Assessing the pandemic potential of MERS-CoV.

Assessing the pandemic potential of MERS-CoV.HT: Croft.

Via The Lancet: Assessing the pandemic potential of MERS-CoV. Excerpt:

Breban and colleagues4 apply a specialised statistical method to estimate the R₀ of MERS-CoV.11 By carefully constructing different scenarios for who infected whom in recent MERS-CoV clusters, the investigators compute R₀ under best-case and worst-case scenarios for MERS-CoV transmission trees. 

In the worst-case scenario, R₀ is only 0·69 (95% CI 0·50—0·92). Despite the small number of confirmed cases so far, the upper 95% CI on the R₀ is less than 1, meaning that MERS-CoV is unlikely to cause a pandemic, although a 99·7% CI might also have been useful to estimate pandemic risk, in addition to the standard 95% interval. For comparison, the investigators estimate that R₀ was 0·80 (95% CI 0·54—1·13) for prepandemic SARS-CoV in southeast Asia (2002—03). 

Breban and colleagues4 also provide calculations that enable the R₀ estimates to be updated as more information about new MERS-CoV cases is reported. If the next index patient infects eight or more individuals, the investigators estimate that there is a 5% chance that R₀ is actually above 1, under the worst-case scenario. 

Hmmm.......If the Saudis are releasing the 'real' numbers! 

Saudi Arabia: 2 new MERS cases, 1 death in Riyadh.

T. nudiventris bats - aka 'Tomb Bat'.

Saudi Arabia: 2 new MERS cases, 1 death in Riyadh.HT: Croft.

Via the Saudi Ministry of Health: Two New Cases of Novel Coronavirus Recorded and another Case Passed Away in Riyadh.

Within the framework of the epidemiological surveillance of the novel Coronavirus (MERS-CoV), the Ministry of Health (MOH) has announced that two confirmed cases of this virus have been recorded in Riyadh. The first infected case is a 50-year-old female citizen with cancer and other chronic diseases. She is currently at the ICU receiving the proper treatment.   

As for second case, he is a 70-year-old resident with several chronic diseases. He is currently at the ICU receiving the proper treatment.   

Moreover, the Ministry of Health has announced the death of a 54 year-old citizen with chronic diseases; who had been previously announced to be infected with this virus- May Allah have mercy upon him.

Related:  Two news MERS-CoV cases and the death of an existing case, all from Riyadh

A very piecemeal way of disclosing public health information. I can't imagine this gives many prospective visitors a good sense of the situation being under control and carefully managed.

  Middle East Respiratory Syndrome Coronavirus in Bats, Saudi Arabia

Coverup? Bisha man ‘dies from swine flu’ or was it MERS, returning home from Mecca following an Umrah trip.

Coverup? Bisha man ‘dies from swine flu’ or was it MERS, returning home from Mecca following an Umrah trip.(SaudiGazette).

A citizen from the southern city of Bisha has died of swine flu after returning home from Makkah following an Umrah trip during the just-concluded month of Ramadan, his family has alleged.

They told Al-Hayat newspaper on Tuesday that the Ministry of Health has not issued any statement about the death of Hamoud Al-Nashiri as of Monday.

His brother Saad said Hamoud died on the second day of Eid from the disease.

“My brother started suffering from the symptoms of the disease after his return home from Makkah.

“We took him to King Abdullah Hospital in Bisha but he was not given any proper medical attention.”

The brother also accused the hospital’s department of preventive medicine of ignoring routine medical examinations that are usually carried out on people who have accompanied patients who die from such diseases. “The department did not take blood samples from us to find out if we have contracted the disease or not.”

Saad said his brother’s wife started displaying symptoms of swine flu before his death.

“We brought her to the hospital but they could not find a suitable bed for her, so she was secluded in an unsuitable room in an outside building.

“Her blood samples were taken on Friday but they were only sent to the lab on Sunday.”

He said Hamoud’s brother-in-law, who stayed with him until his death, was not yet examined to see if he got the disease.

The newspaper said it tried to repeatedly contact Bisha Health Affairs spokesman Abdullah Al-Ghamdi but he did not respond.

Medical sources in Bisha said a statement on Al-Nashiri’s death was delayed because most of the hospital staff were away because of the Eid holidays.

Hmmm......Related:  

Saudi Arabia: Two weeks without a MERS announcement

It's a Bird....A Bat...Oh No....Scientists find MERS-like antibodies in camels.

It's a Bird....A Bat...Oh No....Scientists find MERS-like antibodies in camels.HT: Ottowa citizen.By By Helen Branswell.

European scientists have uncovered a clue to the mystery of where the new MERS coronavirus resides in nature, reporting evidence that dromedary camels can be infected with the virus.

