Tuesday, January 26, 2016

WHO EMRO: Recent High Level Mission To Saudi Arabia On MERS-CoV


As the epicenter of MERS infections in the Middle East, Saudi Arabia arguably has the most to lose from a larger outbreak, and has repeatedly pledged to take the lead in investigating the disease. 

Progress has been slower than hoped (see WHO EMRO: Scientific Meeting Reviews MERS Progress & Knowledge Gaps), and KSA hasn't always been quick to share what it knows with the rest of the world. 

Six months ago we saw the WHO Statement On The 10th Meeting Of the IHR Emergency Committee On MERS criticize the Saudi Response to MERS in unusually blunt terms, particularly over their handling of asymptomatic or mild cases (see WHO Guidance On The Management Of Asymptomatic MERS Cases).

Earlier this month WHO conducted a high level mission to Saudi Arabia to review their progress and agree on a joint operational plan for combating the virus. Their report acknowledges improvements made by the Saudis in recent months, cites areas that still need work, and makes recommendations for moving forward.

Excerpts from a much longer report follow, so click the link to read it in its entirety.

Executive summary


Since its emergence in 2012, cases of Middle East respiratory syndrome (MERS) continue to occur in countries of the Eastern Mediterranean Region signifying that the global threat of MERS has not yet subsided. Last year, the outbreak in South Korea was a strong reminder that MERS-CoV remained an international health threat and could cause severe disruption to health, economic and social services if health systems remain unprepared. It also became evident last year that hospital outbreaks of MERS in Saudi Arabia could escalate both nationally and internationally into a perpetual global health threat. In view of this, it was necessary to assess and understand what progress has been made in Saudi Arabia, where over 80% of laboratory-conformed cases of MERS have occurred, in controlling the virus, including preventing its international spread. 


The objectives of the current mission, which was conducted in Saudi Arabia from 11 to 14 January 2016, were to:
  • review the ongoing MERS situation;
  • assess progress in implementing previous mission recommendations;
  • identify main areas of public health research to better address remaining knowledge gaps; and 
  • agree on a joint operational plan for WHO and the Ministry of Health of Saudi Arabia for collaborative work and research to prevent and control MERS-CoV.


Summary of findings and observations

The mission noted the substantial progress made in the control of MERS-CoV in last 12 months, including in:
  • accumulating knowledge and learning lessons to control hospital outbreaks and  and applying evidence-informed hospital infection control measures to prevent hospital outbreaks of MERS;
  • establishing a mechanism to monitor compliance by hospitals in implementing appropriate infection prevention and control (IPC) measures;
  • improving collaboration between the human and animal health sectors;
  • establishing an electronic surveillance system for MERS and real-time mechanism to track and respond to cases or outbreaks;
  • conducting research to evaluate information gaps identified during previous WHO missions, and 
  • establishing a mechanism to support and fund priority health research on MERS to address key knowledge gaps. 

Surveillance for human infections from MERS

The mission acknowledged that the surveillance system for detecting and monitoring both suspected and laboratory-confirmed cases of MERS has improved through the establishment of the Health Electronic Surveillance Network (HESN). All suspected and laboratory-confirmed cases of MERS are now entered into this web-based surveillance system, which is accessible to most health care facilities and facilitates for the Ministry a real-time alert, investigation and response. However, the surveillance systems remain “responsive” in detecting suspected cases early. It is important to establish a sentinel-based surveillance system for severe acute respiratory infection (SARI) in the countrywhich would facilitate identification and systematically testing for in order to identify and test systematically for MERS-CoV any cases that present to health facilities with pneumonia or pneumonia-like syndromes and to monitor testing rates in order to reduce the risk of missed cases. Other challenges  include a shortage of human resources, especially a trained public health workforce for joint animal/human investigation and contact tracing.    

Conclusion and recommendations 

The mission acknowledged that the first phase of the MERS response was designed to respond to acute events, such as the repeated nosocomial outbreaks. The country is now ready to move to the next phase, which is to focus on preparedness to respond to and prevent primary infections in the community and future outbreaks in hospitals. 
Therefore, the mission recommended to scale up the following strategic actions in leadership, coordination and operational areas.

1. Expand the national strategic plan for control of MERS with a strong focus on preventing primary cases in the community, as well as stopping rapidly the nosocomial transmission in hospitals through involving all concerned ministries in the country. The plan will require identification of a leader with necessary authority, responsibility and accountability and allocation of appropriate human and financial resources for the plan's effective implementation.  

2. Scale up engagement with other sectors, such as the Ministry of Agriculture, Ministry of Municipalities, etc. in preventing community-acquired infections. Of particular importance would be to reinforce and systematize joint investigation by both the animal and human health sectors of each reported case of community-acquired infection. Such joint and collaborative investigation and control efforts under the “one health” approach could effectively contribute to preventing human infections acquired in the community.

3. Identify and implement research to address the key public health questions on MERS that remain unanswered to date. Based on the list of research questions recommended in the last international scientific meeting organized by WHO in Cairo on 5–6 May 201 , the mission recommended that, in consultation with WHO, the new research body King Abdulaziz City for Science and Technology prioritizes research areas to be funded and calls for researchers across the world to submit their research proposals based on this prioritized list. 

4. Document and share widely, both nationally and internationally, institutional lessons learnt in the Kingdom in the areas of IPC measures to prevent nosocomial outbreaks of MERS. Such lessons should capture the risk factors for hospital outbreaks and the institutional lessons learnt on best ICP practices for controlling outbreaks of MERS.

5. Elevate the CCC into a multisectoral body, able to effectively coordinate and collaborate with other ministries and sectors involved with any important aspect of MERS-CoV, especially the Ministry of Agriculture, veterinary services, and wildlife sector. Such a multisectoral body could ensure a consistent government policy and communications on all cross-sectional issues related to MERS-CoV and should direct and guide an effective and coordinated response to an outbreak through optimizing communications and collaboration with all government and nongovernmental sectors and agencies involved in a response operation. 

MERS remains a global health concern. The scaling up of preventive and control efforts of MERS in the Kingdom of Saudi Arabia, where the majority of global cases have so far occurred, would effectively contribute to enhanced global response to this health threat. It would be a collective responsibility to prevent escalation of any event related to MERS-CoV. In the next course of action, WHO would like to work collaboratively with the Ministry of Health to develop an action plan with time sensitive and achievable goals, in accordance with the agreement reached during the meeting of the mission members with His Excellency the Minister of Health to implement the mission’s recommendations.

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