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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Infectious diseases epidemic threats and mass gatherings: refocusing global attention on the continuing spread of the Middle East Respiratory syndrome coronavirus (MERS-CoV)</title><author><name sortKey="Zumla, Alimuddin" sort="Zumla, Alimuddin" uniqKey="Zumla A" first="Alimuddin" last="Zumla">Alimuddin Zumla</name><affiliation><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="GRID">grid.83440.3b</institution-id><institution-id institution-id-type="ISNI">0000000121901201</institution-id><institution>Division of Infection and Immunity,</institution><institution>University College London,</institution></institution-wrap>London, UK</nlm:aff></affiliation><affiliation><nlm:aff id="Aff2"><institution-wrap><institution-id institution-id-type="GRID">grid.451056.3</institution-id><institution-id institution-id-type="ISNI">0000000121163923</institution-id><institution>NIHR Biomedical Research Centre, UCL Hospitals NHS Foundation Trust,</institution></institution-wrap>London, UK</nlm:aff></affiliation></author><author><name sortKey="Alagaili, Abdulaziz N" sort="Alagaili, Abdulaziz N" uniqKey="Alagaili A" first="Abdulaziz N." last="Alagaili">Abdulaziz N. Alagaili</name><affiliation><nlm:aff id="Aff3"><institution-wrap><institution-id institution-id-type="GRID">grid.56302.32</institution-id><institution-id institution-id-type="ISNI">0000000417735396</institution-id><institution>KSU Mammals Research Chair, Zoology Department,</institution><institution>College of Science, King Saud University,</institution></institution-wrap>Riyadh, Saudi Arabia</nlm:aff></affiliation></author><author><name sortKey="Cotten, Matthew" sort="Cotten, Matthew" uniqKey="Cotten M" first="Matthew" last="Cotten">Matthew Cotten</name><affiliation><nlm:aff id="Aff4"><institution-wrap><institution-id institution-id-type="GRID">grid.5645.2</institution-id><institution-id institution-id-type="ISNI">000000040459992X</institution-id><institution>Viroscience Department,</institution><institution>Erasmus Medical Center,</institution></institution-wrap>Rotterdam, Netherlands</nlm:aff></affiliation></author><author><name sortKey="Azhar, Esam I" sort="Azhar, Esam I" uniqKey="Azhar E" first="Esam I." last="Azhar">Esam I. Azhar</name><affiliation><nlm:aff id="Aff5"><institution-wrap><institution-id institution-id-type="GRID">grid.412125.1</institution-id><institution-id institution-id-type="ISNI">0000000106191117</institution-id><institution>Special Infectious Agents Unit, King Fahd Medical Research Centre, King Abdulaziz University,</institution></institution-wrap>Jeddah, Saudi Arabia</nlm:aff></affiliation><affiliation><nlm:aff id="Aff6"><institution-wrap><institution-id institution-id-type="GRID">grid.412125.1</institution-id><institution-id institution-id-type="ISNI">0000000106191117</institution-id><institution>Medical Laboratory Technology Department,</institution><institution>Faculty of Applied Medical Sciences, King Abdulaziz University,</institution></institution-wrap>Jeddah, Saudi Arabia</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">27604081</idno><idno type="pmc">5015245</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5015245</idno><idno type="RBID">PMC:5015245</idno><idno type="doi">10.1186/s12916-016-0686-3</idno><date when="2016">2016</date><idno type="wicri:Area/Pmc/Corpus">000226</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000226</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Infectious diseases epidemic threats and mass gatherings: refocusing global attention on the continuing spread of the Middle East Respiratory syndrome coronavirus (MERS-CoV)</title><author><name sortKey="Zumla, Alimuddin" sort="Zumla, Alimuddin" uniqKey="Zumla A" first="Alimuddin" last="Zumla">Alimuddin Zumla</name><affiliation><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="GRID">grid.83440.3b</institution-id><institution-id