Another death from the MERS-CoV has been reported by the Saudi Ministry of Health, the World Health Organization informed today. MERS-CoV has killed 31 people so far. MERS-CoV stands for Middle East Respiratory Syndrome Coronavirus.

The patient was an 83-year old male from Al-Ahsa who had more than one underlying medical condition. He started showing flu-like symptoms on May 27th and died four days later. Al-Ahsa was the location of an MERS-CoV outbreak in April this year.

We know about 55 laboratory-confirmed cases of MERS-CoV infection since September 2012, says WHO.

A group of WHO experts (Joint Mission) are currently in Saudi Arabia helping local health authorities in their investigation. According to spokesperson, Glenn Thomas, the investigation should be completed tomorrow.

Update: June 17th, 2013Saudi Arabia informed today of four more deaths from MERS-CoV infection, bringing the death toll in the country to 32. Thirty-seven humans have died from MERS-CoV infection globally.

Last month, the Director-General of WHO, Margaret Chan, warned that MERS-CoV is a “threat to the entire world”.

According to the Calgary Herald, the US Centers for Disease Control and Prevention (CDC) is still waiting to test samples of MERS-CoV that made a Qatari man very ill and killed a Saudi man. The samples are caught up in a lengthy negotiation for an MTA (material transfer agreement) in Saudi Arabia, an agreement the Saudi authorities require the CDC to sign.

Dr. Ziad Memish, the Saudi deputy health minister, has complained publicly about the Dutch laboratory that first identified MERS-CoV, the Erasmus Medical Center. Dr. Ziad says the Dutch lab applied for a patent on its genetic sequence of MERS-CoV and insists that laboratories wishing to receive samples of the virus sign an MTA (material transfer agreement).

CDC scientists say that when there is an ongoing investigation of an outbreak, it is highly unusual for them to have to sign an MTA. These scientists had visited Saudi Arabia last year because the kingdom’s government had asked them to come.

Negotiating and signing an MTA never takes this long, said Mark Pallansch, director of viral diseases at the CDC. The Calgary Herald quotes Pallansch as saying “We are told at this point that we are close (to signing an MTA). “So I do have some degree of hope that we will indeed have this completed in the near future. We are certainly in discussion with WHO, the European CDC and other key partner public health agencies. And I think there is very little disagreement among all of those agencies in terms of what are the important epidemiologic and virologic questions that need to be addressed. So I think that we all are trying to find out how that information can be made more readily available.”

Ramadan (a Muslim month of fasting during daylight hours) starts on July 9th this year, and could attract up to two million pilgrims from around the planet to the holy sites of Saudi Arabia. Umrah is a Muslim pilgrimage to the holy city of Mecca which can be done at any time of the year. One of the peak times is during the last ten days of Ramadan.

WHO and health authorities in Saudi Arabia are concerned about so many people gathered together with a new highly pathological coronavirus in circulation.

At the best of times, controlling infectious diseases during huge gatherings is a public health challenge, some would call it a nightmare. This year, with Saudi health authorities trying to battle MERS-CoV and only the barest of details on this new pathogen, many experts are worried about the potential complications.

In the first half of May 2013, Saudi health officials announced 13 new cases of MERS-CoV infection over the course of a few days. There have been 38 new laboratory-confirmed human infections since the beginning of May 2013, of whom 20 have died. Thirty-one of those 38 infections occurred in Saudi Arabia.

Scientists know very little about MERS-CoV – we have no idea where it lives and how people contract it. How does WHO advise pilgrims, the pilgrimage host country, and the health authorities of countries the pilgrims will be returning to?

WHO and competent health authorities have to consider the following factors, circumstances and potential complications:

  • MERS-CoV is a cousin of SARS-CoV (the SARS coronavirus), which broke out in China at the end of 2002, and spread from Hong Kong to various cities and countries around the world, including Toronto.
  • Health authorities do not want to start advising people to avoid infection hubs, as occurred during the SARS outbreak. Measures taken in Mexico during the swine flu outbreak devastated the economies of tourist local resorts for months (tourists stopped going there). Telling people to avoid places has economic consequences, which in turn trigger new problems.
  • Does one sit back and recommend nothing during the impending Umrah pilgrimage and the even larger Hajj pilgrimage which follows in October this year?
  • What to do if the number of human infections skyrockets during the pilgrimage? Hindsight is great, but does not save lives.
  • What if one of these huge gatherings triggered a global pandemic?

