by RR ASSESSMENT · 2019 — Available from: who.int/ith/ITH-Haj-2019.pdf. 9. European Centre for Disease Prevention and Control. Rapid Risk Assessment –
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Suggested citation: European Centre for Disease Prevention and Control. Public health risks related to communicable diseases during the hajj 2019, Saudi Arabia, 9 14 August 2019 2 Jul y 2019. Stockholm: ECDC; 2019. © European Centre for Disease Prevention and Control, Stockholm, 201 9 RAPID RISK ASSE SSMENT Public health risks related to communicable diseases during the hajj 2019, Saudi Arabia , 914 August 2019 2 July 2019 Main conclusions and options for response In 2019 , the hajj will take place between 9 and 14 August. The risk for EU/EEA citizens to become infected with communi cable diseases during the 2019 h ajj is considered low, thanks to the vaccination requirements for travelling to Makkah (Mecca) and the Saudi Arabia n preparedness plans that address the management o f health hazards during and after hajj . As with other mass gathering events , the risk of communicable disease outbreaks is greatest for food – and waterborne diseases and respiratory diseases. Outbreaks of MERS -CoV continue to be reported from the Arabian P eninsula, specifically from Saudi Arabia , which implies that there is a risk of importation of cases to Europe after the hajj . The risk of vaccine -preventable and vector -borne diseases is considered low if preventive measures are applied. Advice for those making the hajj Prior to travelling It is important that t ravellers seek advice from healthcare providers on the health requirements and recommendations for Saudi Arabia . Travellers should be advised to f ollow recommendations issued by the Saudi Arabia n Ministry of Health and WHO . A dvice issued by ECDC should also be taken into account . According to the Saudi authorities, pilgrims are required to provide proof of vaccination with the conjugated meningococcal ACW135Y vaccine administered no less than ten day s prior to arrival in Saudi Arabia in order to obtain an entry visa. Travellers making the hajj should be up to date with immunisations routinely administered in their EU country of residence , including vaccinations for measles, mumps and rubella (MMR) and diphtheria -tetanus -polio (see ECDC vaccine schedule site ). Additional vaccinations such as hepatitis A, hepatitis B, influenza, and rabies may be indicated .
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RAPID RISK ASSESSMEN T Public health risks related to communicable diseases during the 2019 h ajj , Saudi Arabia 2 July 2019 2 During the hajj Travellers making the haj j should take the following into account : Pay attention to personal hygiene and adhere to food and water hygiene regulations in order to decrease the risk of gastrointestinal illnesses. Practise respiratory hygiene and cough etiquette to reduce the risk of respiratory infections. Practise insect and tick bite avoidance measures day and night. Visit only licensed barbers for shaving. Due to the expected high temperatures , avoid direct sun exposure and drink sufficient amount s of liquid . After the hajj Travel lers returning from the hajj should seek medical attention immediately if they experience symptoms suggestive of any type of infection, e.g. gastrointestinal or respiratory . They should also mention their travel history to their healthcare provider. Due to continuing reports of MERS – CoV disease in Saudi Arabia, people returning from the hajj should be made aware of the need to seek immediate medical advice if they have a fever (38 ºC and over), cough or difficult ies breathing within 14 days of their return. T ravel history and previous hospitalisation should be reported to the healthcare provider if a person returning from the hajj require s hospitalisation within one year after returning from the hajj . This is to ensure that the possible acquisition of antimi crobial – resistant (AMR) bacteria will be considered and that appropriate measures can be implemented in accordance with national guidelines for the prevent ion of AMR. Event background and general precautions Every year, m ore than one million pilgrims make the hajj to Saudi Arabia. In August 2018, 1 758 722 foreign and 612 953 domestic pilgrims took part in the hajj . In 2018, most of the foreign pilgrims arrived by air (9 4 %), while only five percent crossed land border s; one per cent came by sea  . In 2017, the hajj took place between 30 August and 4 September, resulting in an increase in travel from the EU during the month preceding the hajj . A similar increase was observed in 2016 when the hajj took place between 10 and 15 September (Figure 1). According to IATA data for 2016 and 2017, almost 900 000 travellers from EU countries travelled to Saudi Arabia throughout the year. The majority of the travellers originated from the United Kingdom (41%) , Germany (14%) and France (13%). International mass gatherings can pose a risk for communicable disease outbreaks and global spread of infectious diseases. The aim of this document is to present the health requirements and recommendations from t he Ministr y of Health in Saudi Arabia for hajj and umrah pilgrims and assess the potential health risks related to communicable diseases and other health threats for EU citizens in the course of the hajj pilgrimage between 9 and 14 August 2019 in Saudi Arabia .