institution-id-type="ISNI">0000000121901201</institution-id><institution>Division of Infection and Immunity,</institution><institution>University College London,</institution></institution-wrap>London, UK</nlm:aff></affiliation><affiliation><nlm:aff id="Aff2"><institution-wrap><institution-id institution-id-type="GRID">grid.451056.3</institution-id><institution-id institution-id-type="ISNI">0000000121163923</institution-id><institution>NIHR Biomedical Research Centre, UCL Hospitals NHS Foundation Trust,</institution></institution-wrap>London, UK</nlm:aff></affiliation></author><author><name sortKey="Alagaili, Abdulaziz N" sort="Alagaili, Abdulaziz N" uniqKey="Alagaili A" first="Abdulaziz N." last="Alagaili">Abdulaziz N. Alagaili</name><affiliation><nlm:aff id="Aff3"><institution-wrap><institution-id institution-id-type="GRID">grid.56302.32</institution-id><institution-id institution-id-type="ISNI">0000000417735396</institution-id><institution>KSU Mammals Research Chair, Zoology Department,</institution><institution>College of Science, King Saud University,</institution></institution-wrap>Riyadh, Saudi Arabia</nlm:aff></affiliation></author><author><name sortKey="Cotten, Matthew" sort="Cotten, Matthew" uniqKey="Cotten M" first="Matthew" last="Cotten">Matthew Cotten</name><affiliation><nlm:aff id="Aff4"><institution-wrap><institution-id institution-id-type="GRID">grid.5645.2</institution-id><institution-id institution-id-type="ISNI">000000040459992X</institution-id><institution>Viroscience Department,</institution><institution>Erasmus Medical Center,</institution></institution-wrap>Rotterdam, Netherlands</nlm:aff></affiliation></author><author><name sortKey="Azhar, Esam I" sort="Azhar, Esam I" uniqKey="Azhar E" first="Esam I." last="Azhar">Esam I. Azhar</name><affiliation><nlm:aff id="Aff5"><institution-wrap><institution-id institution-id-type="GRID">grid.412125.1</institution-id><institution-id institution-id-type="ISNI">0000000106191117</institution-id><institution>Special Infectious Agents Unit, King Fahd Medical Research Centre, King Abdulaziz University,</institution></institution-wrap>Jeddah, Saudi Arabia</nlm:aff></affiliation><affiliation><nlm:aff id="Aff6"><institution-wrap><institution-id institution-id-type="GRID">grid.412125.1</institution-id><institution-id institution-id-type="ISNI">0000000106191117</institution-id><institution>Medical Laboratory Technology Department,</institution><institution>Faculty of Applied Medical Sciences, King Abdulaziz University,</institution></institution-wrap>Jeddah, Saudi Arabia</nlm:aff></affiliation></author></analytic><series><title level="j">BMC Medicine</title><idno type="eISSN">1741-7015</idno><imprint><date when="2016">2016</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p id="Par1">Media and World Health Organization (WHO) attention on Zika virus transmission at the 2016 Rio Olympic Games and the 2015 Ebola virus outbreak in West Africa diverted the attention of global public health authorities from other lethal infectious diseases with epidemic potential. Mass gatherings such as the annual Hajj pilgrimage hosted by Kingdom of Saudi Arabia attract huge crowds from all continents, creating high-risk conditions for the rapid global spread of infectious diseases. The highly lethal Middle Eastern respiratory syndrome coronavirus (MERS-CoV) remains in the WHO list of top emerging diseases likely to cause major epidemics. The 2015 MERS-CoV outbreak in South Korea, in which 184 MERS cases including 33 deaths occurred in 2 months, that was imported from the Middle East by a South Korean businessman was a wake-up call for the global community to refocus attention on MERS-CoV and other emerging and re-emerging infectious diseases with epidemic potential. The international donor community and Middle Eastern countries should make available resources for, and make a serious commitment to, taking forward a “One Health” global network for proactive surveillance, rapid detection, and prevention of MERS-CoV and other epidemic infectious diseases threats.