The World Health Organization (WHO) has called for an Emergency Committee meeting to discuss emergency plans in case MERS-CoV (Middle East Respiratory Syndrome Coronavirus) escalates, spreads or becomes a global pandemic. The biggest problem is that experts know so little about it.

The Emergency Committee consists of experts from all over the world. Their function is to provide expert advice to Margaret Chan, Director-General of WHO, in the context of a “Public Health Emergency of International Concern” (PHEIC). Put simply, the Emergency Committee will determine whether a PHEIC is underway.

If, after considering the Emergency Committee’s advice, the WHO Director-General determines that a PHEIC is underway, the Emergency Committee advises on the Temporary Recommendations of health measures that need to be implemented. Exactly which recommendations are implemented are decided by Margaret Chan.

Saudi Arabia’s Ministry of Health announced yesterday (Sunday) that two more people have died from MERS-CoV infection – a 53-year-old man in Eastern province and a 2-year-old child in Jeddah. Another three infections have also been confirmed

In a press conference on July 5th, Dr Keiji Fukuda, Assistant Director General for Health Security and the Environment on MERS-Coronavirus, confirmed that so far there have been 79 cases of human infection and illness with MERS-CoV and 42 deaths. He added that these numbers may change at any moment.

MERS-CoV epidemiology – According to Dr. Fukuda, some data are clear and evident, but there is still a great deal we do not know about this virus.

This new coronavirus clearly can infect people of all age groups, but elderly individuals, particularly older men, still make up the majority of cases. More specifically, older men with chronic illnesses (comorbidities) are much more likely to become ill with MERS-CoV and also have a significantly higher risk of dying from the infection.

MERS-CoV death rate (mortality) – Dr. Fukuda said “The fatality for this infection still remains pretty high, running around 60%.” (If we use just the figures available so far, which might not be very reliable if there are many other undetected or unreported cases out there, 42 deaths out of a total of 79 cases is a death rate of 53.2%.)

How are people becoming infected with MERS-CoV? – there are two main ways people are becoming infected:

  • In communities – sporadic infections are occurring in towns and villages. Nobody understands yet why. “We don’t know what is the main exposure, what are the main risk factors for those sporadic cases occurring in communities,” said Dr. Fukura.
  • Limited human-to-human transmission – some people are becoming infected after being exposed to an infected person. Fukuda emphasizes that this is occurring mainly within families. For example, a family member who spends a great deal of time nursing sick person at home, i.e. close and sustained human contact.

    Human-to-human transmission is also occurring in hospitals, either patient-to-patient or patient-to-healthcare worker. There was no information on whether healthcare workers might be infecting patients.

Fukuda mentioned that it is interesting that MERS-CoV is much less human transmissible than the SARS-CoV virus of a decade ago. Significantly fewer healthcare workers who care for MERS-CoV infected patients are becoming ill compared to their counterparts who nursed SARS-CoV patients. Nobody is certain why this is the case. One possible explanation might be that infection control practices improved during and after the SARS epidemic. Researchers from Johns Hopkins University, however, said in June 2013 that MERS-CoV is easily transmitted in a healthcare setting.

Dr. Fukuda said “I think importantly, however, in terms of this person to person transmission, we are not seeing it sweep through communities and so it’s important to understand this is a kind of local limited person to person transmission in certain instances but we don’t see it sweeping through communities in big outbreaks. So, if we summarise what we are seeing in the Middle East, it’s kind of a combination of where we have these community cases and then we have some local person to person transmission.”

Travel-related MERS-CoV infections – there have been cases of people in Europe infected with MERS-CoV after having travelled to or through the Middle East, with some cases of person-to-person transmission. However, this new coronavirus has not established itself in those countries. “They have not become endemic infections, they have not caused big outbreaks in those countries,” Fukuda pointed out.

A steady number of cases – WHO informs that the pattern of reported MERS-CoV infections has not changed much over the last three months:

  • In April there were 19 reported cases.
  • In May 21 cases.
  • In June 22 cases.

What we have had over the last few months has been a steady pattern of cases with no big explosions.

