Asogun, D

Ntoumi, F

Petersen, E

Zumla, A

English

UCL Discovery

1    Fastrack Editorial accepted version - BMJ Title:  The Grand Magal of Touba in the era of Monkeypox being a Global Public Health Emergency of International Concern – reducing risk  for all epidemic prone infections    Authors:    Eskild Petersen, Danny Asogun, Francine Ntoumi and Alimuddin Zumla  Institutional affiliations:  Eskild Petersen MD: Institute for Clinical Medicine, Faculty of Health Sciences, University of Aarhus, Denmark; European Society for Clinical Microbiology and Infectious Diseases [ESCMID] Task Force for Emerging Infections, Basel, Switzerland.                                                Email: eskild.petersen@gmail.com  Danny Asogun FWACP: Irrua Specialized Teaching Hospital, Irrua, Nigeria.                                   Email: asogun2001@yahoo.com  Francine Ntoumi FRCP: Fondation Congolaise pour la Recherche Médicale, Brazzaville, Republic of Congo; Faculty of Sciences and Technology, University Marien Ngouabi, Brazzaville, Republic of Congo.  Email: fntoumi@fcrm-congo.com    Alimuddin Zumla FRCP: Department of Infection, Division of Infection and Immunity, Centre for Clinical Microbiology, University College London and NIHR Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London NW1 OPE, UK. Email: a.zumla@ucl.ac.uk    Keywords:  Religious, Mass Gatherings, Infectious diseases, Monkeypox, COVID-19, Dengue, ONE-HEALTH, Africa, The Grand Magal of Touba Word Count:   818 words        References:    16             *Correspondence:  Professor Eskild Petersen: eskild.petersen@gmail.com                               Professor Alimuddin Zumla: a.zumla@ucl.ac.uk   We acknowledge other contributing authors: Avinash Sharma PhD: DBT-National Centre for Cell Science, Pune, Maharashtra, India. Email: avinash.nccs@gmail.com  Esam I Azhar FRCP: Special Infectious Agents Unit-BSL3, King Fahd Medical Research Center; Department of Medical Laboratory Sciences, Faculty of Applied Medical Sciences, King Abdulaziz University, Jeddah, Saudi Arabia.  Email: eazhar@kau.edu.sa  Shuja Shafi FRCPath: Mass Gatherings and Global Health Network, London, UK.  Email: msshafi12@gmail.com  2  EDITORIAL The spread of a range of epidemic-prone infections pose perennial public health risks to global health security(1). Mass gathering religious, sporting and festival events are the focus of host countries and the World Health organization(WHO) since they attract millions of people from across the world and are known to create optimal conditions for importation, acquisition, transmission, and onward spread of infectious diseases(2,3). Recent global attention is focused on monkeypox (MPX). On 14th and 15th September 2022, one of the world’s largest, recurring annual mass gathering religious pilgrimage event, The Grand Magal of Touba, will be held in the city of Touba, 200 kilometres east of the capital Dakar, Senegal(4). Around 4 million pilgrims will arrive in Touba from across West African countries, USA, Europe and Middle East. Pilgrims will live together performing religious rituals including partial circumambulation of the central mosque, and visit to the mausoleum of Cheikh Amadou Bamba founder of the Mouride brotherhood.  Whilst over the past two decades West African countries have experienced intermittent outbreaks of other epidemic-prone zoonoses such as Lassa Fever, Ebola, Yellow Fever and Marburg, currently, the focus of global public health authorities is now on the unprecedented monkeypox (MPX) epidemic(5). On 23rd July 2022, MPX was declared a Public Health Emergency of International Concern (PHEIC) by WHO(6). It is the seventh time such a declaration for an epidemic has been made. Previous PHEICs included 2009 H1N1 (swine flu), 2014 polio, 2013–2016 Ebola, 2015–16 Zika virus epidemic, the 2018-2020 Kivu Ebola epidemic, the COVID-19 in 2020(7). Monkeypox cases and clusters continue to be reported concurrently from both non-endemic and endemic countries in widely disparate WHO geographical areas. Between 1st January and 23rd July 2022, 16 016 laboratory confirmed cases of MPX, with five deaths, have been reported to WHO from 75 countries across all continents (5).  Cases reported from outside Africa have been mostly among gay, bisexual and men who have sex with men (MSM). Of 528 confirmed MPX cases studied in Europe, 95% were MSM (8).  