Will WHO declare MERS a PHEIC?

Will WHO declare MERS a PHEIC? HT: Crofs.

 PHEIC stands for Public Health Emergency of International Concern.

Via epidemi, a very interesting Norwegian website: WHO convenes Emergency Committee for MERS. The author, Dr. Preben Aavistland, is former state epidemiologist of Norway. Excerpt:

On July 5, WHO announced that the organization is appointing an Emergency Committee under the International Health Regulations (IHR) for the Middle East Respiratory Syndrome (MERS). This is the first such committee to be appointed since the committee for Swine Flu in April 2009. 

Procedures and legal framework 

The Emergency Committee will meet by telephone on July 9 and, if needed on July 11. The membership will be announced on July 8. (After 2009, WHO was criticised for keeping the membership list secret until after the committee had ended its function.) 

According to the IHR (Article 12), the Director-General of WHO may, based on inter alia the advice of an Emergency Committee, determine that an event, such as an outbreak of an infectious disease, constitutes a public health emergency of international concern (PHEIC). 

A PHEIC is defined in the IHR (Article 1) as «an extraordinary event which is determined, as provided in these Regulations: (i) to constitute a public health risk to other States through the international spread of disease and (ii) to potentially require a coordinated international response». 

The ad hoc Emergency Committee is made up of technical experts that are drawn from the IHR Expert Roster (Article 47) and from advisory panels to WHO. WHO Member States and intergovernmental organizations have since 2007 proposed members to this roster. 

The tasks of the Emergency Committee (Article 48) are to advise the Director-General on whether an event constitutes a PHEIC, when this PHEIC is terminated, and proposals for temporary recommendations (Article 15) to member states on health measures to «prevent or reduce the international spread of disease and minimize interference with international traffic» (Article 1), including modification and termination of these recommendations. These measures may concern travel advice, surveillance, clinical management, infection control and other areas. 

Member states are expected to follow the recommendations. If member states want to implement additional health measures, they must justify this according to a certain procedure (Article 43). 

The main effect of a PHEIC declaration, is thus that WHO is given the power to issue temporary recommendations. 

          How dangerous is MERS?

The main factors in a risk assessment is virulence («severity»), transmissibility and population immunity. Information may come from studies of the virus, the reservoirs, the population, animal experiments, and epidemiological investigations around cases.

Virulence: The MERS-CoV is highly virulent and seems to be causing severe disease or even death in most patients (as of today 42 of 79 known patients have died). However, we do not yet know the full clinical spectrum of this disease. There may be several milder cases that remain undiagnosed.

Transmissibility: The reservoir of MERS-CoV is unknown and so is the source of infection for most known cases. There have been a few instances of transmission between humans, especially in hospital and family care settings. Probably, the route of transmission between humans is droplet spread and direct contact with body fluids. Still, the transmission seems to be not very effective.

Population immunity: It is likely that very few people have protective immunity against this virus.

In conclusion, MERS is currently not a great danger to global health. However, the case-fatality risk seems very high, much is still unknown about the virus, and cases are still occurring in the Middle East with occasional leakage to European countries by returning travellers

Will WHO declare MERS a PHEIC? 

Since the IHR went into force on June 15 2007 there have been several events that fulfil the definition of a PHEIC. Still, only the 2009 swine influenza pandemic has been declared a PHEIC (lasting from April 25, 2009 till 10 august, 2010). This probably means that WHO considers that not all such events need to be declared a PHEIC. The WHO probably will make such a determination only when it sees an actual need now or in the near future. 

There are some costs of declaring a PHEIC: 

Firstly, the administrative burden of convening an Emergency Committee, communicating with member states and so on may be substantial. 

Secondly, the actual determination in itself may cause worries, influence people’s risk perception and lead to unnecessary measures, such as screening in airports or quarantining travellers. Labelling MERS as a PHEIC may lead to false beliefs in the dangers of this outbreak. (And this tendency is worsened by the fact that the only previous PHEIC was the 2009 influenza pandemic.) Thus, any declaration of a PHEIC needs to be accompanied by clear risk assessment and risk communication. 

Still, the fact that WHO is convening an Emergency Committee, in my view, means that WHO is seriously considering declaring MERS a PHEIC.

I advice my readers to add the website Crofs to their daily reading portion STAY INFORMED on MERS.

Related: Thanks to Greg Folkers for sending the link to this Journal of Virology report: Bilateral Entry and Release of Middle East Respiratory Syndrome-Coronavirus Induces Profound Apoptosis of Human Bronchial Epithelial Cells. According to Wikipedia, apoptosis is "programmed cell death." The abstract:

The newly emerged MERS-CoV infects human bronchial epithelial Calu-3 cells. Unlike SARS-CoV which exclusively infects and releases through the apical route, this virus can do so through either side of polarized Calu-3 cells. Infection results in profound apoptosis within 24 hrs irrespective of its production of titers that are lower than those of SARS-CoV. Together, our results provide new insights into the dissemination and pathogenesis of MERS-CoV and may indicate that differs markedly from SARS-CoV.