Strengthening health security by implementing the International Health Regulations (2005)

WHO advice for international travel and trade in relation to MERS-CoV

16 September 2018

Situation

In August and September, two cases of MERS-CoV infection were reported by the United Kingdom and the Republic of Korea, respectively. On 22 August 2018, the International Health Regulations (IHR 2005) National Focal Point for the United Kingdom of Great Britain and Northern Ireland notified WHO about a laboratory-confirmed Middle East respiratory syndrome coronavirus (MERS-CoV) infection. The patient is a resident of the Kingdom of Saudi Arabia who was visiting the United Kingdom of Great Britain and Northern Ireland. On 8 September 2018, the International Health Regulations (IHR 2005) National Focal Point (NFP) of the Republic of Korea notified WHO of a laboratory-confirmed case of Middle East respiratory syndrome coronavirus (MERS-CoV) infection, in a Korean national travelling back from Kuwait via Dubai. Detailed information about the infection with MERS-CoV, the history of this case and the current response measures can be found in the WHO Fact sheet and the Disease Outbreak News. These events raise the opportunity to provide an update on the potential risks for travellers in relation to infection with MERS-CoV, and on the potential risks of spread via international travel and trade.

Risk of individual exposure for international travellers

MERS-CoV is a zoonotic virus that has repeatedly entered the human population via direct or indirect contact with infected dromedary camels, mainly in the Arabian Peninsula. Human-to-human transmission has been limited, but can be amplified in health care settings when infection prevention and control procedures are not adequate. To date, there is no evidence of sustained human-to-human transmission anywhere in the world. Currently, there are no vaccine or MERS-specific treatment available. Treatment is supportive and based on the patient’s clinical condition. The risk of individual exposure for international travellers remains low, in particular if travellers do not come in direct contact with infected dromedary camels or are not exposed to potential infection in health care settings.

Risk of importation of cases via air travel

Currently, cases of MERS-CoV outside the Middle East region were either returning travellers or individuals who had close contact with imported cases. Since 2012, there have been less than 25 imported cases reported outside the Middle East region: to North America (United States), Asia (China, Malaysia, the Philippines, the Republic of Korea, and Thailand) and Europe (Austria, France, Germany, Greece, Italy, the Netherlands, Turkey and the United Kingdom. In one instance, one case imported to the Republic of Korea in 2015 resulted a large multi-site hospital outbreak of 186 confirmed cases, mainly through in-hospital transmission.

MERS-CoV is circulating in dromedary camels in large parts of Africa, in the Middle East and in some parts of South Asia. As long as the transmission of the MERS-CoV between dromedaries and humans continue, the risk of importation of cases outside the Middle East region will still be present. All regions are at risk given the large volume of air traffic between the Middle East region and the rest of the world. According to ICAO Air Transport Yearly Monitor, international passenger traffic grew by 7.0% year-on-year in 2015, and by 6.3% year-on-year in 2016, with the Middle East being the fastest growing region.

The ability to mitigate the risk of secondary infections from imported cases depends on the available capacities of countries to detect and manage cases quickly. These include laboratory capacity to detect MERS-CoV, health care facilities equipped with isolation rooms, public health authority capacities for contact tracing and case management, as well an adequate standard infection prevention and control measures in health care settings.

Travel-related recommendations to prevent the international spread of MERS-CoV infection

International travellers

Travellers to Middle East countries should avoid visiting farms, markets, barns, or other places where dromedary camels are present. Travellers should practice general hygiene measures at all times, including regular hand washing before and after touching animals, and should avoid contact with sick animals. People with pre-existing medical conditions, such as diabetes, chronic lung disease, chronic renal disease, and immunodeficiency are more likely to develop a severe form of MERS if infected with MERS-CoV.

Information on general health precautions for travellers can be provided via travel health clinics, travel agencies, conveyance operators or at points of entry. This includes:

  • hand hygiene and respiratory hygiene (covering mouth and nose when coughing or sneezing, washing hands after contact with respiratory secretions, and keeping a distance ≥1 metre with other persons when having acute febrile respiratory symptoms);
  • adhering to good food-safety practices, such as avoiding undercooked meat or food prepared under unsanitary conditions, consuming raw camel milk or camel urine and properly washing fruits and vegetables before eating them;
  • maintaining good personal hygiene.
Measures at points of entry

Entry screening at destination, including temperature checks and/or health questionnaires, is unlikely to detect passengers with MERS-CoV infection, due to a number of reasons:

  • passengers may travel during their incubation period, and hence are asymptomatic;
  • MERS-CoV-like symptoms (fever, coughing, diarrhoea) can be due to other infectious diseases;
  • fever can also be due to other factors such as hot beverages or menstrual period in women;
  • fever measurement can be inaccurate due to inadequate calibration of thermos-scans;
  • passengers can conceal their fever by taking anti-pyretic drugs before travel;
  • passenger may conceal accurate reporting of travel history and exposure to risk factors;
  • passengers with MERS-CoV infection may not show typical MERS-CoV symptoms and be missed during screening procedures.

For these reasons, it is generally considered that entry screening offers little benefit while requiring considerable resources.

WHO does not recommend entry screening at points of entry for MERS, nor does it recommend the application of any travel or trade restrictions. WHO encourages countries to provide information on MERS-CoV, including this travel advice, to transport operators and ground staff. Information on how to avoid exposure and where and when to seek medical care should be provided to travellers to affected areas before, during and after travel.

As provided by the International Health Regulations (2005) (IHR), countries should ensure that:

  • routine measures are in place at points of entry for assessing ill travellers detected on board conveyances (such as planes and ships);
  • procedures and means are in place for communicating information on ill travellers between conveyances and points of entry as well as between points of entry and national health authorities;
  • safe transportation of symptomatic travellers to hospitals or designated facilities for clinical assessment and treatment is organized;
  • capacity is in place to implement measures for responding to events that may constitute a public health emergency of international concern.

If a sick traveller is on board a ship/ a plane, and in accordance to articles 37 and 38 of IHR, the model of Maritime declaration of health (Annex 8 of IHR)/ the health part of the aircraft general declaration (Annex 9 of IHR) shall be used, when required by a State Party. Also, a passenger locator form can be used in the event of a sick traveller detected on board a plane. This form is useful for collecting contact information for passengers, and can be used for follow-up if necessary. Travellers should also be encouraged to self-report if they feel ill.

If a passenger on board of an aircraft has symptoms suggestive of MERS-CoV infection, the pilot should follow the International Air Transport Association (IATA) guidelines for infection control and notify public health authorities at the destination airport via air traffic control, in accordance with the International Civil Aviation Authority Procedures for Air Navigation Services – Air Traffic Management (ICAO PANS-ATM) .

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