The finding is the first confirmation of MERS infection in a species other than humans, though it does not prove that the animals are the source of infections in people, the authors were quick to say.
"I think it shows that something — either MERS or something that looks very similar to it — has been going around in camels, and that that really needs to be looked at as a possible source. That's as far as we can go, I would say," senior author Dr. Marion Koopmans said in an interview about the study, published in this week's issue of Lancet Infectious Diseases.
Koopmans and colleagues found antibodies to MERS or a closely related coronavirus in the blood of camels from Oman on the Arabian Peninsula and also on the Canary Islands, an archipelago off northwestern Africa which is part of Spain.
The fact that camels may be a source of the virus adds urgency to the task of finding out how people are getting infected and trying to prevent future infections.
That's because the animals are among a number slaughtered for sacrifice as part of the Hajj, the massive annual pilgrimage that draws several million Muslims to the holy city of Mecca in Saudi Arabia. All Muslims who are able are required by their faith to make the pilgrimage at least once in their lifetime.
To complete the responsibilities of the Hajj, each pilgrim must participate in the sacrifice of an animal. That participation often takes the form of contributing to the cost of buying and slaughtering the animal and then distributing the cooked meat to family members and the poor.
The animal sacrifices take place during Eid al Adha — the feast of sacrifice — that concludes the Hajj. This year the pilgrimage will occur in early to mid-October.
"Given that animal sacrifice is an essential and a mandatory component of the Hajj of the pilgrims ... finding an answer as quickly as possible would be quite important," said Dr. Kamran Khan, an infectious diseases physician at Toronto's St. Michael's Hospital who specializes in using airline traffic data to predict the global movement of diseases.
"I do think what this really does is helps guide some of the further investigations now. But there is certainly some time sensitivity around it."
The World Health Organization's lead expert on the MERS virus agreed getting answers sooner rather than later would be a good idea in light of the fast-approaching Hajj.
"If this virus is actually transmitting and circulating in camels and-or other animals, that could be a time of exposure," said Dr. Anthony Mounts. "It does mean that we need to do the investigations to find out the routes of transmission."Read the full story here.

Saudi Arabia confirms more MERS cases.

Saudi Arabia confirms more MERS cases.

JEDDAH, SA – Three more confirmed cases of Middle East Respiratory Syndrome (MERS) coronavirus infections in Saudi Arabia have been recorded, the Ministry of Health said on Thursday. 

A statement posted on the ministry’s website said one of the patients is a 67-year-old woman in Riyadh, who had been suffering from various chronic diseases. She is now under intensive care, receiving the health care and proper treatment. The two other cases are both women health workers, one of them living in Asir region and the other in Riyadh. “They have mild symptoms but their health status is stable,” said the MOH. The new cases bring to 92 the total number of people who have contracted the virus worldwide, including 71 in Saudi Arabia.
Of the 92 cases registered with the World Health Organization since last year, 46 have died, including 39 in Saudi Arabia. The latest MERS death in the Kingdom, announced by the Ministry of Health on July 25, was an 83-year-old man in Asir. Saudi and UK scientists studying MERS said the coronavirus is more deadly, unpredictable and has significant differences from severe acute respiratory syndrome (SARS) virus that erupted in Asia in 2003 and infected 8,273 people, nine percent of whom died. Ziad Memish, Saudi deputy minister for public health, earlier said: “MERS coronavirus appears to be more deadly, with 60 percent of patients with co-existing chronic illnesses dying, compared with the one-percent toll of SARS.”

He said that the MERS infecting humans is unpredictable because the source of the virus is not yet known. While sharing clinical similarities with the SARS-like fever, cough and incubation period, he said there are also some important differences such as the rapid progression to respiratory failure of up to five days. The progression occurs earlier than in SARS. In a Lancet Infectious Diseases publication, Saudi and UK scientists also noted a trend of older patients with more men and patients with underlying medical conditions succumbing to the disease. The symptoms of patients suffering from MERS coronavirus are fever (98 percent), chills (87 percent), cough (83 percent), shortness of breath (72 percent), and muscle pain (32 percent). A quarter of patients also experience gastrointestinal symptoms, including diarrhea and vomiting. However, in SARS, the majority of cases (96 percent) occurred in people with underlying chronic medical conditions including diabetes (68 percent), high blood pressure (34 percent), chronic heart disease (28 percent), and chronic renal disease (49 percent).

Read the full story here, Albawaba.

Related: NEJM on person-to-person spread of MERS

MERS: Silence in the Gulf.

MERS: Silence in the Gulf.(Croft).

Click through to HAAD News, the English website of the Health Authority of Abu Dhabi, and you'll see the most recent news item is dated June 17. Yet The National, a newspaper in the United Arab Emirates, published a report on July 19 about four local doctors who'd contracted MERS. WHO reported the same cases on July 18. Meanwhile, the Saudi Ministry of Health reports only when it has new cases, when it also slips in any "passed away" cases. Other Gulf states' media are also silent in the face of the new threat.
In a sense, this is understandable. Unlike flu bloggers, few people like to dwell on bad news, and would rather not deal with it unless they have to. For governments, disease poses a threat far worse than mere illness—embarrassment. Hence the Cuban government's silence about cholera (see below).
But surely these governments' media experts (to say nothing of their public health experts) must be telling them this strategy is counterproductive. It only inspires skepticism in their publics about the competence and concerns of their rulers.
By contrast, consider the Centre for Public Health in Hong Kong, a continent away from the Gulf but studiously reporting every suspected MERS patient who turns up...and also keeping Hong Kongers aware of the confirmed cases in the Gulf.
Apart from informing its constituents, the CHP is also building credibility with every report. I like to poke affectionate fun at the CHP because it tells us about every outbreak of sniffles in every kindergarten in the region. But because it takes pains with the small stuff, a serious alarm from CHP will command instant public attention.
The Gulf strategy has another drawback: It defines MERS in terms of deaths and recoveries, not in terms of the public-health response to it. This turns the disease into a series of shocks, and conditions us to wait anxiously in the pauses for the next death.
If instead the Gulf states (especially Saudi Arabia) were releasing news about the condition of the patients, the research efforts being made to learn about the disease, and what's being learned, the death reports would be incidents in an ongoing story—not the bombshells they now are.