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RAPID RISK ASSESSMEN T Public health risks related to communicable diseases during the 2019 h ajj , Saudi Arabia 2 July 2019 3 Figur e 1. Number of travellers from EU countries to Saudi Arabia, by month, 2016 2017 Source: IATA Every hajj season, the Ministry of Health in Saudi Arabia publishes a list of health requirements and recommendations for the hajj . This includes general healt h guidance , vaccination requirements and general recommendations . Before the event, pilgrims should make sure that they meet the visa requirements, receive the required and recommended vaccines, and get all routine immunisations , including booster dose s recommended in their home country. The national health authorities in the countries of origin of hajj pilgrims should have appropriate strategies for the prevention and control of communicable diseases before, during, and after the completion of the hajj . The current international collaboration efforts (planning vaccination campaigns, developing visa quotas, arranging rapid repatriation, and managing health hazards at the hajj ) are crucial steps in this process. Returning pilgrims are advised to be vigila nt for symptoms of acute respiratory illness with fever and cough during the first two weeks after their return. Returning pilgrims experiencing such symptoms should seek immediate medical attention and inform health attendants of their recent travel to Saudi Arabia in order to detect and manage all diseases associated with those symptoms (e.g. MERS -CoV, influenza). Influenza infection is a relatively common disease , and early detection of influenza is important to enable the appropriate management of the d isease . This includes antiviral treatment, minimised contact with others, strict cough etiquette, and respiratory hygiene  . Health facil ities should ensure that appropriate arrangements are in place for testing returning pilgrims who present with symptoms suggestive of MERS -CoV. Recommendations of the Saudi Arabia n Ministry of Health General public health recommendations Standard hygiene recommendations. The Ministry of Health in Saudi Arabia advises all pilgrims to comply with local public health recommendations  , includ ing the following: Wash ing hands with soap and water or a disinfectant, especially after coughing and sneezing, after using toilets, before handling and consuming food, and after touching animals. Practising respiratory hygiene and cough etiquette to reduc e the risk of respiratory infections , e.g. using disposable tissues when coughing or sneezing and dispos ing them in a garbage bin .Wear ing face masks when in crowded places. Trying as much as possible to eyes, nose and mouth. Avoid ing conta ct with those who appear ill and avoid sharing their personal belongings. Avoid ing contact with camels in farms, markets, or barns.
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RAPID RISK ASSESSMEN T Public health risks related to communicable diseases during the 2019 h ajj , Saudi Arabia 2 July 2019 4 Avoid ing consumption of unpasteuri s ed milk or raw meat, or certain animal products, including camel products that have not b een thoroughly cooked. Food – and waterb orne d iseases . Authorities in Saudi Arabia do not permit the import ation of food in conjunction with hajj and umrah arrivals except for very small quantities for personal consumption and in properly canned or sealed c ontainers  . The Ministry of Health in Saudi Arabia recommends that all pilgrims should observe the following: Washing hands before and a fter eating and after going to the toilet. Thoroughly cleaning and washing fresh vegetables and fruit. Food should be cooked thoroughly. Food should be kept at safe temperatures. Raw and cooked food should be kept separated. Insect – borne disease s. The Mini stry of Health in Saudi Arabia recommends that pilgrims should take measures to avoid mosquito bites during the day and evening, e.g. by wearing protective clothing , using physical barriers such as window screens and closed doors , and applying insect repel lent to skin or clothing . Repellents should contain DEET, IR3535 or Icaridin , and be applied as indicated in the product . Health education . Health authorities in the countries of origin are requested to provide basic health education to pilg rims prior to travel. This may include food safety, heat exhaustion, and means of preventing infectious diseases  . Recommendations for s pecific