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The Middle East respiratory syndrome coronavirus (MERS-CoV) is a lethal zoonotic pathogen that was first identified in humans in Saudi Arabia and Jordan in 2012. Intermittent sporadic cases, community clusters, and nosocomial outbreaks of MERS-CoV continue to occur. Between April 2012 and December 2019, 2499 laboratory-confirmed cases of MERS-CoV infection, including 858 deaths (34·3% mortality) were reported from 27 countries to WHO, the majority of which were reported by Saudi Arabia (2106 cases, 780 deaths). Large outbreaks of human-to-human transmission have occurred, the largest in Riyadh and Jeddah in 2014 and in South Korea in 2015. MERS-CoV remains a high-threat pathogen identified by WHO as a priority pathogen because it causes severe disease that has a high mortality rate, epidemic potential, and no medical countermeasures. This Seminar provides an update on the current knowledge and perspectives on MERS epidemiology, virology, mode of transmission, pathogenesis, diagnosis, clinical features, management, infection control, development of new therapeutics and vaccines, and highlights unanswered questions and priorities for research, improved management, and prevention.

Mass gathering events are associated with major public health challenges. The 2014 Lancet Series on the new discipline of mass gatherings medicine was launched at the World Health Assembly of Ministers of Health in Geneva in May, 2014. The Series covered the planning and surveillance systems used to monitor public health risks, public health threats, and experiences of health-care providers from mass gathering events in 2012 and 2013. This follow-up Review focuses on the main public health issues arising from planned mass gathering events held between 2013 and 2018. We highlight public health and research data on transmission of infectious diseases and antibiotic-resistant bacteria, mass casualty incidents, and non-communicable diseases, including thermal disorders. In the events discussed in this Review, the combination of a large influx of people, many from countries with outbreak-prone infectious diseases, with a high degree of crowd interactions imposed substantial burdens on host countries' health systems. The detection and transmission of antibiotic-resistant bacteria in pilgrims attending the Kumbh Mela and the Hajj raise concern of possible globalisation from mass-gathering religious events. Priorities for further investments and opportunities for research into prevention, surveillance, and management of these public health issues are discussed.

All three coronaviruses induce excessive and aberrant non-effective host immune responses that are associated with severe lung pathology, leading to death.2–4 Similar to patients with SARS-CoV and MERS-CoV, some patients with 2019-nCoV develop acute respiratory distress syndrome (ARDS) with characteristic pulmonary ground glass changes on imaging. In most moribund patients, 2019-nCoV infection is also associated with a cytokine storm, which is characterised by increased plasma concentrations of interleukins 2, 7, and 10, granulocyte-colony stimulating factor, interferon-γ-inducible protein 10, monocyte chemoattractant protein 1, macrophage inflammatory protein 1 alpha, and tumour necrosis factor α.2–6 In those who survive intensive care, these aberrant and excessive immune responses lead to long-term lung damage and fibrosis, causing functional disability and reduced quality of life.7,8 Specific drugs to treat 2019-nCoV will take several years to develop and evaluate. Infection with 2019-nCoV appears to be initially associated with an increased Th2 response,4 which might reflect a physiological reaction to curb overt inflammatory responses, a clinical phenomenon that guided the optimal timing of interferon treatment in patients with sepsis, resulting in increased survival.14 Interleukin 17 blockade might benefit those patients who have a 2019-nCoV infection and increased plasma concentration of interleukin 17.

This study aimed to identify coronavirus disease 2019 (COVID-19) vaccine perception, acceptance, confidence, hesitancy, and barriers among health care workers (HCWs). An online national cross-sectional pilot-validated questionnaire was self-administered by HCWs in Saudi Arabia, which is a nation with MERS-CoV experience. The main outcome variable was HCWs' acceptance of COVID-19 vaccine candidates. The factors associated with vaccination acceptance were identified through a logistic regression analysis, and the level of anxiety was measured using a validated instrument to measure general anxiety levels. Out of the 1512 HCWs who completed the study questionnaire-of which 62.4% were women-70% were willing to receive COVID-19 vaccines. A logistic regression analysis revealed that male HCWs (ORa = 1.551, 95% CI: 1.122-2.144), HCWs who believe in vaccine safety (ORa = 2.151; 95% CI: 1.708-2.708), HCWs who believe that COVID vaccines are the most likely way to stop the pandemic (ORa = 1.539; 95% CI: 1.259-1.881), and HCWs who rely on the Centers for Disease Control and Prevention website for COVID 19 updates (ORa = 1.505, 95% CI: 1.125-2.013) were significantly associated with reporting a willingness to be vaccinated. However, HCWs who believed that the vaccines were rushed without evidence-informed testing were found to be 60% less inclined to accept COVID-19 vaccines (ORa = 0.394, 95% CI: 0.298-0.522). Most HCWs are willing to receive COVID-19 vaccines once they are available; the satisfactoriness of COVID-19 vaccination among HCWs is crucial because health professionals' knowledge and confidence toward vaccines are important determining factors for not only their own vaccine acceptance but also recommendation for such vaccines to their patients.