Earlier this month, the ministry issued health rules and regulations for Haj and Umrah pilgrims for the current year in the wake of an outbreak of Middle East Respiratory Syndrome (MERS). These included postponing Haj and Umrah rituals by those above the age of 65 as well as chronic patients, including those suffering from diseases of heart and kidney, and also those having respiratory problems. Pregnant women and children below the age of 12 were also discouraged from performing the rituals at least for the time being. 

MERS and the Hajj a recipe for pandemic?

MERS and the Hajj a recipe for pandemic?(Crofts).

Thanks to Jennifer Yang for tweeting the link to this PLOS Curents Outbreaks article: Potential for the International Spread of Middle East Respiratory Syndrome in Association with Mass Gatherings in Saudi Arabia. The abstract:

Background: A novel coronavirus (MERS-CoV) causing severe, life-threatening respiratory disease has emerged in the Middle East at a time when two international mass gatherings in Saudi Arabia are imminent. While MERS-CoV has already spread to and within other countries, these mass gatherings could further amplify and/or accelerate its international dissemination, especially since the origins and geographic source of the virus remain poorly understood. 

Methods: We analyzed 2012 worldwide flight itinerary data and historic Hajj pilgrim data to predict population movements out of Saudi Arabia and the broader Middle East to help cities and countries assess their potential for MERS-CoV importation. We compared the magnitude of travel to countries with their World Bank economic status and per capita healthcare expenditures as surrogate markers of their capacity for timely detection of imported MERS-CoV and their ability to mount an effective public health response. 

Results: 16.8 million travelers flew on commercial flights out of Saudi Arabia, Jordan, Qatar, and the United Arab Emirates between June and November 2012, of which 51.6% were destined for India (16.3%), Egypt (10.4%), Pakistan (7.8%), the United Kingdom (4.3%), Kuwait (3.6%), Bangladesh (3.1%), Iran (3.1%) and Bahrain (2.9%). Among the 1.74 million foreign pilgrims who performed the Hajj last year, an estimated 65.1% originated from low and lower-middle income countries. 

Conclusion: MERS-CoV is an emerging pathogen with pandemic potential with its apparent epicenter in Saudi Arabia, where millions of pilgrims will imminently congregate for two international mass gatherings. Understanding global population movements out of the Middle East through the end of this year’s Hajj could help direct anticipatory MERS-CoV surveillance and public health preparedness to mitigate its potential global health and economic impacts.

CIDRAP: Four more MERS cases cited in UAE, 2 in Saudi Arabia.

CIDRAP: Four more MERS cases cited in UAE, 2 in Saudi Arabia.(Crofts).

Via CIDRAP, Robert Roos wraps up a surprising day: Four more MERS cases cited in UAE, 2 in Saudi Arabia. Excerpt:

The six new cases raise the unofficial global count of MERS cases to 90, including 45 deaths. The WHO count, which does not yet include the two new Saudi cases, is 88 cases with 45 deaths. Saudi Arabia's posted tally is now 70 cases and 38 deaths. 

The four UAE cases apparently bring that country's case count to six, which includes an 82-year-old man whose illness was reported last week and a UAE man who was flown to Germany for treatment and died there in March. In addition, a 65-year-old man from France fell ill with MERS in May after traveling in the UAE. 

The eight cases reported in the past 2 days are in keeping with a recent trend noted by the WHO last week: younger patients, less severe illness, and more women. In particular, eight other asymptomatic cases were reported in late June, including four in female healthcare workers and four in children, all in Saudi Arabia. 

The new unofficial tally of 90 cases and 45 deaths represents a case-fatality ratio of 50%—lower than the 56% cited by the WHO in its MERS situation summary on Jul 9. 

In that report, the WHO also observed that cases resulting from person-to-person transmission seem to be milder than those apparently involving transmission from non-human sources. The agency said it was unclear whether that phenomenon was an artifact of surveillance and case-finding efforts or signaled that infections acquired from non-human sources are more virulent.

Doctor helps hospitals in Middle East, US to prepare for MERS.

Doctor helps hospitals in Middle East, US to prepare for MERS.(Croft).

