Laboratory-confirmed invasive meningococcal disease: effect of the Hajj vaccination policy, Saudi Arabia, 1995 to 2011.

Saudi Arabia (SA) experienced two large invasive meningococcal disease (IMD) outbreaks during the 2000 and 2001 Hajj pilgrimages. In 2002, polysaccharide quadrivalent ACWY vaccines became mandatory for Mecca and Medina pilgrims/residents older than two years. This study aimed to analyse IMD surveillance data among citizens, residents and pilgrims in SA from 1995 to 2011, focusing on changes before and after the new vaccination policy. For all laboratory-confirmed IMD cases in the national surveillance database from 1995 to 2011, serogroup and age were retrieved. The cases' seasonal distribution as well as the case fatality ratios (CFR) were obtained. For Saudi citizens/residents and Hajj pilgrims, annual rates were calculated using mid-year population estimates. The Student's t-test was used to compare means between the pre-epidemic (1995-1999) and post-epidemic (2002-2011) periods, excluding outbreak years. From 1995 to 2011, laboratories notified 1,103 cases. Between the pre- and post-epidemic periods, mean annual IMD rates decreased from 0.20 (standard deviation (SD): 0.1) to 0.06 cases/100,000 (SD: 0.06; p=0.02), mean numbers of Hajj-related cases from 13 (SD: 9.3) to 2 cases/year (SD: 2.3; p=0.02) and the mean age from 31 (SD: 1.3) to 18 years (SD: 1.4; p<0.01). The CFR in Saudi citizens (10.4) was lower than among foreign pilgrims (28.9) and decreased from 19.3% (SD: 1.8) in the pre-epidemic to 11.4% (SD: 7.0; p=0.04) in the post-epidemic phase. The decrease of annual IMD rates, CFR and Hajj-related cases between the pre- and post- vaccine era suggests a possible positive effect of the mandatory ACWY vaccination for pilgrims/residents in Mecca and Medina. Regular surveillance with an annual data analysis is necessary to monitor trends and circulating serotypes and to implement appropriate public health measures to avoid new IMD epidemics during upcoming Hajj seasons.

Taking stock of the first 133 MERS coronavirus cases globally--Is the epidemic changing?

Since June 2012, 133 Middle East respiratory syndrome coronavirus (MERS-CoV) cases have been identified in nine countries. Two time periods in 2013 were compared to identify changes in the epidemiology. The case-fatality risk (CFR) is 45% and is decreasing. Men have a higher CFR (52%) and are over-represented among cases. Thirteen out of 14 known primary cases died. The sex-ratio is more balanced in the latter period. Nosocomial transmission was implied in 26% of the cases.

Consensus recommendation for meningococcal disease prevention for Hajj and Umra pilgrimage/travel medicine.

The Islamic Hajj to Makkah (Mecca) has been associated with outbreaks of invasive meningococcal disease and the global spread of Neisseria meningitidis serogroup W-135. For Hajj pilgrims the quadrivalent vaccination against serogroups A, C, W-135 and Y is a mandatory requirement. Novel conjugate vaccines may provide benefits for the community by reduction of carriage. With the introduction of the new generation of quadrivalent meningococcal conjugate vaccines (Menveo, Menactra, and others pending license) and their recent implementation in Saudi Arabia, experts from 11 countries in the Middle East region met at a Meningococcal Leadership Forum (MLF), in Dubai in May 2010 to exchange opinions on meningococcal disease and prevention strategies. These experts discussed the importance of introducing conjugate vaccines for pilgrims and travellers, and elaborated a consensus recommendation to support healthcare professionals and decision-makers.

Saudi Arabia and the emergence of a novel coronavirus.

The novel coronavirus disease outbreak in Saudi Arabia in 2012 predominately affected males and those living in urban areas. Since September and October 2012, when the first 2 cases were published, a total of 15 confirmed cases have been reported. All but 2 have been linked to conuntries of the Arabian peninsula; Saudi Arabian nationals accounted for a majority, 8 in all, and only 1 case was female. Seven patients had severe pneumonia; 2 survived-1 with mild disease and 1 with significant underlying illness. Although transmission of the virus to health-care workers was suspected in Jordan's April 2012 outbreak, similar clusters have not been found in Saudi Arabia's hospitals, nor have additional cases been indentified through retrospective tracing of exposed health-care workers. Two family clusters have been identified, 1 in Riyadh and 1 in Manchester, England. A second Riyadh family cluster is being investigated.

