potential contribution of T. whipplei to travelers diarrhea.