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| Credit WHO |
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The Holy month of Ramadan begins tomorrow (May 4th), and runs until early June. During this time, roughly 1 million religious pilgrims will visit the Holy Cities of Saudi Arabia, and perform Umrah.
Of note: Saudi Arabia hasn't updated their daily MERS surveillance page since April 25th, which one hopes is a sign that the recent surge in MERS cases (n=136 in 2019) has - at least temporarily - subsided.
But long time observers will be quick to note that the Saudis stopped reporting MERS cases a week before Ramadan last year - ostensibly in order to upgrade their website - and did not resume reporting until August.Getting good information on MERS case out of Saudi Arabia - or any of the other countries on the Arabian peninsula - is always a challenge. But it seems to become even more difficult during the sensitive times of the Hajj and Ramadan.
Six years ago, in MERS, Mass Gatherings & Public Health, we looked at some of the immense challenges that Saudi Arabia faces each year with the Hajj.
Emergence of medicine for mass gatherings: lessons from the Hajj
Prof Ziad A Memish MD , Gwen M Stephens MD, Prof Robert Steffen MD , Qanta A Ahmed MD
(Excerpt)
Within the immediate vicinity of the Hajj, there are 141 primary health-care centres and 24 hospitals with a total capacity of 4964 beds including 547 beds for critical care. The latest emergency management medical systems were installed in 136 health-care centres and staffed with 17 609 specialised personnel. More than 15 000 doctors and nurses provide services, all at no charge.
Earlier this week, in WHO Global Influenza Update #340, we saw reports that influenza remains elevated in KSA, which could further increase the burden on Saudi healthcare facilities during Ramadan.
In 2015's EID Journal: ARI’s In Travelers Returning From The Middle East, researchers found respiratory infections are the most commonly reported illness among religious pilgrims. This study also found that `Pneumonia is the leading cause of hospitalization at Hajj, accounting for approximately 20% of diagnoses on admission.’All of which could make the screening for potential MERS cases during Ramadan even more problematic than it normally is. See:
J. Inf. Pub. Health: Diagnostic Delays in MERS Coronavirus Patients & Health Systems
AJIC:Intermittent Positive Testing For MERS-CoV
JIDC: Atypical Presentation Of MERS-CoV In A Lebanese Patient
A Review Of Asymptomatic MERS Cases
Evaluation of a Visual Triage for the Screening of MERS-CoV Patients
Delays in diagnosis, as costly as they can be, are not always avoidable. Because of the difficulties in identifying cases, the WHO continues to advise:
It is not always possible to identify patients with MERS-CoV early because like other respiratory infections, the early symptoms of MERS-CoV are non-specific. Therefore, healthcare workers should always apply standard precautions consistently with all patients, regardless of their diagnosis.
Droplet precautions should be added to the standard precautions when providing care to patients with symptoms of acute respiratory infection; contact precautions and eye protection should be added when caring for probable or confirmed cases of MERS-CoV infection; airborne precautions should be applied when performing aerosol generating procedures.All of which brings us to a cautionary review of the publicly available MERS data from 2017, which warns: `In today’s “global village”, there is probability of MERS-CoV epidemic at any time and in any place without prior notice.'
Below you'll find a few excerpts from a much longer open-access study. Follow the link to read the full report, after which I'll return with a postscript.
Current epidemiological status of Middle East respiratory syndrome coronavirus in the world from 1.1.2017 to 17.1.2018: a cross-sectional study
Kazhal Mobaraki, Jamal Ahmadzadeh, Kazhal Mobaraki, Jamal Ahmadzadeh
1.Epidemiologist in Social Determinants of Health Research Center Urmia University of Medical Sciences Urmia Iran
Open Access Research article
First Online: 27 April 2019
Abstract
Background
Middle East respiratory syndrome coronavirus (MERS-CoV) is considered to be responsible for a new viral epidemic and an emergent threat to global health security. This study describes the current epidemiological status of MERS-CoV in the world.