Report from Georgetown University: Doctor Helps Hospitals in the Middle East and U.S. Prepare for MERS. Excerpt:

A Georgetown expert on global viral outbreaks is helping health departments and hospitals in the Middle East and the United States prepare to fight a new deadly virus before millions of Muslims travel to Mecca in October. 

Dr. Daniel Lucey, an infectious disease and public health physician, and an adjunct professor of microbiology and immunology at Georgetown University Medical Center (GUMC), left for the Middle East on July 4 to help respond to Middle Eastern Respiratory Syndrome Coronavirus (MERS). 

“MERS is SARS until proven otherwise – and it is much more lethal so far in hospitalized patients,” Lucey says, referring to Severe Acute Respiratory Syndrome, which he worked on in the early 2000s. 

According to the Centers for Disease Control and Prevention (CDC), as of July 2 MERS has killed almost 55 percent of its 62 victims in Saudi Arabia, and infected a total of 77 people in eight countries, killing 40 people (64 percent) who contracted the virus. 

IDEAL BREEDING GROUND 

No cases have been reported in the United States, but a few have been in France, Germany, Italy, Tunisia and the United Kingdom. 

Of particular concern in Saudi Arabia is the time between Ramadan, which starts July 9 through the Muslim Hajj in mid-October. 

“The Hajj is the world’s largest annual pilgrimage, when more than 3 million Muslims make there way to Mecca in Saudi Arabia,” Lucey says. 

ENHANCED SURVEILLANCE 

Lucey’s expertise on SARS, MERS and other infectious diseases has led him to travel to five countries – Qatar, Jordan, Egypt, the United Arab Emirates, and France – since April to give lectures and work with hospitals on infection control. 

“This disease represents a significant public health risk under the International Health Regulations …,” the World Health Organization stated in a May 28 press release. “WHO has issue recommendations for enhanced surveillance and precautions for the testing and management of suspected cases, and is working closely with countries and international partners.”

Related:  India: Government indifference to MERS puts airlines in a fix

Over a thousand passengers arrive in Mumbai every day from the Gulf states, including several Umrah pilgrims who return from their Umrah to Saudi Arabia, which has seen the highest number of deaths due to MERS till now. Air India alone flies 600 passengers from Jeddah and Riyadh everyday. Umrah pilgrims fly back after spending 14 days in camps in the United Arab Emirates. 

"Most of the poor subsidised pilgrims fly Air India as it is the official carrier," said an airline official who did not want to be named. "Since they are travelling on a subsidy their camps are not very hygienic. Air India crew, thus, are at the highest risk. But neither the airline nor the government has taken any steps to address this issue." 

MERS likely to spread as UAE-Saudi travel increases.

MERS likely to spread as UAE-Saudi travel increases.(Croft).

Via The National, a report datelined Abu Dhabi: Mers virus likely to spread as UAE-Saudi travel increases. Excerpt:

The Mers virus is more likely to spread as travel increases between the UAE and Saudi Arabia, where most cases of the disease have been found, doctors have warned. 

The Haj will take place in October and Saudi authorities have advised the sick and elderly not to make pilgrimages this year. Those who do travel have been advised to wear face masks. 

More immediately, with unrest elsewhere in the Middle East disrupting holiday plans, increasing numbers of Saudi travellers are now heading for the UAE. That, too, increases the risk that the disease might spread, doctors say. 

The problem is that experts do not know how the Middle East respiratory syndrome coronavirus (Mers-CoV) is spread. 

"We have not confirmed how it is transmitted. We know that Mers-CoV is in the community and I would say everyone, especially medical establishments and emergency departments, needs to be vigilant," said NG Wai-Khuan, the infection prevention section head at Mafraq Hospital in Abu Dhabi. 

The 82nd victim of the virus is in intensive care in an Abu Dhabi hospital after the condition was diagnosed at the weekend. The Emirati, 82, was already being treated for multiple myeloma, a cancer of the bone marrow. Patients with existing conditions are particularly susceptible to Mers. 

Although Mers has a high mortality rate - of 65 people infected in Saudi Arabia, 38 have died - the spread of infection has been very low: about 20 cases a month.

Saudi Arabia warns pilgrims over MERS.

Saudi Arabia warns pilgrims over MERS.(Crofs).

Via BBC News: Saudi Arabia warns pilgrims over coronavirus. Excerpt:

Health officials in Saudi Arabia have asked pilgrims visiting its holy sites to wear masks in crowded places to stop the spread of the MERS coronavirus. 

A list of requirements issued by the health ministry also tells elderly people or those with chronic diseases to postpone their pilgrimage. 

Thirty-eight people have died from the virus in Saudi Arabia. 

Millions of Muslims from around the world are expected to take part in the Hajj this October. 

Once a year, pilgrims make the journey to Mecca in Saudi Arabia and pray together before the Kaaba. Muslims also travel to the site at other times, as well as visiting the Masjid Al-Nabawi, or Mosque of the Prophet, in Medina. 

Health officials urged people taking part to maintain personal hygiene standards, use a tissue when sneezing and coughing, and have the necessary vaccinations.

Emirati man diagnosed with MERS & CDC issues MERS preparedness checklists.