However, there has also been a significant rise in MPX cases reported from West and Central Africa over the past 3 years. Between September 2017 and 10 July 2022, Nigeria recorded over 800 cases of MPX in men women and children(5). Sexual transmission may have been overlooked in the 2017-2018 MPX outbreak in Nigeria(9) where 68% of patients had genital lesions, much higher than previously reported 3%-25% from the Democratic Republic of Congo and United States(10,11).  3  Whilst the WHO currently does not recommend any travel restrictions in lieu of the ongoing MPX outbreaks it has issued specific recommendations related to the optimal use of preventive public health and social measures, including the 3-step risk evaluation, risk mitigation and risk communication approach when planning mass gathering events(5). Mass gatherings attendees are expected to apply individual-level responsibility based on the risk-based approaches.  During the peak of COVID-19 pandemic, the 2020 and 2021 Grand Magal pilgrimages in Senegal went ahead as usual without any restrictions or scaling down, despite anticipated new waves of COVID-19 infections, onward global transmission with possible super spreader events. Importantly, the Senegalese government promoted social distancing and other safe practices and worked closely with WHO together with religious leaders through educational exercises for risk reduction(12,13), influencing pilgrims’ behaviours in sensitive ways in the spirit of the religious gathering. A small cohort study at The Grand Magal in 2020 showed no significant increase in COVID-19(14). These invaluable experiences should be utilised also for the MPX context during the forthcoming 2022 Grand Magal of Touba pilgrimage.  The WHO and the international community must urgently make available Monkeypox diagnostics, treatments, vaccines and resources for  administration to pilgrims and local populations in West and Central Africa should suspected cases of MPX occur. It becomes important that if cases of MPX occur at The Grand Magal of Touba, contact tracing and, if possible, MPX vaccination of close contacts is instituted. Since MSM in Senegal is illegal, this mode of transmission will most probably be missed.  Compared to two other large annual mass gathering religious events, The Hajj in Saudi Arabia and the Kumbh Mela in India(15), The Grand Magal of Touba, despite having over 4 million attendees, has not yet featured prominently in the global dialogue on mass gathering events. Over 90% of research publications on Muslim religious events are related to the Hajj(16). Since The Grand Magal is one of the world’s largest annually recurring events, and West African countries are epicentres of zoonotic disease outbreaks including MPX, it is vital that it features prominently on the radar of global public health authorities. This will also enable global public health authorities, countries hosting mass gathering religious events to benefit from shared experiences and drive priority research to obtain the best evidence-based public health prevention measures for all epidemic prone infections, including MPX. The issue of MSM, transmission of MPX and other sexually transmitted infections at all mass gathering religious events  also requires frank and open discussion. 4   Author acknowledgments:  Authors FN, DA and AZ are members of the Pan-African Network for Rapid Research, Response, Relief and Preparedness for Infectious Diseases Epidemics supported by the European and Developing Countries Clinical Trials Partnership, Horizon 2020, the EU’s Framework Programme for Research and Innovation. AZ holds a UK National Institute of Health Research Senior Investigator Award and is a Mahathir Science Prize and Pascoal Mocumbi Prize laureate.  Author Declarations:  All authors have an interest in high consequence pathogens and mass gatherings. All authors declare no conflicts of interest (COI forms have been submitted to BMJ). The views expressed in this comment are the authors’ own and not of their institutions  Copyright statement:  The Corresponding Author has the right to grant on behalf of all authors and does grant on behalf of all authors, a worldwide licence to the Publishers and its licensees in perpetuity, in all forms, formats and media (whether known now or created in the future), to i) publish, reproduce, distribute, display and store the Contribution, ii) translate the Contribution into other languages, create adaptations, reprints, include within collections and create summaries, extracts and/or, abstracts of the Contribution, iii) create any other derivative work(s) based on the Contribution, iv) to exploit all subsidiary rights in the Contribution, v) the inclusion of electronic links from the Contribution to third party material where-ever it may be located; and, vi) licence any third party to do any or all of the above.                  