Mass gathering (MG) medicine emerged against the backdrop of the 2009 pandemic H1N1 Public Health Emergency of International Concern (PHEIC) when the Kingdom of Saudi Arabia (KSA) hosted the largest annual mass gathering of over 3 million pilgrims from 180 plus countries. However, the events surrounding the latest threat to global health, the PHEIC COVID-19, may be sufficient to highlight the role of mass gatherings, mass migration, and other forms of dense gatherings of people on the emergence, sustenance, and transmission of novel pathogens. The COVID-19 spread illustrates the role of MGs in exacerbation of the scope of pandemics. Cancellation or suspension of MGs would be critical to pandemic mitigation. It is unlikely that medical countermeasures are available during the early phase of pandemics. Therefore, mitigation of its impact, rather than containment and control becomes a priority during pandemics. As the most systematically studied MG-related respiratory disease data come from KSA, the cancellation of Umrah by the KSA authorities, prior to emergence of cases, provide the best opportunity to develop mathematical models to quantify event cancellations related mitigation of COVID-19 transmission in KSA and to the home countries of pilgrims. COVID-19 has already provided examples of both clearly planned event cancellations such as the Umrah suspension in KSA, and where outbreaks and events were continued.

Middle East Respiratory Coronavirus Virus (MERS-CoV) first emerged from Saudi Arabia in 2012 and has since been recognized as a significant human respiratory pathogen on a global level. In this narrative review, we focus on the prevention of MERS-CoV. We searched PubMed, Embase, Cochrane, Scopus, and Google Scholar, using the following terms: ‘MERS’, ‘MERS-CoV’, ‘Middle East respiratory syndrome’ in combination with ‘prevention’ or ‘infection control’. We also reviewed the references of each article to further include other studies or reports not identified by the search. As of Nov 2019, a total of 2468 laboratory-confirmed cases of MERS-CoV were diagnosed mostly from Middle Eastern regions with a mortality rate of at least 35%. A major outbreak that occurred outside the Middle East (in South Korea) and infections reported from 27 countries. MERS-CoV has gained recognition as a pathogen of global significance. Prevention of MERS-CoV infection is a global public health priority. Healthcare facility transmission and by extension community transmission, the main amplifier of persistent outbreaks, can be prevented through early identification and isolation of infected humans. While MERS-CoV vaccine studies were initially hindered by multiple challenges, recent vaccine development for MERS-CoV is showing promise. The main factors leading to sustainability of MERS-CoV infection in high risk courtiers is healthcare facility transmission. MERS-CoV transmission in healthcare facility mainly results from laps in infection control measures and late isolation of suspected cases. Preventive measures for MERS-CoV include disease control in camels, prevention of camel to human transmission.

Middle East respiratory syndrome (MERS) is a new human disease caused by a novel coronavirus (CoV). Clinical data on MERS-CoV infections are scarce. We report epidemiological, demographic, clinical, and laboratory characteristics of 47 cases of MERS-CoV infections, identify knowledge gaps, and define research priorities. We abstracted and analysed epidemiological, demographic, clinical, and laboratory data from confirmed cases of sporadic, household, community, and health-care-associated MERS-CoV infections reported from Saudi Arabia between Sept 1, 2012, and June 15, 2013. Cases were confirmed as having MERS-CoV by real-time RT-PCR. 47 individuals (46 adults, one child) with laboratory-confirmed MERS-CoV disease were identified; 36 (77%) were male (male:female ratio 3·3:1). 28 patients died, a 60% case-fatality rate. The case-fatality rate rose with increasing age. Only two of the 47 cases were previously healthy; most patients (45 [96%]) had underlying comorbid medical disorders, including diabetes (32 [68%]), hypertension (16 [34%]), chronic cardiac disease (13 [28%]), and chronic renal disease (23 [49%]). Common symptoms at presentation were fever (46 [98%]), fever with chills or rigors (41 [87%]), cough (39 [83%]), shortness of breath (34 [72%]), and myalgia (15 [32%]). Gastrointestinal symptoms were also frequent, including diarrhoea (12 [26%]), vomiting (ten [21%]), and abdominal pain (eight [17%]). All patients had abnormal findings on chest radiography, ranging from subtle to extensive unilateral and bilateral abnormalities. Laboratory analyses showed raised concentrations of lactate dehydrogenase (23 [49%]) and aspartate aminotransferase (seven [15%]) and thrombocytopenia (17 [36%]) and lymphopenia (16 [34%]). Disease caused by MERS-CoV presents with a wide range of clinical manifestations and is associated with substantial mortality in admitted patients who have medical comorbidities. Major gaps in our knowledge of the epidemiology, community prevalence, and clinical spectrum of infection and disease need urgent definition. None.

With the global spread of COVID-19, concerns arise about mass gathering events which will further facilitate disease spread. This report welcomes KSA decision to suspend uma