Emirati man diagnosed with MERS and CDC issues MERS preparedness checklists.(Croft).

Thanks to Helen Branswell for tweeting the link to this July 12 GulfNews.com report: Emirati man diagnosed with Sars-like virus .

An 82-year-old UAE national has been diagnosed with novel Coronavirus (MERS-CoV) in one of the hospitals in Abu Dhabi. The patient is male with multiple myeloma and is currently admitted in the ICU. 

The Health Authority in Abu Dhabi (HAAD) has confirmed that it is coordinating with the Ministry of Health and other authorities in the country and has taken the necessary measures as per the international standards and recommendations of the World Health Organization (WHO). 

The Ministry of Health stated that the WHO first issued an international alert in September 2012. Up to date the WHO confirmed a total of 80 laboratory-confirmed cases of infection with MERS-CoV worldwide. This case represents the first diagnosed case of the disease within UAE. 

MOH added that WHO confirmed that the virus is not a concern for public health at the moment, and that the current situation does not require a travel ban to any country in the world, nor screenings at different ports, nor any restrictions on trade.

In her tweet, Branswell says: "Not sure MOH is interpreting @WHO  correctly."

Thanks to Dr. Vincent Racaniello for tweeting the link to this CDC item: MERS-Preparedness. Click through to see the checklists and use the links. Excerpt:

CDC has compiled various tools that can be adapted for MERS-CoV. They were initially developed to assist public health, healthcare, and emergency management in preparing for and reducing surge on the healthcare system due to influenza pandemic and SARS.

WHO convenes emergency meeting on MERS - Updated report.

WHO convenes emergency meeting on MERS - Full report.HT: Crofs.

Margaret Chan, the director-general of the World Health Organisation, said yesterday that she had decided to convene the agency's emergency committee, for just the second time, to help protect travellers to the annual Haj pilgrimage from the coronavirus that has killed 38 people in Saudi Arabia. 

The 15-member committee, which includes the deputy health minister of Saudi Arabia, Ziad Memish, and health officials from six other predominantly Muslim countries, will meet via teleconference today to decide whether the Middle East respiratory syndrome coronavirus (Mers-CoV) represents a public health emergency of international concern. 

Ms Chan last convened the committee to battle the 2009 global flu pandemic.

"Millions of people are going to Mecca and to Medina - we cannot stop that and we should not stop that," said Ms Chan at the WHO's headquarters in Geneva.

"We need to say that it's OK to go, but these are the measures that governments must take."

The previously unknown virus has infected 80 people and killed 45 worldwide, according to the WHO. While most cases have been detected in Saudi Arabia, infections in the UK, France, Germany and Italy have sparked concern of a global outbreak similar to the 2003 Sars epidemic. 

Scientists still don't know where the new virus came from or how it is spreading.

That prompted Ms Chan to say at the WHO's annual World Health Assembly in May that the virus is her "greatest concern".

While the pace of new infections has slowed, Ms Chan said she wanted to be prepared in case it returns.

"Am I still worried? The answer is yes," she said. "Eventually I hope the disease will burn out. But what if it doesn't? We should always have plan A, plan B and plan C."

Recent guidelines

On 5 July, WHO published a guideline for investigation of MERS-CoV cases. It provides recommendations for early case investigation including further case finding, surveillance enhancements, and studies that need to be done around new cases.

On 3 July, WHO published revised case definitions for MERS-CoV confirmed and probable cases based on new epidemiological and clinical information. The document also contains recommendations on further evaluation for cases with inconclusive tests and asymptomatic infections.

On 27 June, WHO published interim surveillance recommendations for human infection with MERS-CoV. The two major changes include a stronger recommendation for the use of lower respiratory tract specimens in addition to nasopharyngeal swabs for diagnostic testing and a longer observation period for contacts of cases.

MERS-CoV summary and literature Update Here.  

Two more die in Saudi Arabia from MERS coronavirus.

Two more die in Saudi Arabia from MERS coronavirus. HT: Crofs.

Via Reuters: Two more die in Saudi Arabia from MERS coronavirus. Excerpt:

Two more people have died of the SARS-like coronavirus MERS, Saudi Arabia's Health Ministry said, bringing to 38 the number of deaths from the disease inside the country shortly before Islam's Ramadan fast when many pilgrims visit. 

A two-year-old child died in Jeddah and a 53-year-old man died in Eastern Province, where the outbreak has been concentrated, the ministry said late on Saturday in a statement on its website. Four people have died outside the kingdom.   

The ministry said another three people had been confirmed as being infected with Middle East respiratory syndrome (MERS), bringing the total number of confirmed cases inside the kingdom to 65 since it was identified a year ago. 

On Friday the World Health Organization said MERS, which can cause fever, coughing and pneumonia, had not yet reached pandemic potential and may simply die out. 

Ramadan, Islam's fasting month, is expected to start in Saudi Arabia on Monday night and is traditionally a time when hundreds of thousands of Muslims come to Mecca for umrah, a pilgrimage that can be carried out at any time of year. 