diseases Yellow fever. The Ministry of Health in Saudi Arabia requires that all travellers arriving from countries or regions at risk of yellow fever transmission must present a valid International Certificate of Vaccination or Prophylaxis document ing YF vaccination . Th e Certificate is valid for life , starting 10 days after vaccination  . Countries/areas at risk of yellow fever tran smission, as per the WHO International Travel and Health Annex 1  are: African states: Angola, Benin, Burkina Faso, Burundi, Cameroon, the Central African Republic, Chad, Congo, Côte e Democratic Republic of the Congo, Equatorial Guinea, Ethiopia, Gabon, The Gambia, Ghana, Guinea, Guinea – Bissau, Kenya, Liberia, Mali, Mauritania, Niger, Nigeria, Senegal, Sierra Leone, Sudan, South Sudan, Togo, and Uganda. South and Central American Stat es: Argentina, Venezuela, Brazil, Colombia, Ecuador, French Guiana, Guyana, Panama, Paraguay, Peru, Bolivia, Surinam, and Trinidad and Tobago. Aircraft, ships and other means of transportation arriving from countries affected by yellow fever are requested to submit a valid certificate indicating that disinsection was applied in accordance with methods recommended by WHO. They may be subject to inspection as a condition of granting free pratique (including permission to enter a port, to embark or disembark, and to discharge or load cargo or stores)  . Figure 2. Countries and regions (in orange) for which proof of yellow fever vaccination is r equired from all travellers arriving to Saudi Arabia
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RAPID RISK ASSESSMEN T Public health risks related to communicable diseases during the 2019 h ajj , Saudi Arabia 2 July 2019 5 Meningococcal disease . Adults and accompanying children older than two years of age arriving for the hajj, umrah, or seasonal work in hajj zones are required to submit a valid vaccination certificate w ith a quadrivalent (ACYW) meningococcal vaccine administered not less than 10 days prior to the planned arrival in Saudi Arabia  . Vaccin ation with one of the following vaccines is acceptable: Quadrivalent (ACYW) polysaccharide vaccine within the last three years. Quadrivalent (ACYW) conjugate vaccine within the last five years. Current scientific evidence suggests that conjugate vaccines a re safe and effective for those above 55 years of age. It is important to document the type of vaccine (e.g. conjugate vaccine ) on the vaccination record. Failure to document the type of vaccine reduces the validity of the certificate to three years. Vacci nation with quadrivalent (ACYW) conjugate vaccine is also required for: domestic pilgrims ;residents of the two holy cities (Makkah and Medina ), and any person who might be in contact with pilgrims , including personnel in healthcare settings and other auth orities. The Ministry of Health in Saudi Arabia may opt to administer prophylactic antibiotics to some travellers to Saudi Arabia at the points of entry if deemed necessary. Poliomyelitis: Travel lers from areas with active poliovirus transmission (i.e. tho se with active transmission of a wild or vaccine -derived poliovirus) and from countries at risk of polio reintroduction are required to submit a valid polio vaccination certificate (Figure 3)  . Travel lers arriving from Afghanistan, the Democratic Republic of the Congo, Mozambique, Niger, Nigeria, Pakistan, Papua New Guinea, Syria, Myanmar, Yemen and Somalia should present proof of vaccinat ion with at least one of the following vaccines: At least one dose of bivalent oral polio vaccine (bOPV) within the previous 12 months and administered at least four weeks prior to arrival or At least one dose of inactivated polio vaccine (IPV) within the previous 12 months and administered at least four weeks prior to arrival. Travel lers arriving from Afghanistan, Nigeria, Pakistan, Papua New Guinea, Syria, Myanmar, Yemen and Somalia will also receive one dose of OPV at the border points of entry in Saudi Arabia regardless of age and vaccination status. Figure 3. Vaccination requirements for Saudi Arabia: c ountries and areas for which proof of poliomyelitis vaccination is required ; countries of origin for which one dose of OPV for travellers is mandatory, regardless of vaccination status Seasonal influenza . The Ministry of Health in Saudi Arabia recommends that all visitors arriving for umrah , hajj or seasonal work in hajj zones get vaccinated against seasonal influenza at least 10 days prior to their arri val  .