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Mccloskey, B" uniqKey="Mccloskey B">B McCloskey</name></author><author><name sortKey="Endericks, T" uniqKey="Endericks T">T Endericks</name></author><author><name sortKey="Catchpole, M" uniqKey="Catchpole M">M Catchpole</name></author><author><name sortKey="Zambon, M" uniqKey="Zambon M">M Zambon</name></author><author><name sortKey="Mclauchlin, J" uniqKey="Mclauchlin J">J McLauchlin</name></author><author><name sortKey="Shetty, N" uniqKey="Shetty N">N Shetty</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Smallwood, Ca" uniqKey="Smallwood C">CA 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<front><journal-meta><journal-id journal-id-type="nlm-ta">BMC Med</journal-id><journal-id journal-id-type="iso-abbrev">BMC Med</journal-id><journal-title-group><journal-title>BMC Medicine</journal-title></journal-title-group><issn pub-type="epub">1741-7015</issn><publisher><publisher-name>BioMed Central</publisher-name><publisher-loc>London</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">27604081</article-id><article-id pub-id-type="pmc">5015245</article-id><article-id pub-id-type="publisher-id">686</article-id><article-id pub-id-type="doi">10.1186/s12916-016-0686-3</article-id><article-categories><subj-group subj-group-type="heading"><subject>Commentary</subject></subj-group></article-categories><title-group><article-title>Infectious diseases epidemic threats and mass gatherings: refocusing global attention on the continuing spread of the Middle East Respiratory syndrome coronavirus (MERS-CoV)</article-title></title-group><contrib-group><contrib contrib-type="author" corresp="yes"><name><surname>Zumla</surname><given-names>Alimuddin</given-names></name><address><email>a.zumla@ucl.ac.uk</email></address><xref ref-type="aff" rid="Aff1">1</xref><xref ref-type="aff" rid="Aff2">2</xref></contrib><contrib contrib-type="author"><name><surname>Alagaili</surname><given-names>Abdulaziz N.</given-names></name><xref ref-type="aff" rid="Aff3">3</xref></contrib><contrib contrib-type="author"><name><surname>Cotten</surname><given-names>Matthew</given-names></name><xref ref-type="aff" rid="Aff4">4</xref></contrib><contrib contrib-type="author"><name><surname>Azhar</surname><given-names>Esam I.</given-names></name><xref ref-type="aff" rid="Aff5">5</xref><xref ref-type="aff" rid="Aff6">6</xref></contrib><aff id="Aff1"><label>1</label><institution-wrap><institution-id institution-id-type="GRID">grid.83440.3b</institution-id><institution-id institution-id-type="ISNI">0000000121901201</institution-id><institution>Division of Infection and Immunity,</institution><institution>University College London,</institution></institution-wrap>London, UK</aff><aff id="Aff2"><label>2</label><institution-wrap><institution-id institution-id-type="GRID">grid.451056.3</institution-id><institution-id institution-id-type="ISNI">0000000121163923</institution-id><institution>NIHR Biomedical Research Centre, UCL Hospitals NHS Foundation Trust,</institution></institution-wrap>London, UK</aff><aff id="Aff3"><label>3</label><institution-wrap><institution-id institution-id-type="GRID">grid.56302.32</institution-id><institution-id institution-id-type="ISNI">0000000417735396</institution-id><institution>KSU Mammals Research Chair, Zoology Department,</institution><institution>College of Science, King Saud University,</institution></institution-wrap>Riyadh, Saudi Arabia</aff><aff id="Aff4"><label>4</label><institution-wrap><institution-id institution-id-type="GRID">grid.5645.2</institution-id><institution-id institution-id-type="ISNI">000000040459992X</institution-id><institution>Viroscience Department,</institution><institution>Erasmus Medical