Hajj: preparations underway.

On Oct 13, the world's largest annual mass gathering will commence as Muslim pilgrims from 180 countries converge on Islam's holiest sites in Makkah, Saudi Arabia, for the annual Hajj pilgrimage. Despite the wealth of knowledge gained through decades of experience in the public health management of large-scale events, this year's Hajj has drawn unprecedented global attention owing to concerns about the potential spread of the Middle East respiratory syndrome coronavirus (MERS-CoV).

Saudi Arabia has reported the highest number of MERS-CoV cases since the virus first emerged in 2012—a total of 119 confirmed cases, with a case fatality of 42%, to date. Owing to ongoing concerns about transmission of the virus, the Saudi Ministry of Health has recommended that pregnant women, children (younger than 12 years), older adults (older than 65 years), or those who have a chronic or acute disease should postpone their plans to perform the Hajj this year.

Beyond this, however, participants at the Third Meeting of the International Health Regulations (IHR) Emergency Committee, on Sept 25, determined that, on the basis of current data, MERS-CoV does not warrant international measures to curtail Hajj-related travel. Rather, all countries (particularly those with returning pilgrims) were advised to strengthen their surveillance capacities and ensure robust reporting of any identified cases, as provided for in the IHR measures adopted by the World Health Assembly in 2005.

Since the emergence of MERS-CoV, the Saudi Ministry of Health has embarked on international collaborations to identify the source of infection and characterise the mode of transmission, while simultaneously making every effort to halt any possible transmission during the upcoming Hajj. A vigilant surveillance programme is already in operation and no cases of MERS-CoV were reported among the 5 million Umrah pilgrims during the recent fasting month of Ramadan.

The Saudi Ministry of Health has issued sanitation and hygiene advice to all pilgrims, including guidance on ensuring effective handwashing, adhering to cough etiquette, wearing face masks in the crowded areas, and maintaining good personal hygiene more generally.

All pilgrims with acute respiratory symptoms suggestive of pneumonia requiring intensive care will be isolated and tested for MERS-CoV. As part of the routine Hajj programme, 25 hospitals at the holy sites will provide a total of 5250 acute clinical care beds—4200 specialised, 500 critical care, and 550 emergency beds—and more than 22 500 health practitioners and Ministry of Health staff will be on duty for the entire Hajj period, Oct 13–16. Additionally, a team from the WHO Regional Office for the Eastern Mediterranean will provide technical support on appropriate public health preparedness measures.

The medical services described are offered free of charge to all pilgrims who require medical care. Additionally, Saudi Arabia has urged all pilgrims' home countries to strengthen their surveillance systems to ensure early detection of any possible cases among returning pilgrims.

Mass gatherings continue to present advanced and complex public health challenges which are best addressed through multicountry channels of trust and equitable collaboration. Saudi Arabia has enhanced its surveillance and health-care system for the wellbeing of all pilgrims.