Monday, February 23, 2015

Saudi Arabia: WHO MERS Mission Summary


Saudi Arabia


# 9742


A little over a week ago (see MERS: WHO Mission Invited To Saudi Arabia) we learned that the World Health Organization, along with several other agencies, were invited to Saudi Arabia to consult on the ongoing MERS threat and recent surge in cases.


Today the WHO has released a brief summary of their findings and recommendations.


Although couched in language diplomatic, the overriding message here is that much more research needs to be done in order to understand how the MERS coronavirus is being transmitted – from animals to humans, within the community, and in the healthcare environment. 


First the press release, which also highlights the need for greater consistency in infection control protocols at local hospitals.


Surveillance, forecasting and response

More progress needed to control the Middle East respiratory syndrome coronavirus (MERS-COV) in Saudi Arabia


Riyadh, Saudi Arabia | 23 February 2015 – A team of experts from  the World Health Organization (WHO), the UN’s Food and Agriculture Organization (FAO), the World Organization for Animal Health (OIE) and Institut Pasteur, France concluded a mission to Saudi Arabia to assess the current situation of the Middle East respiratory syndrome (MERS-CoV) following a surge of cases in the past few weeks and to make recommendations for improving the surveillance, prevention and control of the virus. Already this month, more than 50 cases have been reported in several locations in the Kingdom, including infections acquired in health facilities (called nosocomial infections) in Riyadh, Qassim Region and Damman City, eastern region.

Members of the joint mission held discussions with high-level representatives from the Ministry of Health, visited the Command and Control Centre that has been leading all activities related to the control of the MERS-CoV, and toured the emergency and isolation facilities of the Prince Mohammed Bin Abdulaziz Hospital. Government officials and the WHO-led mission shared their concern about the rising number of MERS-CoV cases in recent weeks and in particular in health care facilities.

“The Kingdom did a lot to control the MERS-CoV. We want to hear WHO experts’ feedback on the Kingdom’s progress but also where we can improve. The government is fully committed to implementing the right control and prevention measures and also to funding any activities needed to control this disease,” said Ahmed Bin Aqeel Al Khateeb, the Saudi Arabian Health Minister.

The Minister also stressed the need to enable any hospital, whether government–run or private to handle a MERS-CoV case.

Although data collection and surveillance have improved globally in recent months, critical gaps in knowledge remain, and several challenges in the country will require further work. For example, how and why infections occur in the community is yet to be understood, and  this is critical for stopping the outbreak. In addition, cases that occur in health-care settings require further analysis to fully understand what steps are needed to ensure infection prevention and control measures are adequately implemented. The fact that infections are still occurring in some health-care settings but not in others indicates that current infection control measures are effective but not implemented. 

“When health workers are infected at work, this puts other health-care workers at risk, but also can be a risk to all other patients who seek care for other health conditions. Understanding where the breach in these measures is occurring and taking the steps needed to fully implement infection prevention and control measures can put an end to these nosocomial infections,” said Dr Keiji Fukuda, WHO Assistant-Director General who led the mission to Saudi Arabia.

“The OIE is encouraging close collaboration between public health and animal health at national and international levels.  OIE is ready to help achieve this,” said Dr Ghazi, Regional representative, OIE.

Besides implementing good infection control and prevention measures, efforts to educate professionals and the public are urgently needed. There are also significant gaps in community engagement to fully understand routes of infection and the preventive steps that should be taken. Defining groups that are most at risk, such as the elderly and those with underlying medical conditions, and how to target these groups with the right health messages remains a challenge.

“There are so many aspects of the virus that are still unknown. FAO is determined to use its expertise to better understand the human and animal interface of this virus,” said Dr Berhe Tekola, Director of Animal Production and Health Division, FAO.

The mission, along with the Saudi Arabian health authorities, identified main areas that should be urgently addressed:

  • Understanding the animal/human interface, that is, modes of infection and transmission;
  • Filling critical knowledge gaps in the science and epidemiology of MERS-CoV by conducting further research studies and by sharing the findings widely and rapidly;
  • Improving disease prevention, especially in health facilities that continue to experience avoidable infections; 
  • Intensifying social mobilization, community engagement activities and communications. The mission also stressed the need for intersectoral cooperation and coordination, especially between health, agriculture, and other sectors.

Additional information from research studies is also required to better understand the risk factors for infection and transmission. Results from case-control studies from affected countries are urgently needed, in particular, from the most affected one, Saudi Arabia. Understanding the evolution of the virus is needed, through studies to address the knowledge gaps at the human/animal interface environment.



The recurring theme running through this report can be summed up by the phrase `critical gaps in knowledge remain’ , which includes, but is not limited to, the Saudi’s long promised case-control study (see WHO 2013 case-control study protocol) which has yet to see the light of day.


As we discussed a few weeks ago, in WHO MERS Update & The Community Transmission Mystery, while some cases are identified as having animal, hospital, or community exposures – for most cases the route of infection remains undetermined. 


One of the tools epidemiologist’s use to determine risks for infection is through case-control study, where they compare laboratory-confirmed cases to a large number of uninfected controls, matched for age, sex, and by neighborhood. 


By examining their respective exposures against their outcomes, patterns of risk are often revealed.


Unknown at this time are what roles mildly – or even asymptomatically – infected cases in the community (who are never diagnosed or identified) play in the transmission of the virus.  Nor do we know why MERS cases are predominantly male, and their ages tend to  skew towards an older cohort.  


While we are coming up on three years since the first known outbreak (Jordan, April of 2012), there is still far too much about this virus that we don’t know. 


And with another spring wave expected, we risk having to learn those answers the hard way.

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