Center,</institution></institution-wrap>Rotterdam, Netherlands</aff><aff id="Aff5"><label>5</label><institution-wrap><institution-id institution-id-type="GRID">grid.412125.1</institution-id><institution-id institution-id-type="ISNI">0000000106191117</institution-id><institution>Special Infectious Agents Unit, King Fahd Medical Research Centre, King Abdulaziz University,</institution></institution-wrap>Jeddah, Saudi Arabia</aff><aff id="Aff6"><label>6</label><institution-wrap><institution-id institution-id-type="GRID">grid.412125.1</institution-id><institution-id institution-id-type="ISNI">0000000106191117</institution-id><institution>Medical Laboratory Technology Department,</institution><institution>Faculty of Applied Medical Sciences, King Abdulaziz University,</institution></institution-wrap>Jeddah, Saudi Arabia</aff></contrib-group><pub-date pub-type="epub"><day>7</day><month>9</month><year>2016</year></pub-date><pub-date pub-type="pmc-release"><day>7</day><month>9</month><year>2016</year></pub-date><pub-date pub-type="collection"><year>2016</year></pub-date><volume>14</volume><elocation-id>132</elocation-id><history><date date-type="received"><day>1</day><month>9</month><year>2016</year></date><date date-type="accepted"><day>6</day><month>9</month><year>2016</year></date></history><permissions><copyright-statement>© The Author(s). 2016</copyright-statement><license license-type="OpenAccess"><license-p><bold>Open Access</bold>This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by/4.0/">http://creativecommons.org/licenses/by/4.0/</ext-link>), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/publicdomain/zero/1.0/">http://creativecommons.org/publicdomain/zero/1.0/</ext-link>) applies to the data made available in this article, unless otherwise stated.</license-p></license></permissions><abstract id="Abs1"><p id="Par1">Media and World Health Organization (WHO) attention on Zika virus transmission at the 2016 Rio Olympic Games and the 2015 Ebola virus outbreak in West Africa diverted the attention of global public health authorities from other lethal infectious diseases with epidemic potential. Mass gatherings such as the annual Hajj pilgrimage hosted by Kingdom of Saudi Arabia attract huge crowds from all continents, creating high-risk conditions for the rapid global spread of infectious diseases. The highly lethal Middle Eastern respiratory syndrome coronavirus (MERS-CoV) remains in the WHO list of top emerging diseases likely to cause major epidemics. The 2015 MERS-CoV outbreak in South Korea, in which 184 MERS cases including 33 deaths occurred in 2 months, that was imported from the Middle East by a South Korean businessman was a wake-up call for the global community to refocus attention on MERS-CoV and other emerging and re-emerging infectious diseases with epidemic potential. The international donor community and Middle Eastern countries should make available resources for, and make a serious commitment to, taking forward a “One Health” global network for proactive surveillance, rapid detection, and prevention of MERS-CoV and other epidemic infectious diseases threats.</p></abstract><kwd-group xml:lang="en"><title>Keywords</title><kwd>MERS-CoV</kwd><kwd>Mass gathering</kwd><kwd>Hajj</kwd><kwd>Infectious diseases</kwd><kwd>Epidemic transmission</kwd><kwd>Control</kwd></kwd-group><custom-meta-group><custom-meta><meta-name>issue-copyright-statement</meta-name><meta-value>© The Author(s) 2016</meta-value></custom-meta></custom-meta-group></article-meta></front><body><sec id="Sec1" sec-type="introduction"><title>Background</title><p id="Par2">Mass gatherings at sporting [<xref ref-type="bibr" rid="CR1">1</xref>, <xref ref-type="bibr" rid="CR2">2</xref>] and religious events [<xref ref-type="bibr" rid="CR3">3</xref>] attract huge crowds, creating high-risk conditions for the rapid spread of infectious diseases. The 2000–2001 meningococcal meningitis outbreak