Using health educators to improve knowledge of healthy behaviour among Hajj 1432 (2011) pilgrims.

The main objective of this study was to assess the short-term effect on health knowledge among pilgrims after being provided specific health education messages. A random sample of 6 entry-point buses was selected. A self-administered questionnaire was used to assess knowledge before and after intervention; 278 pilgrims completed the questionnaire. There was a significant increase in the proportion of participants who answered all questions correctly after the educational intervention (P < 0.05). Almost all respondents stated that they benefited from the health education and that the health educator was successful in delivering the messages. Only 19 (7.2%) reported that they had already received relevant health education messages prior to their arrival in Saudi Arabia. Before the intervention just 50% of the respondents knew that safe shaving prevents dissemination of bloodborne diseases; this rose to 84.7% after the intervention. Direct health education to pilgrims is effective in improving short-term health knowledge.

Seventh TEPHINET Global Scientific Conference in Amman, Jordan, November 2012.

The Jordanian Ministry of Health in collaboration with the Eastern Mediterranean Public Health Network (EMPHNET) hosted the Seventh Global Scientific Conference of the Training Programs in Epidemiology and Public Health Interventions Network (TEPHINET) in Jordan in November 2012. This was the first time this Conference was held in the Eastern Mediterranean region. The Conference theme was "communicable and noncommunicable diseases: public health challenges and successes". Over 400 participants including field epidemiology training program residents, graduates and public health officials from 66 countries attended the Conference as well as 187 people from 57 countries who attended the conference sessions on line. The programme included 121 oral and 130 poster presentations in addition to 5 pre-conference workshops and 9 roundtable discussions. All sessions were recorded and virtually broadcasted and made available on line. The Conference succeeded in creating opportunities for dialogue between residents and graduates of field epidemiology training programmes and public health stakeholders across the region and the globe.

Highlights and conclusions from the technical consultative meeting on novel coronavirus infection, Cairo, Egypt, 14-16 January 2013.

The emergence of a novel strain of coronavirus in the Arabian Peninsula raised a global health concern in 2012, partly because the majority of human infections were fatal and partly due to its presumed animal origin. An urgent meeting of scientific and public health experts was convened by WHO in January 2013 in view of the limited knowledge available on the epidemiological and natural history of infection with this novel virus. The meeting reviewed current evidence and identified critical knowledge gaps to improve better understanding of the public health risk associated with the virus so as to improve preparedness and to safeguard and protect global health.

Saudi Arabian expatriate worker fitness-screening programme: a review of 14 years of data.

Expatriate workers must be medically examined in their country of origin at accredited centres prior to their arrival in any Gulf Cooperation Council (GCC) country and are reexamined when they enter the country. This review investigated the epidemiological profile of registered expatriate workers in Saudi Arabia who were found medically unfit to work. A descriptive analysis was performed on 4,272,480 records of a Ministry of Health database from 1997 to 2010. The greatest proportion of workers was from Indonesia (34.3%). The total proportion of unfit expatriate workers was low (0.71%). The highest rate of unfitness was among workers from Ethiopia (4.06%), followed by Somalia (2.41%). Hepatitis B infection was the most common cause (57.5%), followed by noncommunicable diseases (21.2%) and hepatitis C infection (17.4%). This review suggests that the total number of workers registered in the Saudi Ministry of Health was underestimated, and the rate of unfit workers was lower than for other GCC countries, suggesting that standards and quality assurance in Saudi laboratories require revision.

Emerging respiratory and novel coronavirus 2012 infections and mass gatherings.

