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Letters 453 MJA 199 7 7 October 2013 The Medical Journal of Australia ISSN 0025 729X 7 October 2013 199 7 318 319 The Medical Journal of Australia 2013 au Letters Acute febrile respiratory infection symptoms in Australian Hajjis at risk of exposure to Middle East respiratory syndrome coronavirus T O THE EDITOR Originating in Saudi Arabia in June 2012 the Middle East respiratory syndrome coronavirus MERS CoV a virus similar to the severe acute respiratory syndrome SARS coronavirus has reached nine countries and affected 130 people of whom 58 45 have died 1 The threat of this epidemic to Australia is uncertain During the SARS epidemic Australia was the lucky country it had just six probable SARS cases and no known fatalities 2 However about 4500 pilgrims from Australia travel to Mecca Saudi Arabia for Hajj each year About 50 150 people share a large tent Box and sleep in close proximity to each other for 5 days which increases the risk of viral transmission To assess the risk that MERS CoV poses to Australia we conducted following ethics approval an anonymous survey of Australian Hajj pilgrims in Mecca during October 2012 We identified participants through their tent lists which were provided by Saudi Arabia s Ministry of Hajj and recruited them through their tour group leaders We distributed a questionnaire on respiratory symptoms to 553 pilgrims and all consented to participate 100 response rate Twelve were excluded because they were from New Zealand so data from 541 pilgrims were analysed Pilgrims were asked about recent acute febrile respiratory infection AFRI defined as the presence of subjective fever plus at least one respiratory symptom cough sore throat runny nose or breathlessness Those who had AFRI were asked whether they had decreased urine output or if their urine was darker in colour during the illness and whether they had visited or been admitted to hospital because of the illness Of the 541 Australian pilgrims who were aged 12 83 years median age 41 5 years 337 62 were male Eighty one pilgrims 15 had one or more pre existing medical conditions including diabetes heart disease lung disease and liver disease Forty nine pilgrims 9 had AFRI of whom seven complained of breathlessness four had chronic medical conditions and nine complained of producing less urine T wo of those with less urine output had breathlessness but not severe enough to seek medical attention No pilgrims with AFRI required hospital admission and none had laboratory tests for infections so we cannot rule in any cases These data indicate that fewer Australian pilgrims developed Letters symptoms of acute respiratory infection than Malaysian Hajji pilgrims who were surveyed in 2007 of whom 40 had cough subjective fever and sore throat 3 It has also been reported that no cases of polymerase chain reaction confirmed MERS CoV infection were found among French Hajji pilgrims returning from the Hajj in 2012 4 Although this survey suggests the risk of MERS CoV infection was low for Australian Hajji pilgrims vigilance is needed and preventive measures should be encouraged at the individual and group level A Cochrane review of observational studies of SARS suggests that personal protective measures including simple face masks were effective in reducing transmission of SARS 5 W e are not aware of any clinical trial addressing these measures against SARS so we are conducting a trial to assess the efficacy of face masks against respiratory viruses at this year s and next year s Hajj Harunor Rashid Clinical Research Epidemiologist 1 Osamah Barasheed PhD Candidate 1 Robert Booy Professor and Head of Clinical Research 1 and Researcher 2 1 National Centre for Immunisation Research and Surveillance of V accine Preventable Diseases Children s Hospital at Westmead Sydney NSW 2 Sydney Emerging Infections and Biosecurity Institute Sydney NSW harunor rashid health nsw gov au Competing interests Robert Booy has received funding from Baxter CSL Limited GlaxoSmithKline Merck Novartis Pfizer Roche and Sanofi Pasteur for the conduct of sponsored research travel to present at conferences and consultancy work All this funding is directed to research accounts at the Children s Hospital at Westmead doi 10 5694 mja13 10984 1 World Health Organization Middle East respiratory syndrome coronavirus MERS CoV update http www who int csr don 2013 09 20 en index html accessed Sep 2013 2 Jauncey ME Armstrong PK Morgan EL McAnulty JM Australia was indeed the lucky country in the recent worldwide SARS epidemic letter Med J Aust 2004 181 229 230 3 Deris ZZ Hasan H Sulaiman SA et al The prevalence of acute respiratory symptoms and role of protective measures among Malaysian hajj pilgrims J Travel Med 2010 17 82 88 4 Gautret P Charrel R Belhouchat K et al 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 Clin Microbiol Infect 2013 19 E315 E317 5 Jefferson T Del Mar CB Dooley L et al Physical interventions to interrupt or reduce the spread of respiratory viruses Cochrane Database Syst Rev 2011 7 CD006207 A tent being shared by Australian Hajji in Mecca Saudi Arabia About 50 150 people share a large tent which increases the risk of viral transmission Rashid et al