after the Hajj pilgrimage [<xref ref-type="bibr" rid="CR4">4</xref>] illustrated this threat of infectious diseases on global health security. The International Health Regulations Emergency Committee of the World Health Organization (WHO) declared Zika virus (ZKV) a Public Health Emergency of International Concern [<xref ref-type="bibr" rid="CR5">5</xref>] on 1 February 2016. The media hype on ZKV transmission at the 2016 Rio Olympic Games diverted the attention of global public health authorities from other lethal infectious diseases with epidemic potential [<xref ref-type="bibr" rid="CR6">6</xref>]. Attention and resources must now be refocused on the continuing epidemic threat of the highly lethal Middle East respiratory syndrome coronavirus (MERS-CoV) [<xref ref-type="bibr" rid="CR7">7</xref>, <xref ref-type="bibr" rid="CR8">8</xref>].</p></sec><sec id="Sec2"><title>The global spread of MERS-CoV</title><p id="Par3">Between 8 and 14 September 2016, the cities of Jeddah, Makkah, and Madinah, Kingdom of Saudi Arabia (KSA), hosted the annual Hajj pilgrimage [<xref ref-type="bibr" rid="CR3">3</xref>]. An estimated 2 million pilgrims attended from 184 countries, lived in crowded conditions, and performed religious rites in close proximity, exposing themselves and the local Saudi population to a range of infectious diseases. MERS-CoV was first isolated and identified in a 68-year-old patient who died of pneumonia and multi-organ failure in Jeddah, KSA, in June 2012 [<xref ref-type="bibr" rid="CR9">9</xref>]. This is the second time (after severe acute respiratory syndrome coronavirus, SARS-CoV) [<xref ref-type="bibr" rid="CR10">10</xref>] in the 21st century that a coronavirus has emerged as a new lethal zoonotic pathogen of humans.</p><p id="Par4">Serological studies show that camels have been infected with MERS-CoV for 20 years. MERS-CoV is a common infection in dromedary camels, and there is accumulating evidence that the sporadic human outbreaks are seeded by zoonotic infection from camels [<xref ref-type="bibr" rid="CR11">11</xref>]. There have been intermittent MERS-CoV community cases [<xref ref-type="bibr" rid="CR12">12</xref>] and hospital outbreaks [<xref ref-type="bibr" rid="CR13">13</xref>–<xref ref-type="bibr" rid="CR16">16</xref>], but no sustained epidemic [<xref ref-type="bibr" rid="CR7">7</xref>]. Hospital case clusters of MERS-CoV represent the primary location where rapid human-to-human transmission of MERS-CoV have occurred; although limited spread among family members has been observed [<xref ref-type="bibr" rid="CR17">17</xref>, <xref ref-type="bibr" rid="CR18">18</xref>]. SARS-CoV [<xref ref-type="bibr" rid="CR10">10</xref>] was also predominantly spread through nosocomial transmission, but the epidemiological features of MERS-CoV remain less clear [<xref ref-type="bibr" rid="CR19">19</xref>]. While 90 % of reported MERS-CoV cases have been from KSA, MERS-CoV has spread to 27 countries in Europe, North Africa, Asia, USA, and the Middle East. All cases had travel links with KSA or other countries in the Arabian Peninsula. As of 26 August 2016, 1,800 confirmed MERS-CoV cases have been reported to WHO from over 21 countries, including 640 deaths (35 % case fatality rate). MERS-CoV-related mortality is significantly increased in patients with comorbidities such as diabetes, renal disease, cardiac disease, lung and liver disease, or other immunosuppressive conditions [<xref ref-type="bibr" rid="CR7">7</xref>, <xref ref-type="bibr" rid="CR20">20</xref>]. There are no known effective treatments or preventive vaccines for MERS-CoV [<xref ref-type="bibr" rid="CR21">21</xref>].