Mass gatherings are attended by an increasingly global audience and thus raise the concern of possible acute public health risks not normally encountered by the host population. The potential acute risks to individual and population health include communicable diseases. The communicable disease risks include emerging and re-emerging diseases in host and visiting populations. In this review, we provide an overview ofthe literature on respiratory infections at mass gatherings, then describe the impact of novel coronavirus 2012 (nCoV), an emerging respiratory disease virus, on the preparations for mass gathering. Although, nCoV emerged prior to the 2012 Hajj pilgrimage season, Muslims completed their religious duty without acquiring infections by nCoV. Clearly, the global nature of mass gatherings and their potential risks to international health make it imperative that research on such events and guidelines produced for their management are relevant to diverse contexts and are a collaborative effort between global experts.

The Hajj: updated health hazards and current recommendations for 2012.

This year the Hajj will take place during 24-29 October. Recent outbreaks of Ebola haemorrhagic fever in Uganda and the Democratic Republic of the Congo, cholera in Sierra Leone, and infections associated with a novel coronavirus in Saudi Arabia and Qatar required review of the health recommendations of the 2012 Hajj. Current guidelines foresee mandatory vaccination with quadrivalent meningococcal vaccine for all pilgrims, and yellow fever and poliomyelitis vaccine for pilgrims from high-risk countries. Influenza vaccine is strongly recommended.

The Role of Convalescent Plasma and Tocilizumab in the Management of COVID-19 Infection: A Cohort of 110 Patients from a Tertiary Care Hospital in Oman.

AIM: As Coronavirus Disease-2019 (COVID-19) pandemic continues to evolve, the search for safe and effective therapeutic interventions remain essential. METHODS: We conducted a retrospective cohort study on patients hospitalized with laboratory confirmed severe acute respiratory syndrome coronavirus-2 infection, comparing standard of care along with Convalescent Plasma with or without Tocilizumab (CP vs. CPT). RESULTS: A total of 110 patients were enrolled with an overall mean age of 50 ± 16 years. Patients on CPT were more likely to have had acute respiratory distress syndrome (77% vs. 42%; p < 0.001), sepsis (9.7% vs. 0; p = 0.036), chest X-ray abnormalities (71% vs. 44%; p = 0.004), intensive care unit admission (84% vs. 56%; p = 0.001) as well as being on mechanical ventilation (79% vs. 48%; p = 0.001). After CPT treatment, all measured inflammatory markers, except interleukine-6, showed an overall steady decline over time (all p-values <0.05) and the ventilatory parameters showed significant improvement of PaO2/FiO2 ratio from 127 to 188 within 7 days (p < 0.001). Additionally, 52% (32/62) of the patients had favorable outcome, either as improvement of ventilatory parameters or extubation within 14 days of hospitalization. However, mortality rate in those on CPT was higher than those who received CP alone (24% vs. 8.3%; p = 0.041). CONCLUSION: In patients with severe COVID-19 infection, using tocilizumab with convalescent plasma is associated with improvement in inflammatory and ventilatory parameters but no effect on mortality. These findings require validation from randomized clinical trials.

Establishment of public health security in Saudi Arabia for the 2009 Hajj in response to pandemic influenza A H1N1.

Mass gatherings of people challenge public health capacities at host locations and the visitors' places of origin. Hajj--the yearly pilgrimage by Muslims to Saudi Arabia--is one of the largest, most culturally and geographically diverse mass gatherings in the world. With the 2009 pandemic influenza A H1N1 and upcoming Hajj, the Saudi Arabian Ministry of Health (MoH) convened a preparedness consultation in June, 2009. Consultants from global public health agencies met in their official capacities with their Saudi Arabian counterparts. The MoH aimed to pool and share public health knowledge about mass gatherings, and review the country's preparedness plans, focusing on the prevention and control of pandemic influenza. This process resulted in several practical recommendations, many to be put into practice before the start of Hajj and the rest during Hajj. These preparedness plans should ensure the optimum provision of health services for pilgrims to Saudi Arabia, and minimum disease transmission on their return home. Review of the implementation of these recommendations and their effect will not only inform future mass gatherings in Saudi Arabia, but will also strengthen preparedness efforts in other settings.

The Hajj: communicable and non-communicable health hazards and current guidance for pilgrims.