Dr. Kamran Khan, a specialist in infectious diseases based at Saint Michael’s Hospital Keenan Research Center, Toronto, Canada, said “We still don’t have a good idea where this (virus) is coming from, so taking measures to mitigate risks are constrained.”

Scientists know very little about MERS-CoV. Nobody knows whether the human infections occurred as a result of a single animal-to-human event (zoonotic event) which then went from human-to-human, or whether the fact that people have been infected at several geographic sites means that multiple zoonotic events occurred from a common unknown source.

Coronaviruses have a large genetic diversity – we know that from tests on animals from all over the world. The samples taken from patients suggest a similar genome, which probably means a common source for MERS-CoV. However, data are very limited. Sadly, bureaucracy has hindered the transportation of samples to centers of excellence for analysis and research.

According to limited data (from the EMC/2012 and England/Qatar/2012 date to early 2011), the early cases of MERS-CoV infection involved coronaviruses from a single Zoonotic even.

Experts believe that MERS-CoV had been circulating in the human population for longer than 12 months before the first case was reported, and suggest independent transmission from an unknown source.

WHO Europe believes MERS-CoV originated from bats. WHO scientists suggest that a single variant from bats crossed over to an intermediate animal host species in the Middle East, and subsequently infected humans.

The CDC says it is working closely with WHO and other competent authorities to gain a better understanding of the risk posed by MERS-CoV, formerly known as the novel coronavirus (nCoV).

The first human infection was reported in September 2012. New cases have been reported since, continuously, which indicates that there is an ongoing risk of human transmission in the Arabian Peninsula area. Reports of new cases outside this area raise concerns that MERS-CoV may be spreading geographically.

There is a risk of nosocomial outbreaks – infections occurring/originating within a hospital – which highlights the risk of transmission to healthcare personnel and the importance of infection control procedures.

According to recent data, people with mild respiratory illness might possibly be infected with MERS-CoV; in some cases, infected people do not even have respiratory symptoms. Patients with chronic diseases or weak immune systems have a higher risk of becoming infected and/or developing complications.

Experts warn that MERS-CoV’s incubation period might be longer than previously estimated. Rather than 1 to 9 days, it could well be 9 to 12 days, according to data coming from doctors treating a patient in France. Incubation period refers to the time between initial infection and the appearance of first symptoms.

Patients being investigated should have samples taken from the lower respiratory tract as well as the nose and throat. According to the CDC “An Emergency Use Authorization (EUA) was recently issued by the Food and Drug Administration (FDA) to allow for expanded availability of diagnostic testing in the United States”.

Below are some highlighted data from the CDC:

  • So far (June 7th), fifty-five laboratory-confirmed cases have been reported to WHO
  • All infections have been directly/indirectly linked to one of four countries: Saudi Arabia, Qatar, Jordan and UAE (United Arab Emirates)
  • Saudi Arabia has reported 40 cases
  • Tunisia, France, Italy and the UK have reported cases of returning travelers and their close contacts
  • UK and German hospitals have received sick patients who were transferred from Qatar and the United Arab Emirates
  • No cases have been reported in the USA
  • WHO, CDC, Health Canada, and European health authorities have not issued any travel advisories
  • The median age of infected patients is 56 years, ranging from 2 to 94 years
  • There are 2.6 male patients to every female patient
  • Apart from a 2- and 14-year old, all infected patients were aged 24 years or more
  • All infected patients so far had respiratory symptoms while ill. Most of them experienced severe acute respiratory disease while in hospital. Several patients also had accompanying gastrointestinal symptoms. However, experts are also warning that there may be infected people walking about with no symptoms
  • 31 of the 55 infected patients died. MERS-CoV currently has a fatality rate of 56%
  • According to WHO, a significant percentage of patients had chronic underling medical conditions or immunosuppression
  • There is clear evidence of human-to-human transmission

Number of confirmed cases of MERS-CoV (N = 55) reported as of June 7, 2013

Written by Christian Nordqvist