Millions are also expected to travel to Mecca for the main pilgrimage, haj, that will take place in October, although the authorities have cut the number of visas this year, citing safety concerns over expansion work at the main mosque site.

The Ministry of Health's own statement is here. Arab News also has the story. It mentions that one of the three new cases is a health worker. Saudi Gazette spins the story to the bright side, stating that "only three" new cases have been reported.

Via his blog Virology Down Under, Dr. Ian Mackay muses on MERS-CoV cases at ~ 80.

...and at least 42 deaths (WHO have 79 and 44 in recent press conference). My numbers say that 66% of cases are male as are 76% of mortalities. 

I think it's worth noting, again, that (and these are my numbers only) 9 cases have no discernible age and 8 have no sex noted in press releases. 25 cases have no date of illness onset, 11 no date of death and 69 no specific date of hospitalisation. 

A recent Saudi Arabian Ministry of Health release noted the death of the 2-year old boy, who was already suffering from chronic underlying lung disease.

This brings up something that's been bothering me about the Saudis' MERS reports. They don't report their cases in a consistent manner, never mind a detailed one.
Sometimes we learn where a case has been identified, or we learn the age of a patient, but we never get a clear, progressive description of the progress of MERS in Saudi Arabia. If it's a case in the Eastern Region, is that the same as Al-Ahsa? And which of the Al-Ahsa cases is this one? When was onset?
Go back to last year's first English-language accounts in the Jordan Times of what we now call MERS; you'll see the same vagueness. But no one knew what it was then, or whether it would spread. Everyone, including the Saudis, now understands that this could be a very nasty bug. The whole world needs to know about it, and the world's entire health community may be needed to stop it.
Some virologist in Manila or Minneapolis, given enough information, might figure out where the source of MERS might be hiding. Some public-health veteran of H1N1 in Hanoi or Hong Kong, or some group of expert Americans, might imagine a way to slow down the rate of nosocomial infection.
But to do that, they need a lot more information than the Saudis (or WHO) have provided so far.

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.

MERS virus doesn’t yet have pandemic potential, but that could change: study.

MERS virus doesn’t yet have pandemic potential, but that could change: study.(Crofs).

Via Globalnews.ca, a fascinating report by Helen Branswell of The Canadian Press: MERS virus doesn’t yet have pandemic potential, but that could change: study. Read her whole article as well as the Lancet article it discusses. Excerpt:

The new MERS coronavirus currently doesn’t spread well enough among people to trigger a pandemic, says a new study that calculates the rate at which the virus is transmitting person to person. 

But the senior author says the pattern of how the virus is spreading now cannot be used to predict whether MERS will become a bigger threat in the future. 

“There is absolutely no guarantee that this virus will stay as it is. It could very well follow the same path as SARS did 10 years ago,” Dr. Arnaud Fontanet, who heads the emerging diseases epidemiology unit at the Institut Pasteur in Paris, said in an interview. 

Others too say the study should not be used to write off the new virus. 

“The virus has shown a potential for human-to-human transmission. And whether such transmission is sustained depends on the intensity of control measures as well as the characteristics of the people involved in transmission,” said Marc Lipsitch, an infectious diseases specialist who teaches at Harvard University. 

“For that reason, I think it’s premature to say that this virus does not present a pandemic threat.” 

The study, published in the journal The Lancet, analyzes what is known about how often people who have been infected with the MERS virus spread it to one or more other people. The authors used the data to calculate what is called the basic reproduction number, known in the parlance of infectious diseases as the R nought. 

In order for a disease to achieved sustained spread, the average infected person must spread a bacterium or virus to at least one other person. That is an R nought of one. A pathogen with a basic reproduction number of less than one would peter out. 

The measles virus, which is very contagious, has a basic reproductive number of between 12 and 18, meaning that among people who are susceptible to the virus, each infected person would be expected to pass the virus to between a dozen and 18 other people. In a 2003 study in the journal Science, Lipsitch and colleagues estimated the R nought of SARS to be three. 

Using the publicly available data on MERS cases, Fontanet and his co-authors set out to figure out what the basic reproduction number for the new coronavirus has been to date. 

There are many holes in the available data. For instance, Saudi Arabia, which is responsible for 63 of the 77 confirmed MERS cases, often does not disclose if new infections have links to previous ones – which might mean they caught the virus from another person – or are what are called sporadic cases, people thought to have been infected by an animal or exposure to the virus in the environment. 

The authors tried to work around the gaps by calculating best- and worst-case scenarios. Both, it turns out, came up with a reproductive number of less than one, which suggests the virus doesn’t yet have pandemic potential, they said. Those rates were 0.60 and 0.69 respectively. 

The authors noted that in the early stages of SARS it had a reproductive number of 0.80, closer to one than what is currently seen with the MERS virus. But they suggested that even though the viruses are cousins, people should be cautious about drawing too many comparisons because the viruses are different and have cropped up in different parts of the world.

And the commentary, by researchers from the applied mathematics department of the University of Waterloo in Waterloo, Ont., said the future behaviour of the virus could also be affected by factors like changes in the season, or events like the Hajj, in which as many as three million pilgrims from around the world flock to the Muslim faith’s holiest site, Mecca.