</p></sec><sec id="Sec3"><title>The continuing spread and epidemic threat of MERS-CoV</title><p id="Par5">The risk of sustained person-to-person transmission appears to be very low and MERS-CoV is considered to have a low epidemic potential [<xref ref-type="bibr" rid="CR20">20</xref>, <xref ref-type="bibr" rid="CR22">22</xref>]. Nevertheless, we have constant reminders of the epidemic threat of MERS-CoV from several hospital-associated outbreaks started by a single case [<xref ref-type="bibr" rid="CR13">13</xref>–<xref ref-type="bibr" rid="CR16">16</xref>, <xref ref-type="bibr" rid="CR23">23</xref>]. Of particular concern was the 2015 MERS-CoV outbreak in the Republic of South Korea [<xref ref-type="bibr" rid="CR23">23</xref>, <xref ref-type="bibr" rid="CR24">24</xref>], in which 184 MERS cases (including 33 deaths) occurred in 2 months [<xref ref-type="bibr" rid="CR23">23</xref>]. These were linked to a South Korean businessman who had travelled to four countries in the Middle East and contracted MERS-CoV infection. Falling ill after his return to Seoul, the patient waited in overcrowded hospital emergency rooms [<xref ref-type="bibr" rid="CR24">24</xref>] and was responsible for MERS-CoV super-spreading events at five hospitals [<xref ref-type="bibr" rid="CR25">25</xref>]. While this major outbreak should have been a wake-up call [<xref ref-type="bibr" rid="CR26">26</xref>–<xref ref-type="bibr" rid="CR28">28</xref>], the attention of global public health authorities at the time was diverted by the Ebola virus disease epidemic in West Africa [<xref ref-type="bibr" rid="CR29">29</xref>] and, more recently, by the ZKV epidemic [<xref ref-type="bibr" rid="CR30">30</xref>].</p><p id="Par6">It remains an enigma that, while SARS-CoV spread rapidly globally and caused >8,000 cases and 775 deaths (10 % mortality) before disappearing within 8 months of discovery [<xref ref-type="bibr" rid="CR10">10</xref>], MERS-CoV continues to circulate 4 years after first identification [<xref ref-type="bibr" rid="CR9">9</xref>], causing intermittent community and hospital-associated outbreaks [<xref ref-type="bibr" rid="CR19">19</xref>]. The exact mode of transmission to humans from camels and other possible animal sources remains undefined. Worryingly, the very high mortality and absence of specific MERS-CoV treatments or vaccines will seriously impact healthcare services of countries from which Hajj pilgrims originate if a Korea-like outbreak [<xref ref-type="bibr" rid="CR23">23</xref>–<xref ref-type="bibr" rid="CR25">25</xref>] occurs from returning pilgrims.</p></sec><sec id="Sec4"><title>MERS-CoV: vigilance, early detection, and infection control measures</title><p id="Par7">The past three annual Hajj pilgrimages (14 October 2013, 3 October 2014, and 23 September 2015) have passed by without any increase in travel-related MERS-CoV cases [<xref ref-type="bibr" rid="CR19">19</xref>]. While KSA authorities are on full alert for MERS-CoV, with their healthcare systems in place and resources to tackle MERS-CoV outbreaks, the healthcare institutions in the home countries of pilgrims need to remain vigilant for MERS-CoV cases [<xref ref-type="bibr" rid="CR28">28</xref>]. Advice has been made available for pilgrims to take precautions to minimize health risks [<xref ref-type="bibr" rid="CR31">31</xref>]. Pilgrims with chronic medical conditions such as diabetes or chronic heart, liver, and lung conditions, and those taking steroids or other immunosuppressive treatments are more susceptible to serious MERS-CoV disease and should seek medical advice before embarking on pilgrimage. The risk of MERS-CoV infection after exposure to camels or camel products is real [<xref ref-type="bibr" rid="CR7">7</xref>, <xref ref-type="bibr" rid="CR11">11</xref>, <xref ref-type="bibr" rid="CR14">14</xref>]. Pilgrims must avoid visiting places where camels are found – highways between cities, camel farms and camel races, farms, barns, or market areas in any part of KSA. They should not consume raw camel milk or camel products or food that may be contaminated with animal secretions. In light of growing evidence, KSA authorities banned the slaughtering of camels for sacrifice and the movement of camels around Makkah and Madinah during the 2016 Hajj [<xref ref-type="bibr" rid="CR32">32</xref>].