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RAPID RISK ASSESSMEN T Public health risks related to communicable diseases during the 2019 h ajj , Saudi Arabia 2 July 2019 6 Influenza vaccination is particularly important for pregnant women, children under five years of age , the elderly, individuals wit h chronic medical conditions ( e.g. chronic cardiac, pulmonary, renal, metabolic, neurodevelopmental, liver or hematologic diseases) , individuals with immunosuppressive conditions ( e.g. HIV/AIDS ) , people with malignanc ies, and people undergoing chemotherapy or receiving steroids. Countries are encouraged to secure adequate quantities of the most recent influenza vaccine recommended for use in their country to be administered to those intending to make the hajj . For this year’s hajj , the southern hemisphere v accine is expected to be available before the hajj , and the Ministry of Health in Saudi Arabia recommends that all pilgrims from the southern hemisphere or from countries which use the southern hemisphere vaccine should get vaccinated at least 10 days befo re embarking on the hajj . The Ministry of H ealth in Saudi Arabia requires all domestic pilgrims and health workers in the hajj and umrah areas to receive the most recently seasonal i nfluenza vaccine 10 days prior to their arrival to hajj and umrah areas. E CDC comment : In the northern hemisphere , influenza vaccine is usu ally available as early as late August or early S eptember . P ilgrims vaccinated during the previous flu season may still have some protection . P ilgrims planning to make the hajj next year shou ld ensure they get vaccinated for the upcoming flu season as this may still confer some protection for their planned hajj next year . WHO ha s already released the recommended composition of influenza virus vaccines for use in the 2019 southern hemisphere in fluenza season  . MERS – CoV . Efforts to prevent MERS – CoV infections during mass gatherings have been successful. However, other viral respiratory tract infections are common  . ECDC comment : WHO does not advise special screening at points of entry with regard to t he hajj nor does it currently recommend the application of any travel or trade restrictions [5,6] . Zika virus disease and dengue. A d isinsection certificate, fulfilling the WHO method recommendations, is required by t he Ministry of Health in Saudi Arabia for aircraft, ships, and other means of transportation coming from countries affected with the Zika virus and/or dengue fever  . Pilgrims are advised to the take necessary measures to avoid mosquito bites during the day and evening, which includes wearing protective clot hing (preferably light – coloured) that covers as much of the body as possible , using physical barriers such as window screens and closed doors , and applying insect repellent that contains DEET, IR3535 or Icaridin to skin or clothing as indicated in the prod . ECDC comment : ECDC published a risk assessment on Zika virus transmission for EU/EEA travellers in April 2019  ; also relevant in this context is a WHO document  . A list of dengue – affected countries can be found in ECDC Communicable Disease Threats Report s and on the WHO website  . Recommendatio n for routine immunisations The Ministry of Health in Saudi Arabia recommends that all pilgrims should be up to date with their routine immunisation schedule , including vaccination s against diphtheria, tetanus, pertussis, polio, measles, varicella and mump s  . Other conditions Heat – related c onditions: Th e Ministry o f Health in Saudi Arabia recommends that all pilgrims, especially older peop le , should avoid direct sun exposure and drink sufficient amount s of liquids . Countries are urged to provide advice on health – related illness to their pilgrims prior to travel. Medications that can exacerbate dehydration (e.g. diuretics) or interfere with heat exchange may need adjustment by treating physicians  . Responding to International Health Events: In a Public Health Emergency o f In ternational Concern (as defined by WHO) or in an event subject to notification under the International Health Regulations (2005), the health authorities in Saudi Arabia in consultation with WHO will take all necessary measures  . Physical ability and health education : Before embarking on the hajj or umrah, people who would like to make the pilgrimage are encouraged to assess their physi cal fitness and health or should have it assessed by a medical professional before applying for a visa . Those with severe medical conditions such as terminal cancers, advanced cardiac disease , respiratory diseases , liver or kidney disease , and senility a re exempt from religious duties such as pilgrimages  . Health authorities in the countries of origin are requested to provide basic healt h education to pilgrims prior to travel. This may include information on food safety, heat exhaustion, and means of preventing infectious diseases  .