The Hajj has become the epicenter of mass migration of millions of Muslims of enormous ethnic diversity. No other mass gathering can compare, either in scale or in regularity. Communicable disease outbreaks of various infectious diseases have been reported repeatedly, during and following the Hajj. The Hajj 2010 starts in the first week of November 2010 and this report is a timely reminder that many infectious diseases can be avoided or averted by adopting appropriate prophylactic measures.

Rare case of COVID-19 presenting as acute abdomen and sepsis.

Coronavirus disease 2019 (COVID-19) may present as acute abdomen, although the pathophysiology remains obscure. We report the case of a 45-year-old-man with severe COVID-19 pneumonia with associated pulmonary embolism who presented with acute abdomen. He underwent emergency laparotomy and resection of an ischaemic area of the jejunum. Postoperatively, he had septic shock, acute respiratory distress syndrome and acute kidney injury necessitating continuous renal replacement therapy. We administered antibiotics and therapeutic anticoagulation along with two sessions of haemoadsorption by CytoSorb filter, in conjunction with continuous renal replacement therapy. The patient survived. Bowel ischaemia due to thromboembolic disease should be promptly treated. Extracorporeal blood purification may be useful in managing sepsis in severe COVID-19.

Mobile populations across the Mediterranean Sea and beyond: travel medicine, mass gathering medicine and homeless health.

The Méditerranée Infection institute is internationally recognized for its expertise in infectious diseases and tropical medicine, and is one of the most active research centres for infectious diseases in Europe. Surveillance and research addressing infectious diseases in globally mobile populations is one of the strong components of the research conducted at the institute. A significant amount of clinical, microbiologic and epidemiologic works have been conducted in international travellers, pilgrims participating in large international religious gatherings, economic migrants and homeless migrant people over the last decades by our group. Our strong anchoring in several countries around the Mediterranean Sea and beyond, as well as the pivotal role of Marseille in the EuroTravNet and GeoSentinel international networks that monitor travel-associated diseases, reinforce our leading position in the fields of travel and tropical medicine, mass gathering medicine and homeless health.

Evaluation of visual triage for screening of Middle East respiratory syndrome coronavirus patients.

The emergence of Middle East respiratory syndrome coronavirus (MERS-CoV) in September 2012 in Saudi Arabia had attracted the attention of the global health community. In 2017 the Saudi Ministry of Health released a visual triage system with scoring to alert healthcare workers in emergency departments (EDs) and haemodialysis units for the possibility of occurrence of MERS-CoV infection. We performed a retrospective analysis of this visual score to determine its sensitivity and specificity. The study included all cases from 2014 to 2017 in a MERS-CoV referral centre in Riyadh, Saudi Arabia. During the study period there were a total of 2435 suspected MERS cases. Of these, 1823 (75%) tested negative and the remaining 25% tested positive for MERS-CoV by PCR assay. The application of the visual triage score found a similar percentage of MERS-CoV and non-MERS-CoV patients, with each score from 0 to 11. The percentage of patients with a cutoff score of ≥4 was 75% in patients with MERS-CoV infection and 85% in patients without MERS-CoV infection (p 0.0001). The sensitivity and specificity of this cutoff score for MERS-CoV infection were 74.1% and 18.6%, respectively. The sensitivity and specificity of the scoring system were low, and further refinement of the score is needed for better prediction of MERS-CoV infection.

Methicillin-resistant Staphylococcus aureus: a 5-year review of surveillance data in a tertiary care hospital in Saudi Arabia.