“In terms of what the public should take home from this, it’s that we’re definitely not out of the woods,” said Waterloo’s Chris Bauch.

“It could go up not only because it (the virus) evolves but because the Hajj is coming up. And not only are you going to have slaughter of (potentially) infected animals, but you’re also going to have a possibility for transporting it to other countries.”

Fontanet said the priority now should be finding the source of the virus and limiting the chances it has to spread to people. The more times the virus infects people, the more chances it has to develop mutations that would help it adapt to spreading easily among humans, he said.

“It’s precisely because it is not yet that transmissible that it’s the perfect timing for identifying the animal reservoir and stopping it at the source,” he continued.

Man being treated in a London hospital for a lethal 'Sars-like' MERS has died.

Man being treated in a London hospital for a lethal 'Sars-like' MERS has died. HT: AstuteBlogger.(Telegraph).

"In the end his lungs were worn down, so secondary infection is the real problem. The virus effectively turns your lungs to jelly."

The man, a Qatari national, had been admitted to a private clinic in London in September, before being transferred to the specialist centre at Guy's and St Thomas' Hospital.He was diagnosed as suffering from the Mers virus – Middle East Respiratory Syndrome – which has affected 77 people worldwide, with 43 deaths.

"Guy's and St Thomas' can confirm that the patient with severe respiratory illness due to novel coronavirus (MERS-nCV) sadly died on Friday 28 June, after his condition deteriorated, despite every effort and full supportive treatment," said Robin Wilkinson, a spokesman for the hospital.

The death of the Qatari man brings to three the number of victims who have died in the UK.

In February two members of the same family died from the virus. One, a 39-year-old man, died in Birmingham having picked up the virus from his father, who had recently travelled to Saudi Arabia. The father then died around a month later in Manchester's Wythenshaw hospital. A female relative was also treated for mild Mers symptoms, raising fears of human-to-human contact.
 The disease is spread by people coughing or sneezing and can cause breathing difficulties, lung damage and pneumonia.

"We still don't know exactly what killed him," said Dr Jon Bible, a virus expert at Guy's and St Thomas'."In the end his lungs were worn down, so secondary infection is the real problem. The virus effectively turns your lungs to jelly."

Known cases of the illness have quadrupled since April, and it is deadlier than Sars, which killed 774 people in 2003. SARS killed one in ten affected people; Mers has proved fatal in 65 per cent of cases.
The majority of the cases have been in Saudi Arabia, or in patients who have recently travelled to the region.

But with the annual Hajj pilgrimage due in October, and an estimated three million people travelling to Mecca, concerns are mounting that the deadly virus could spread swiftly."We need to get the facts clear and get the appropriate advice to all your countries where your pilgrims want to go to Mecca," said Margaret Chan, head of the World Health Organisation, in May. "It is something quite urgent."

Cases have been reported in Jordan, Qatar, United Arab Emirates, Britain, France, Italy, Tunisia and Saudi Arabia – the country with the most confirmed infections.
Belgian medics have warned Muslims not to travel to Mecca, because the Hajj threatens to spread the virus worldwide. Doctors expressed concerns that the mass gatherings are "ideal hotbeds for respiratory diseases" and that numbers of Mers cases are greater than actually reported in Saudi Arabia.
The unnamed man in London had been treated in a "negative pressure room" – an isolation chamber within the hospital, which means that contaminated air is not pumped back out into the hospital. All doctors treating the patient would have been equipped with protective suits, which were incinerated after use.
He had initially shown signs of improvement, but his condition deteriorated and he passed away last week. It is unclear how he contracted the disease, although there are known cases in Qatar. Read the full story here.

For more in depth info on The MERS - Corona Virus and other click HERE.

Killer coronavirus: Experts link deadly Mers disease to UAE and Qatar.

Killer coronavirus: Experts link deadly Mers disease to UAE and Qatar.(TheNational).

ABU DHABI // A strain of the Sars-like virus that killed an Emirati man has origins in the UAE and Qatar, a report has revealed. The 73-year-old Abu Dhabi man died in a hospital in Germany on March 26, 11 days after developing flu-like symptoms, including a fever and a cough, which turned out to be the Middle East respiratory syndrome coronavirus, or Mers-CoV.

A report by experts published in the Lancet medical journal has now said the man died from a strain similar to that of a Qatari man, who was treated in Germany six months before the Abu Dhabi man.

Stool samples from the Qatari victim had shown he had a “clustering of viruses derived from Qatar and the UAE”, the report said.

Mers-CoV has so far killed 38 people worldwide, most of those in Saudi Arabia, but the Health Authority Abu Dhabi has urged the public to remain calm.

One consultant and head of infectious disease at Mafraq Hospital, Dr Asim Malik, said: “Ever since we first got the reports of the first few cases in Saudi, we have worked in close collaboration with Health Authority Abu Dhabi and Seha.

“It’s not just Mafraq Hospital but all Seha healthcare facilities, namely Sheikh Khalifa Medical City and Tawam.

