Infection control at mass religious gatherings
BMJ 2022; 378 doi: https://doi.org/10.1136/bmj-2022-072884 (Published 26 August 2022) Cite this as: BMJ 2022;378:e072884
- Eskild Petersen, professor1,
- Danny Asogun, professor2,
- Francine Ntoumi, professor3,
- Alimuddin Zumla, professor4
- 1Institute for Clinical Medicine, Faculty of Health Sciences, University of Aarhus, Denmark
- 2Irrua Specialized Teaching Hospital, Irrua, Nigeria
- 3Fondation Congolaise pour la Recherche Médicale, Brazzaville, Republic of Congo
- 4Department of Infection, Division of Infection and Immunity, Centre for Clinical Microbiology, University College London, London, UK
- Correspondence to: A Zumla a.zumla{at}ucl.ac.uk
Infectious diseases that can cause epidemics are an ongoing risk to global health security.1 Mass gatherings such as religious, sporting, and festival events attract millions of people from across the world and create optimal conditions for importation, acquisition, transmission, and onward spread of infectious diseases,23 including monkeypox.
One of the world’s largest annual mass gatherings of religious pilgrims, the Grand Magal of Touba, will be held on 14 and 15 September 2022 in Touba, a city 200 km east of Senegal’s capital, Dakar.4 Around four million pilgrims are expected from across west Africa, the US, Europe, and the Middle East. Pilgrims will live together and perform religious rituals together, including partial circumambulation of the central mosque and visits to the mausoleum of Sheikh Amadou Bamba, founder of the Mouride brotherhood.
Over the past two decades, west African countries have experienced intermittent outbreaks of infectious diseases such as Lassa fever, Ebola, yellow fever, and Marburg virus disease, but global public health authorities are currently focused on a monkeypox epidemic.5 The World Health Organization declared monkeypox a public health emergency of international concern on 23 July 2022,6 the seventh time such a declaration has been made. Between 1 January and 7 August 2022, 27 814 confirmed cases of monkeypox, including 11 deaths, were reported to WHO from 89 countries across all continents.5
Reports of monkeypox from outside Africa are mostly confined to men who have sex with men.567 However, the incidence in west and central Africa has also increased substantially over the past three years. Between September 2017 and 10 July 2022, authorities in Nigeria recorded over 800 cases of monkeypox in men, women, and children.5 Sexual transmission may have been overlooked in the 2017-18 outbreak in Nigeria, where 68% of patients had genital lesions,8 a much higher proportion than reported in earlier outbreaks in the Democratic Republic of Congo and the US (3%-25%).910 Thus, sexual contact seems to be an important underestimated primary route of transmission in all settings.
Monkeypox is transmitted through skin to skin, mouth to mouth, and mouth to skin contact during sexual activity.57810 Transmission through respiratory droplets and from contaminated surfaces or material is also documented. Close, prolonged, and frequent interactions between people attending mass gatherings, including unsafe sexual practices, will encourage spread of monkeypox virus. This must be factored into planning, prevention, and surveillance of monkeypox during all mass gatherings, including religious pilgrimages, especially in host countries where sexual activity between men is illegal.
Preventive measures
Steps should be taken to ensure that all religious pilgrims and organising staff are aware of the risks of monkeypox and other infectious diseases with epidemic potential through educational leaflets, posters in common areas of worship and bathing, event websites, event apps, and social media, along with measures to reduce risk of exposure or transmission. Hand hygiene and cough etiquette should be promoted through these channels, as well as information on safe sexual practices. Messaging promoting condom use should emphasise that condoms do not fully protect against transmission of monkeypox during sexual contact.
People with clinically diagnosed monkeypox and their contacts should be excluded from the event. The international community must take urgent steps to ensure that monkeypox diagnostics, vaccines, and other resources are available for surveillance and prevention in low and middle income countries. Effective contact tracing and isolation, combined with vaccination of close contacts using WHO recommended vaccines, will be essential if cases of monkeypox occur at the Grand Magal of Touba.1112
The 2020 and 2021 Grand Magal pilgrimages in Senegal went ahead during the peak of the covid-19 pandemic, despite predictions of new waves of covid-19, ongoing global transmission, and the possibility that pilgrimages could be super spreader events. The Senegalese government worked closely with WHO and religious leaders to promote social distancing and other hygienic practices and to influence pilgrims’ behaviours in ways that were sensitive to the spirit of a religious gathering.1314 These experiences should be used to inform management of the forthcoming 2022 Grand Magal pilgrimage in the context of monkeypox.
Although a small cohort study at 2020 Grand Magal found no significant increase in covid-19,15 the four million attendees were not routinely tested so accurate data on covid-19 transmission are not available. Planned and coordinated surveillance, testing, and epidemiological research are therefore required before, during, and after all mass religious events. Despite its large size, the Grand Magal of Touba has a lower global profile than comparable events such as the Hajj in Saudi Arabia and the Kumbh Mela in India,16 and remains neglected in global dialogue about mass religious gatherings.1317
Since west African countries are often at the epicentre of zoonotic disease outbreaks, including monkeypox, health authorities across the world must give more attention to the Grand Magal. This will allow them to benefit from shared experiences that can inform research to identify the most effective prevention and control measures for all epidemic causing infections.3 Most importantly, the possibility of transmission between men who have sex with men must be discussed openly and planned for so that all pilgrims have equal access to vital information about staying safe during pilgrimage.
Acknowledgments
We thank Avinash Sharma, Esam I Azhar, and Shuja Shafi for their contributions.
Footnotes
Competing interests: The BMJ has judged that there are no disqualifying financial ties to commercial companies. The authors declare no other interests. Further details of The BMJ policy on financial interests are here: https://www.bmj.com/sites/default/files/attachments/resources/2016/03/16-current-bmj-education-coi-form.pdf.
Provenance and peer review: Not commissioned; externally peer reviewed.