Methods
Epidemiological analysis was performed on data derived from all MERS-CoV cases recorded in the disease outbreak news on WHO website between 1.1.2017 and 17.1.2018. Demographic and clinical information as well as potential contacts and probable risk factors for mortality were extracted based on laboratory-confirmed MERS-CoV cases.
Results
A total of 229 MERS-CoV cases, including 70 deaths (30.5%), were recorded in the disease outbreak news on world health organization website over the study period. Based on available details in this study, the case fatality rate in both genders was 30.5% (70/229) [32.1% (55/171) for males and 25.8% (15/58) for females].
The disease occurrence was higher among men [171 cases (74.7%)] than women [58 cases (25.3%)]. Variables such as comorbidities and exposure to MERS-CoV cases were significantly associated with mortality in people affected with MERS-CoV infections, and adjusted odds ratio estimates were 2.2 (95% CI: 1.16, 7.03) and 2.3 (95% CI: 1.35, 8.20), respectively. All age groups had an equal chance of mortality.
Conclusions
In today’s “global village”, there is probability of MERS-CoV epidemic at any time and in any place without prior notice. Thus, health systems in all countries should implement better triage systems for potentially imported cases of MERS-CoV to prevent large epidemics.
(SNIP)
Discussion
The findings have important implications for infection control practice. Especially, we found evidence that was contrary to many studies declaring that the high mortality rates are related to MERS infection with increasing age [16, 17, 18]. Our results on MERS-CoV cases in global level showed that all age groups are somewhat at risk of death from this infection. The chance of mortality in MERS-CoV cases in all age groups is fairly equal.
Therefore, in the care and treatment of MERS-CoV cases, our results suggest that this important point is better to be considered on behalf of health care staff. In this study, we observed a higher disease occurrence and death of MERS-CoV in men than in women (Table 1). A possible explanation for a higher disease occurrence and mortality of MERS-CoV among men is that men are likely to spend more time outdoors and hence have a higher risk of exposure to a source of infection.While we've seen scattered exported cases from KSA and other Middle Eastern nations - some even leading to major outbreaks (see Superspreaders & The Korean MERS Epidemiological Report) - MERS-CoV hasn't embarked on a global tour the way that SARS did in 2003
The evidence linking MERS-CoV transmission between camels and humans cannot be ignored. Several studies have shown that persons with direct and indirect contact with dromedary camels had a significantly higher risk of MERS-CoV infection. Our finding was inconsistent with other studies that did not mention such evidence (Table 1). Random error may be one of the reasons for obtaining this result since there were not details of exposure to camels and camel milk consumption for laboratory-confirmed MERS-CoV cases.
Our research is consistent with many studies that provided evidence of human-to-human transmission for MERS-CoV infection [15, 19, 20]. Figure 1 shows two peaks during June until September, which coincides with the largest mass gathering of Muslims around the world in Saudi Arabia to perform Hajj and Umrah ceremony. This finding highlights the effect of congregation in the spread of MERS-CoV infection.
(Continue . . . )
We have seen analyses, however (see Study: A Pandemic Risk Assessment Of MERS-CoV In Saudi Arabia), suggesting the virus doesn't have all that far to evolve before it could pose a genuine global threat.Last year, in the WHO List Of Blueprint Priority Diseases, we saw MERS-CoV listed among the 8 disease threat in need of urgent accelerated research and development.
List of Blueprint priority diseases
(SNIP)
The second annual review occurred 6-7 February, 2018. Experts consider that given their potential to cause a public health emergency and the absence of efficacious drugs and/or vaccines, there is an urgent need for accelerated research and development for*:
- Crimean-Congo haemorrhagic fever (CCHF)
- Ebola virus disease and Marburg virus disease
- Lassa fever
- Middle East respiratory syndrome coronavirus (MERS-CoV) and Severe Acute Respiratory Syndrome (SARS)
- Nipah and henipaviral diseases
- Rift Valley fever (RVF)
- Zika
- Disease X
All of which makes gaining a better understanding of how - and how well - the MERS coronavirus continues to spread in the community a high priority.
