title: Potential for the international spread of middle East respiratory syndrome in association with mass gatherings in saudi arabia.
abstract: BACKGROUND
  A novel coronavirus (MERS-CoV) causing severe, life-threatening respiratory disease has emerged in the Middle East at a time when two international mass gatherings in Saudi Arabia are imminent. While MERS-CoV has already spread to and within other countries, these mass gatherings could further amplify and/or accelerate its international dissemination, especially since the origins and geographic source of the virus remain poorly understood.
  
  
  METHODS
  We analyzed 2012 worldwide flight itinerary data and historic Hajj pilgrim data to predict population movements out of Saudi Arabia and the broader Middle East to help cities and countries assess their potential for MERS-CoV importation. We compared the magnitude of travel to countries with their World Bank economic status and per capita healthcare expenditures as surrogate markers of their capacity for timely detection of imported MERS-CoV and their ability to mount an effective public health response.
  
  
  RESULTS
  16.8 million travelers flew on commercial flights out of Saudi Arabia, Jordan, Qatar, and the United Arab Emirates between June and November 2012, of which 51.6% were destined for India (16.3%), Egypt (10.4%), Pakistan (7.8%), the United Kingdom (4.3%), Kuwait (3.6%), Bangladesh (3.1%), Iran (3.1%) and Bahrain (2.9%). Among the 1.74 million foreign pilgrims who performed the Hajj last year, an estimated 65.1% originated from low and lower-middle income countries.
  
  
  CONCLUSIONS
  MERS-CoV is an emerging pathogen with pandemic potential with its apparent epicenter in Saudi Arabia, where millions of pilgrims will imminently congregate for two international mass gatherings. Understanding global population movements out of the Middle East through the end of this year's Hajj could help direct anticipatory MERS-CoV surveillance and public health preparedness to mitigate its potential global health and economic impacts.
authors.affiliation: Department of Medicine, Division of Infectious Diseases, University of Toronto, Toronto, Canada; Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada.
authors.forename: Kamran
authors.initials: K
authors.lastname: Khan
authors.forename: Jennifer
authors.initials: J
authors.lastname: Sears
authors.forename: Vivian Wei
authors.initials: VW
authors.lastname: Hu
authors.forename: John S
authors.initials: JS
authors.lastname: Brownstein
authors.forename: Simon
authors.initials: S
authors.lastname: Hay
authors.forename: David
authors.initials: D
authors.lastname: Kossowsky
authors.forename: Rose
authors.initials: R
authors.lastname: Eckhardt
authors.forename: Tina
authors.initials: T
authors.lastname: Chim
authors.forename: Isha
authors.initials: I
authors.lastname: Berry
authors.forename: Isaac
authors.initials: I
authors.lastname: Bogoch
authors.forename: Martin
authors.initials: M
authors.lastname: Cetron