It has been just over three years since a novel coronavirus – MERS, but originally dubbed nCoV - was first identified in a Saudi man who presented with acute renal failure and pneumonia (see Sometimes They Come Back). In the next few months a small number of additional cases were uncovered as testing for the virus became more common, including the retrospective identification of a hospital cluster in Jordan in April of 2012.
By the end of 2012 there were perhaps a dozen laboratory confirmed cases, but that number jumped more than 10-fold (n=179) by the end of 2013. By the end of 2014, another big leap increased to 944 the number laboratory confirmed cases.
Today, there have been more than 1550 cases, and of those, 80% have occurred in Saudi Arabia. Until South Korea’s outbreak earlier this summer, Saudi Arabia was the source of more than 90% of all known cases. Despite pledges early on to fully investigate the virus, and to share their findings with the rest of the world, we’ve seen distressingly little information released by the Saudis over the past three years.
The discoverer of the virus, Dr. Ali Mohamed Zaki - who announced the first Saudi case in a letter to ProMed Mail in 2012 - was subsequently fired. We’ve seen only the barest of epidemiological data on most of the 1250 Saudi cases, and the long promised case-control study on the virus has yet to see the light of day.
As a result, there remain major gaps in our understanding of how this virus is transmitting in the community (see WHO EMRO: Scientific Meeting Reviews MERS Progress & Knowledge Gaps), particularly regarding the role (if any) of mild and asymptomatic cases in the spread of the virus.
It is sobering to note that three years into the SARS outbreak – which was a far more contagious coronavirus - not only had there already been hundreds of studies published, the virus had been successfully eradicated for two years.
By contrast, three years into MERS and the number of MERS cases continues to climb, large nosocomial outbreaks remain commonplace, and there are no signs we are getting any closer to containing the virus.
A couple of weeks ago, in the WHO Statement On The 10th Meeting Of the IHR Emergency Committee On MERS, we saw an unusually candid criticism of the Saudi Response to MERS, with the Committee stating:
The Committee further noted that its advice has not been completely followed. Asymptomatic cases that have tested positive for the virus are not always being reported as required.
Timely sharing of detailed information of public health importance, including from research studies conducted in the affected countries, and virological surveillance, remains limited and has fallen short of expectations.
Inadequate progress has been made, for example, in understanding how the virus is transmitted from animals to people, and between people, in a variety of settings. The Committee was disappointed at the lack of information from the animal sector.
Today, the ECDC has published a brief news article on the above IHR Committee meeting’s findings, and adds a comment of their own.
17 Sep 2015
On 2 September 2015, for the tenth time since Middle East respiratory syndrome (MERS) was first reported in 2012, WHO convened its Emergency Committee on MERS to consider if the situation constitutes a Public Health Emergency of International Concern, taking into account the recent cases and transmission patterns in the Middle East. It was the third time this committee convened in 2015, having previously met to consider the outbreak in South Korea in June and the surge in cases in February.
While agreeing once again that the situation still does not constitute a Public Health Emergency of International Concern (PHEIC), the committee emphasised a “heightened sense of concern about the overall MERS situation” and concluded that, since the emergence of MERS three years ago, steps to combat the disease have been insufficient and that the global community stands at significant risk of further MERS outbreaks. As illustrated by the recent outbreak in South Korea, a MERS outbreak in a new setting can lead to widespread transmission.
The committee pointed to:
- insufficient awareness about the urgent dangers posed by MERS;
- insufficient engagement by all relevant sectors including animal and human health;
- insufficient implementation of infection control measures, especially in healthcare settings such as emergency departments;
- inadequate progress in understanding how MERS is transmitted in various settings.
The Emergency Committee issued additional advice to governments and other authorities, highlighting the need to address deeper systemic issues impeding the control of MERS in both animals and humans, as well as calling for rapid and timely sharing of information of public health importance, and accelerated development of human and animal vaccines and therapeutics, among other measures.
Through its risk assessment updates on MERS, ECDC has repeatedly emphasised the importance of infection control measures and heightened vigilance among healthcare workers and travellers from areas with continued MERS transmission. The current nosocomial outbreaks in Riyadh and Amman are the latest reminder of the need for healthcare systems to be prepared.
The source of infection for cases without known exposure to camels, confirmed MERS cases or healthcare settings remains unknown. More in-depth epidemiological and virological analyses in affected countries are needed to identify risk factors and relationships between infection chains. Publicly available sequences of a sufficient amount of viruses is useful in order to better understand viral evolution. Detailed epidemiologic descriptions and analysis on the current hospital-related outbreaks, as well as communication on timing and implementation of control measures, are necessary for ongoing risk assessments.
In the current circumstances, sporadic imported cases of MERS can be expected in the EU/EEA and are associated with a risk of nosocomial transmission. This highlights the need for awareness among healthcare workers, early detection through functioning testing algorithms, preparedness planning and stringent infection control precautions. However, the risk of widespread transmission of MERS-CoV in the community after sporadic importation into the EU/EEA remains low.