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RAPID RISK ASSESSMEN T Public health risks related to communicable diseases during the 2019 h ajj , Saudi Arabia 2 July 2019 8 Studies in western Saudi Arabia reporting DENV- 2 and DENV- 3 isolates w ith strains fro m Africa, India, and Singapore highlig ht the role tha t the hajj pilgrimage might play in the importa tion and subsequent exporta tion of the dengue virus [24,25] . In addition, in 2018, two travel-related cases o f dengue (DENV-3) were reported by France throug h the EU Early Warning and Response Syste m (EWRS). The cases were siblings who developed dengue-like syndrome o n retur n from a pilgrimage to Makkah and Medina. Alkhumra haemorrhagic fever (AH F) is a tick-borne disease found in Saudi Arabia and in Egypt . In Saudi Arabia, outbreaks occurred in Jedda h and Makka h in 1995, 1 999 and 2001 [13,26,27] . The virus is transmitted by ticks, following contac t with livestock, e.g. sheep. The risk o f AHF is probably low, but it should be considered as a differentia l diagnosis fo r vira l haemorrhagic fevers. Tuberculosis It is diffic ult to assess the transmission o f tuberculosis during the hajj due to the long incuba tion period. However, based o n the orig in of the pilgrims, many o f who m come fro m areas where tuberculosis is endemic, a risk fo r the spread o f tuberculosis exists. Contributing factors are overcrowding and co-morbidities that make pilgrims susceptible to infection or reactivation of latent tuberculosis. The Saudi Ministry of Health notes that these factors increase the risk for tuberculosis transmission during the hajj. This is acerbated by the fact that some pilgrims come fro m places where the disease is endemic . The Saudi Ministry o f Hea lth advises patients w ith tuberculosis to postpone the ir hajj , with the exception o f specific cases described o n the Ministry o f Heal th website  . People suffering from continuing coug h for more tha n two weeks have to undergo the necessary tests before making the hajj in orde r to rule o ut tuberculosis. Other blood-borne and sexually transmitted diseases To avoid infec tion with hepatitis B, hepatitis C and HIV, pilgrims are advised to choose a suitable barbe r (no t a stree t barber) and use disposable razors  . Pilgrims are also advised to practice safe sex to avoid a ny sexually transmitted diseases. Midd le East respirator y syndrome Althoug h no cases o f MERS-CoV infec tion have bee n associated with the hajj events since the discovery o f the virus, the disease still raises a conce rn as outbreaks linked to came l contac t and transmissio n in healthcare settings continue to be reported in Saud i Arabia [28,29]. As o f 27 May 2019, 2 455 laboratory- -CoV, including 889 associated deaths (case fatality rate: 36.2%) were reported globally (Figure 4); the majority of these cases were reported fro m Saud i Arabia, w ith 2 051 cases, including 793 related deaths w ith a case fatality rate o f 38.7% (Figure 5) . Many o f the primary cases reported direc t came l contac t or consump tion of raw came l milk, while the secondary cases mostly occurred in healthcare settings. In 2019, two hospital outbreaks were detected in Wad i Aldwasi r and Al-Kharj, Saudi Arabia, i n January and April, respectively . While camel contac t is unlikely during participation in the hajj, pilgrims admitted to a hospita l may become exposed to MERS-CoV. Transmission in home countries afte r travelling to a MERS-CoV-affected country has been documented in several instances, e.g. in the UK, France, and South Korea, albe it not in the conte xt of the hajj [31- 33].
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RAPID RISK ASSESSMEN T Public health risks related to communicable diseases during the 2019 h ajj , Saudi Arabia 2 July 2019 9 Figure 4. Worldwide distribution of confirmed MERS -CoV cases , by reporting country , April 2012 to 27 May 2019 Figure 5. Geographical distribution of confirmed MERS -CoV cases by probable region of infection and probable source of exposure , 2019 (as of 29 April 2019 )
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RAPID RISK ASSESSMEN T Public health risks related to communicable diseases during the 2019 h ajj , Saudi Arabia 2 July 2019 10 Antimicrobial resistance and healthcare – associated infections High rates of ant imicrobial resistance (AMR) in gram – negative and gram – positive bacteria are reported from the eastern Mediterranean region  . Increasing resistance in gram – negative bacteria have been reported for Saudi Arabia; this includes increases of carbapenemase – producing Enterobacteriaceae and carbapenem – resistant Acinetobacter baumannii, as well as hosp ital outbreaks of multidrug – resistant (MDR – )bacteria [35 – 38] . L ocal risk factors contributing to the emergence of AMR include o ver – the – counter use of antibiotics without prescription, heavy international travel due to the pilgrimage , a large population of expatriates, and challenges with adherence to infection control measures such as hand hygiene in hospitals  . A recent systematic review showed a high prevalence and/or a high risk of acquis ition of MDR bacteria in pilgrims during the hajj  . Factors promoting the acquisition of MDR bacteria during the hajj include crowding, lack of food hygiene , lack of personal hygiene, and the acquisition