What we don’t know about MERS-CoV – this new coronavirus is still an enigma for health authorities, WHO and virologists say.

We still do not know:

  • What the animal reservoir is.
  • Why humans in communities are becoming infected. Despite what Fukuda describes as “a fair amount of investigation”, we still do not know whether infection results from exposure to some animal or a contaminated environment.
  • Are there infected people with mild symptoms or no symptoms at all that we do not know about? We know of one man in Jordan who was infected with MERS-CoV but had no symptoms (he was not ill from the infection).
  • Can asymptomatic infected people transmit the infection to others?

Dr. Fukuda said “Because we have gaps in that kind of information, it makes it very hard to peer into the future and make any predictions.”

  • It fades away – MERS-CoV could simply fade away and what we are seeing at the moment might gradually disappear into the background. The new coronavirus may just become an interesting virus of no serious consequence.
  • The current pattern continues – the current pattern of 20 or so reported cases of MERS-CoV infection and about ten deaths each month could carry on for some time.
  • MERS-CoV changes – the virus may undergo some kind of mutation and change in the transmission. This might lead to more outbreaks, more cases, the death rate might change, or it could eventually evolve into a full-blown global pandemic. In this “loose-cannon” scenario anything could happen.

Dr. Fukuda said:

All of these things are possible and it is simply guesswork right now to think what’s going to happen.

So, based on this overall situation, what we see and what we know that we don’t know, we have been discussing this situation a fair amount and what we have decided to do at WHO is go ahead next week and to convene an International Health Regulations Emergency Committee. . . . we really want to be in a position to be ready for any possibility and we want countries to be in a position of being ready for any possible directions that this virus could take.”

The members of the Emergency Committee do not physically meet face-to-face. They will be connected by telephone this coming Tuesday, and possibly Thursday as well. WHO and countries affected by MERS-CoV infection will provide the members with all the data they have gathered so far. The Emergency Committee then has the task of determining whether the current situation constitutes a Public Health Emergency of International Concern.

Then, they will be asked whether WHO should make any additional recommendations beyond those already issued.

Dr. Fukuda stressed “We are not in the midst of any acute event right now. There’s no acute emergency related to the MERS situation going on.”

According to WHO’s International Health Regulations, a PHEIC is “an extraordinary event which is determined to constitute a public health risk to other States through the international spread of disease and to potentially require a coordinated international response”.

The definition suggests that the situation is:

  • Unexpected, unusual, sudden or serious
  • Carries public health implications for countries beyond the affected nation’s borders
  • May require urgent international action

Margaret Chan, WHO’s Director-General, who may seek the recommendations of the IHR Emergency Committee, takes the final decision on whether an event is a PHEIC.

The Muslim month of fasting during daylight hours, Ramadan, starts on July 9th. During the second half of Ramadan approximately 2 million pilgrims from every corner of the globe are expected at the holy sites located in Saudi Arabia.

Saudi health authorities and WHO are concerned about what might happen when so many people congregate in one place and then fly back home with this highly pathological MERS-CoV in circulation. Over 80% of all infections and deaths have occurred in Saudi Arabia.

Masjid al-Haram panorama

Pilgrims at Masjid al-Haram, Mecca, Saudi Arabia

Controlling infectious diseases is a public health challenge at the best of times. Trying to battle MERS-CoV with the barest of details makes it extremely difficult to know how to advise people on what precautions to take. Some people wonder why WHO waited so long to convene an Emergency Committee – pilgrims will have already bought their tickets and made their travel arrangements.

With such little knowledge about MERC-CoV, how do Saudi Authorities and WHO advise pilgrims? If you tell people not to travel and the new coronavirus turns out to be a tiny threat, what do you say to all the people who depended on the pilgrims for their living and lost their jobs? During the swine-flu outbreak, strict measures were taken in Mexico which devastated Mexican tourist resorts for several months.

However, if the number of human infections skyrockets when the pilgrims arrive, and MERS-CoV spreads in a big way after they return home….?

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

Written by Christian Nordqvist