BACKGROUND: Staphylococcus aureus is an important pathogen that leads to serious infections in the community and in hospitals. Evidence has shown that the prevalence of infection and colonization with drug-resistant S. aureus, such as methicillin-resistant S. aureus (MRSA) and glycopeptide intermediately susceptible S. aureus, is increasing. Authorities must be aware of the prevalence of MRSA infection and colonization in their country in order to implement and monitor infection control policies that help curtail further emergence of this pathogen. OBJECTIVES: To examine the trend of hospital-acquired MRSA infection and colonization in a tertiary care institution in Saudi Arabia during a 5-year period in order to identify specific areas at high risk for MRSA transmission, and to review our MRSA decolonization procedure and outcomes. METHODS: Surveillance data prospectively collected from January 1, 2000, through December 31, 2004, on hospital-acquired (HA) MRSA were analyzed, with an emphasis on the trend of HA-MRSA infection and colonization, areas of high transmission, risk factors, and effectiveness of the implemented decolonization policy. RESULTS: During the study period, 442 cases of HA-MRSA infection and colonization were identified. Of these, 51.2% were infections, and 48.8% were colonizations. An increasing trend in the incidence rates of infection and colonization was noticed during the study period, and most cases were identified on the surgical ward (33.3%) and medical ward (32.1%). Of the 34 infected patients who underwent systematic decolonization, 35.3% were successfully decolonized, and of the 11 who underwent topical decolonization, 63.6% were successfully decolonized. CONCLUSION: The increasing trend of HA-MRSA infections has been a noticeable global problem. We identified a gradual increase in the rates of MRSA colonization and infection in a tertiary care center Saudi Arabia and recognize the importance of abiding by strict infection control policies, including hand hygiene and proper isolation practices. Continued surveillance for MRSA and other emerging multidrug-resistant pathogens is also needed.

Brucellosis in the middle East: a persistent medical, socioeconomic and political issue.

Human brucellosis remains endemic in the majority of Middle Eastern countries, accounting for tens of thousands of new annual cases, despite partly successful efforts at disease control. In the Middle East, more pronouncedly than elsewhere, brucellosis exhibits significant socioeconomic and political correlations, including population literacy and distribution, and development of health networks. Currently, Middle Eastern countries, having a vast pool of human cases, generate important information regarding the disease's clinical manifestations, diagnosis, and treatment. Given the socioeconomic framework of brucellosis endemicity, specific approaches allowing for rapid, cost-effective diagnosis, and efficient cost-effective therapy should be pursued. Overall, attempts at controlling disease without altering the socioeconomic and political correlations may prove futile, unfortunately projecting similar fates for attempts related to more important communicable diseases.

Emergence and trends of penicillin non-susceptible Streptococcus pneumoniae in Saudi Arabia and Kuwait - perspective and outstanding issues.

For many years in the past Streptococcus pneumoniae was uniformly susceptible to penicillin until the sudden and unexpected emergence of clinical infections caused by penicillin-resistant S. pneumoniae (PRSP) in 1967. Within the following decade, reports of nosocomial and community outbreaks of infections due to PRSP became widespread all over the world. Recent reports suggest that the incidence of resistance rates is rising in many countries although there are geographical variations in the prevalence and patterns of resistance between countries. The problem of antibiotic resistance is further compounded by the emergence of resistance to many beta-lactam antibiotics. The first report of PRSP in Saudi Arabia was in 1991. Barely a year after, PRSP infection was reported in Kuwait in 1992. Since then, studies from various parts of these countries have recorded prevalence rates ranging from 6.2% in Riyadh to 34% in Jeddah and 20% to 56% in neighboring Kuwait. These suggest considerable variation in the prevalence of PRSP in different cities in the Saudi Kingdom and Kuwait. The mechanism of resistance is due to chromosomally mediated alteration of penicillin-binding proteins (PBPs), which are target sites for beta-lactam antibiotics. It would appear that the spread of PRSP strains in Saudi Arabia is driven by the selective pressure created by excessive use and misuse of antimicrobial agents made possible by the easy availability of these agents, often frequently obtainable over the counter. In Kuwait, irrational and misguided use of antibiotics may be the major driving force favoring the spread of PRSP. The serotypes of strains encountered in Saudi Arabia and Kuwait are almost identical, with serotypes 19, 6, 15, 14 and 23 being the most common; together they constitute about 70% of the isolates circulating in these countries. In general, almost 90% of the serotypes included in the 23-polyvalent vaccine are present in the general population. However, a much lower percentage of these serotypes is found in the conjugated vaccines, which are more relevant to our communities. This paper reviews the emergence and the steady increase in the prevalence of penicillin-resistant pneumococcal strains in Saudi Arabia and Kuwait during the last 10 years. It discusses the trends, mechanisms of resistance and factors associated with the emergence, dissemination, and colonization of resistant organisms and suggests options available to clinicians for management of infections due to PRSP.