of res piratory and gastrointestinal infections with subsequent antimicrobial use and healthcare exposure  . Pilgrims who acquire MDR bacteria abroad and return to their home countries represent a potential reservoir f or onward transmission of MDR bacteria to the community and in hospitals. ECDC advice and WHO recommendations ECDC strongly advises that adults and children travell ing to Saudi Arabia are vaccinated with two doses of measles – containing vaccine and have up – to – date vaccination s against other diseases, in accordance with the national recommendations in their home countr ies [18,41] . In order to prevent food – and waterborne diseases , standard recommendations on food safety should be followed. There are also vaccines available against hepatitis A and typhoid fever. In the EU/EEA, hepatitis A vaccines are available as stand – alone vaccinations or in combination with HBV antigen or typhoid antigen. Typhoid vaccine i s also available as a stand – alone vaccine. WHO recommendations are available for childhood and for life – long protection against diphtheria, tetanus, pertussis, polio, hepatitis B, haemophilus influenzae type b, pneumococcal and rotavirus (infants only) inf ections, measles, mumps, rubella, t yphoid, yellow fever and rabies  . The WHO position papers also provide travel recommendations. It is strongly recommended that non – immune pilgrims initiate, and ideally complete, their immunisations prior to travelling . If a primary course wa s not completed or a booster is routinely recommended, the schedule should be completed upon return to the home country  . Pilgrims shoul d only use antibiotics when prescribed by a certified health professional. They should be advised to If pilgrims require hospitalisation within on e year after returning from the hajj , they should be aware of the need to report their travel history and previous hospitalisations to their healthcare provider in order to consider the possible acquisition of antimicrobial – resistant (AMR) bacteria or MERS – CoV; this makes it possible to implement appropriate control measures in accor dance with national guidelines. ECDC risk assessment The hajj and importation of in fectious diseases related to the crowded conditions during the pilgrimage. This may contribute to the international spread of diseases and the amplification of infectious disease outbreaks. Despite a few outbreaks that have previously affected the EU after the hajj , the hajj poses a low risk for the importation and spread of communicable disease s in the EU because of the strict precautionary measures taken by Saudi Arabia. ECDC r isk monitoring ECDC monitors current outbreaks worldwide and publishe s the resu lts in the weekly Communicable Diseases Threat Report  . In addition, ECDC publish es an epi demiological update on detected events that could pose a public health threat to the EU/EEA Member States before the hajj in August 2019 . Based on the general risks during mass gathering events, and in accordance with the internal procedures applied to those events, ECDC will conduct enhanced epidemic intelligence surveillanc e for communicable diseases between 2 and 21 August 2019. In the event of a Public Health Emergency o f International Health Concern (PHEIC), or in the case of any disease outbreak subject to notification under the International Health Regulations 2005, th e health authorities in Saudi
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RAPID RISK ASSESSMEN T Public health risks related to communicable diseases during the 2019 h ajj , Saudi Arabia 2 July 2019 11 Arabia following consultation with WHO will take additional preventive precautions to avoid the spread of  . Source and date of request ECDC internal decision, 24 June 2019 . Consulted experts ECDC experts (in alphabetic order): Jordi Borrell Pique, Sergio Brusin, Laura Espinosa, Alice Friaux, Grazina Mirinaviciute, Thomas Mollet, Ariana Wijermans . External experts: Dipti Patel, Director, NaTHNaC, United Kingdom. All experts have submitted declarations of interest ; a review of these declarations did not reveal any conflict of inter est. Experts from WHO have reviewed the risk assessment, but the views expressed in this document do not necessarily represent the views of WHO. Disclaimer ECDC issues this risk assessment document based on an internal decision and in accordance with Artic le 10 of Decision No 1082/13/EC and Article 7(1) of Regulation (EC) No 851/2004 establishing a European centre for assessment is to present diff erent options on a certain matter. The responsibility on the choice of which option to pursue and which actions to take, including the adoption of mandatory rules or guidelines, lies exclusively with the EU/EEA Member States. In its activities, ECDC strive s to ensure its independence, high scientific qualit y, transparency and efficiency. This report was written with the coordination and assistance of an Internal Response Team at the European Centre for Disease Prevention and Control. All data published in t his risk assessment are correct to the best of our knowledge at the time of publication . Maps and figures published do not represent a statement on the part of ECDC or its partners on the legal or border status of the countries and territories shown.
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