</p><p id="Par8">The risk of returning pilgrims infected with MERS-CoV to their home countries remains. Thus, health professionals and healthcare systems should remain vigilant at all times [<xref ref-type="bibr" rid="CR28">28</xref>], and especially in the months after the end of the Hajj. Many pilgrims remain in KSA for several weeks after the Hajj, but because symptoms of MERS-CoV infection can occur up to 2 weeks after first infection [<xref ref-type="bibr" rid="CR7">7</xref>], early detection is important. Pilgrims should be advised to seek medical attention promptly, and they should inform the doctor of their travel to KSA. As the Korean MERS-CoV outbreak showed [<xref ref-type="bibr" rid="CR16">16</xref>], gaps in infection control measures are driving factors for nosocomial outbreaks. Early identification of the possibility of MERS-CoV and rapid implementation by healthcare workers of appropriate infection control measures for suspected cases is crucial to avoid outbreaks. Isolation of suspected and confirmed MERS-CoV cases managed under airborne-infection control precautions [<xref ref-type="bibr" rid="CR33">33</xref>, <xref ref-type="bibr" rid="CR34">34</xref>] has been shown to be effective in containing nosocomial outbreaks [<xref ref-type="bibr" rid="CR14">14</xref>–<xref ref-type="bibr" rid="CR16">16</xref>, <xref ref-type="bibr" rid="CR24">24</xref>]. Contact tracing and screening should be undertaken by relevant public health authorities [<xref ref-type="bibr" rid="CR33">33</xref>, <xref ref-type="bibr" rid="CR34">34</xref>].</p></sec><sec id="Sec5"><title>Need for more collaborative approach for optimal management, prevention, and control of MERS-CoV</title><p id="Par9">MERS-CoV remains in the WHO list of top “emerging diseases likely to cause major epidemics” [<xref ref-type="bibr" rid="CR35">35</xref>]. However, many questions on MERS-CoV epidemiology, pathogenesis, management, and control remain unanswered [<xref ref-type="bibr" rid="CR36">36</xref>–<xref ref-type="bibr" rid="CR38">38</xref>]. At long last, hope for filling the knowledge gaps and advancing research activities comes from the recent “MERS-CoV R&D Program” initiative, a joint endeavor by three KSA institutions: Ministry of Health, Ministry of Agriculture, and King Abdulaziz City for Science and Technology (KACST) [<xref ref-type="bibr" rid="CR39">39</xref>]. This program has made competitive research grant funding available specifically to Saudi Arabian researchers to build local capacity. It is anticipated that this will lead to a more collaborative and coordinated international MERS-CoV response plan to better define MERS-CoV epidemiology, transmission dynamics, molecular evolution, pathogenesis, optimal treatment, and prevention interventions for humans and camels. Animal, human, and environmental factors play a crucial role in the persistence, continuing outbreaks, and evolution of MERS-CoV. All 184 countries from which pilgrims originate should strengthen their public health systems, and the international donor community, including the wealthy Middle Eastern countries, should make available resources for a “One Health” framework for early detection and prevention of any future epidemics of MERS-CoV and other zoonotic infectious diseases [<xref ref-type="bibr" rid="CR40">40</xref>]. Only then will the risk of recurring global zoonotic epidemics be reduced.</p></sec></body><back><ack><sec id="FPar1"><title>Authors’ contributions</title><p id="Par10">All authors contributed equally to the article. All authors read and approved the final manuscript.</p></sec><sec id="FPar2" sec-type="COI-statement"><title>Competing interests</title><p id="Par11">All authors have an interest in MERS research. 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