5  References     1. Al Rabeeah A, Memish ZA, Zumla A, Shafi S, McCloskey B, Moolla A,  et al. Mass gatherings medicine and global health security. Lancet. 2012 Jul 7;380(9836):3-4. doi: 10.1016/S0140-6736(12)61073-3. PMID: 22770444.  2. Petersen E, Memish ZA, Zumla A, Maani AA. Transmission of respiratory tract infections at mass gathering events. Curr Opin Pulm Med. 2020 May;26(3):197-202. doi: 10.1097/MCP.0000000000000675. PMID: 32149751.  3.  Zumla A, Traore T, Amao L, Ntoumi F, Sharma A, Azhar EI, et al. Reducing the threat of epidemic-prone infections at mass gathering religious events. Lancet. 2022 Jul 9;400(10346):80-82. doi: 10.1016/S0140-6736(22)01194-1. Epub 2022 Jun 27. PMID: 35772412.  4. Serigne DS, Mbacke S, Cultural Commission of Mourides. Grand Magal of Touba: The Ritual Acts of the Thanksgiving on the Occasion of the Magal of Touba.2004 1-42. ISBN-10 : 1503278344, ISBN-13: 978-1503278349. Publisher: CreateSpace Independent Publishing Platform.  5.  WHO. 2022: Second meeting of the International Health Regulations (2005) (IHR) Emergency Committee regarding the multi-country outbreak of monkeypox. https://www.who.int/publications/m/item/multi-country-outbreak-of-monkeypox--external-situation-report--2---25-july-2022 -accessed 8th August 2022.  6. WHO 2022: WHO Director-General's statement at the press conference following IHR Emergency Committee regarding the multi-country outbreak of monkeypox - 23 July 2022. https://www.who.int/director-general/speeches/detail/who-director-general-s-statement-on-the-press-conference-following-IHR-emergency-committee-regarding-the-multi--country-outbreak-of-monkeypox--23-july-2022 -accessed July 23rd 2022.  7. WHO 2019: Emergencies: International health regulations and emergency committees. https://www.who.int/news-room/questions-and-answers/item/emergencies-international-health-regulations-and-emergency-committees  (Accessed 23rd July, 2022)  8. Thornhill JP,  Barkati S. Walmsley J. Rockstroh A. Antinori L.B. Harrison et al. Monkeypox Virus Infection in Humans  across 16 Countries — April–June 2022.  New Engl J Med 21 July 2022. DOI: 10.1056/NEJMoa2207323   9. Ogoina D, Iroezindu M, James HI, Oladokun R, Yinka-Ogunleye A, Wakama P et al. Clinical Course and Outcome of Human Monkeypox in Nigeria. Clin Infect Dis 2020; 71:e210-14. DOI: 10.1093/cid/ciaa143  10. Jezek Z, Szczeniowski M, Paluku KM, Mutombo M. Human monkeypox: clinical features of 282 patients. J Infect Dis. 1987; 156:293–8.  11. Huhn GD, Bauer AM, Yorita K, et al. Clinical characteristics of human monkeypox, and risk factors for severe disease. Clin Infect Dis 2005; 41:1742–51.  12. WHO 2021: Safe practices during the Pilgrimage to the Grand Magal of Touba in Senegal during the COVID-19 Pandemic. 6  https://www.who.int/about/accountability/results/who-results-report-2020-mtr/country-story/2020/safe-practices-during-the-pilgrimage-to-the-grand-magal-of-touba-in-senegal-during-the-covid-19-pandemic -accessed July 20th, 2022  13. Sokhna C, Mboup BM, Goumbala N, Dieng M, Sylla AB, Raoult D,  et al. Establishing Medical Coverage and Epidemiological Surveillance during the Grand Magal of Touba in Senegal: A Public Health Need. J Epidemiol Glob Health. 2020 Dec;10(4):247-249. doi: 10.2991/jegh.k.200620.001. Epub 2020 Jun 26. PMID: 32959622; PMCID: PMC7758853.  14. Goumballa N, Sambou M, Bassene H, Dieng M, Aidara A, Fenollar F, et al. High influenza A prevalence but no SARS-CoV-2 among 2021 Grand Magal pilgrims in Touba, Senegal. Travel Med Infect Dis. 2021 Nov-Dec;44:102189. doi: 10.1016/j.tmaid.2021.102189. Epub 2021 Oct 22. PMID: 34695566.  15. Memish ZA, Steffen R, White P, Dar O, Azhar EI, Sharma A et al.  Mass gatherings medicine: public health issues arising from mass gathering religious and sporting events. Lancet. 2019 May 18;393(10185):2073-2084. doi: 10.1016/S0140-6736(19)30501-X.  16. Sweileh WM. Health-related research publications on religious mass gatherings of Muslims: a bibliometric analysis (1980-2020). Trop Dis Travel Med Vaccines. 2022 Jan 4;8(1):1. doi: 10.1186/s40794-021-00158-y. PMID: 34980277               

Infection control at mass religious gatherings

https://discovery.ucl.ac.uk/id/eprint/10161772/1/Zumla_BMJ%20Editorial%20%20accepted%20%20version%20BMJ%20editorial.pdf

Infection control at mass religious gatherings

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