“We met and developed … guidelines and protocols that were put in place in preparation and anticipation of suspected or confirmed cases of coronavirus.”

The Abu Dhabi victim was first admitted to Mafraq Hospital with suspected pneumonia before he was transferred from the intensive care unit by air ambulance to the Klinikum Schwabing hospital in Munich on March 19.

He died of septic shock seven days later after his kidneys failed and he did not respond to intensive antibiotics and dialysis treatment.

Relatives of the man said he owned camels and had come into contact with a diseased animal shortly before becoming ill. No animal samples could be retrieved, the report said.

Research showed the man had an underlying health condition, having been diagnosed with multiple myeloma, a cancer that affects production of normal blood cells, in 2008.

The report suggested the man had a cancer relapse in November last year and may have had a weaker immune system.

He became the 11th person to die from the virus, which has now claimed 38 lives worldwide, according to the World Health Organisation (WHO).

The report was carried out by doctors and disease experts in research centres in Germany, the US and the UK.

The results of their research paper came as the Saudi Ministry of Health announced an additional four confirmed cases of the virus on Saturday.

The first case is a 43-year-old woman in the country’s eastern region who has recovered. The other three cases are female healthcare workers, aged 29, 39 and 45, who cared for two previously confirmed Mers-CoV cases.

Research has shown that Mers-CoV spreads easily between people, with hospitals, in particular, areas of proliferation.

Worldwide, 68 people have been confirmed as having contracted the virus since September, WHO said. In addition to the UAE, Qatar and Saudi, cases have also been identified in Jordan, Tunisia, the UK, Germany, France and Italy.

The outbreak of the virus has recently prompted Margaret Chan, the director general of WHO, to call it her “greatest concern”.

“The novel coronavirus is not a problem that any single affected country can keep to itself or manage all by itself,” she said in a speech last month at the 66th World Health Assembly.

“We understand too little about this virus when viewed against the magnitude of its potential threat.”

More than 100 health experts gathered in Cairo, Egypt, at the weekend to discuss what urgent actions are needed at a national level to stem the growing outbreak of Mers-CoV, which belongs to the same family of viruses as the one responsible for Sars, which ultimately triggered a global outbreak that killed about 800 people. WHO yesterday said it is continuing to monitor the situation. Hmmmm.......Qatar and SaudiArabia.Read the full story here.

Killer MERS coronavirus: Eight new MERS PCR Confirmations In Asymptomatic HCWs and Children.

Killer MERS coronavirus: Eight new MERS PCR Confirmations In Asymptomatic HCWs and Children.HT: Recombinomics.

The Ministry of Health that through investigation epidemic disease virus Corona new (MERS-CoV) has been monitoring the virus in four of the contacts of confirmed cases in the areas of Riyadh and the eastern region between the ages of 7 and 15 years old, did not show them any symptoms of the disease, all in good health.

The ministry also announced monitor virus in عاملتين of صحيتين in the eastern region and Hasa and they show no symptoms also,

The above translation from the June 23 Kingdom of Saudi Arabia Ministry of Health (KSA-MoH) update describes six more asymptomatic confirmed MERS-CoV cases.  Two of the cases are health care workers (HCWs) from nosocomial outbreaks in Al Hasa, as well as a second location in the eastern province.  These are in addition to the two asymptomatic HCW cases in Taif, which is in the western region of KSA and adjacent to Mecca (see map).  The asymptomatic cases in Taif are in addition to a mild MCW case and two fatal cases in sisters (65F and 68F) in Taif, signaling a nosocomial outbreak in the west.

In addition, the four confirmed MERS-CoV cases in asymptomatic children who are contacts of cases in Riyadh and the eastern region are the first such cases reported.  The reasons for the dramatic increase in confirmed asymptomatic cases is unclear.

WHO reported the asymptomatic and mild HCW cases in Taif as “weak positives”, which was the terminology used to describe PCR positives in asymptomatic contacts in Italy, which included at least five HCWs  A second lab failed to confirm the weak positives, but different primers were used, raising the possibility that the first set of primers was more sensitive, leading KSA to switch primers.

A NEJM publication of the large nosocomial outbreak in the eastern region described a super spreader and multiple long transmission chains similar to those reported for SARS coronavirus in 2003.  However, the NEJM report also cited 11 probable cases who developed pneumonia and were contacts of confirmed cases but were not confirmed (either because they were not tested or tested negative one time).  The failure to detect MERS included fatal cases that included the index case and the super spreader, signaling serious sensitivities issues.  This may have prompted a change to more sensitive PCR primers and the detection of the asymptomatic cases.

Alternatively, the NEJM paper included full sequences of four of the nosocomial cases generated through a collaboration between the Welcome Trust and the KSA-MoH.  This relationship may have led to sequencing of inserts from PCR tests which proved that the weak positives were true positives, leading to an explosion of confirmed asymptomatic cases which increased the total from 0 to 8 in the past two days. 

As expected these new cases led to a plummet in the case fatality rate for cases with outcomes, which has fallen from 82% (32/39) to 63% (34/54).