WHO EMRO: Recent High Level Mission To Saudi Arabia On MERS-CoV

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As the epicenter of MERS infections in the Middle East, Saudi Arabia arguably has the most to lose from a larger outbreak, and has repeatedly pledged to take the lead in investigating the disease. 

Progress has been slower than hoped (see WHO EMRO: Scientific Meeting Reviews MERS Progress & Knowledge Gaps), and KSA hasn't always been quick to share what it knows with the rest of the world. 

Six months ago we saw the WHO Statement On The 10th Meeting Of the IHR Emergency Committee On MERS criticize the Saudi Response to MERS in unusually blunt terms, particularly over their handling of asymptomatic or mild cases (see WHO Guidance On The Management Of Asymptomatic MERS Cases).



Earlier this month WHO conducted a high level mission to Saudi Arabia to review their progress and agree on a joint operational plan for combating the virus. Their report acknowledges improvements made by the Saudis in recent months, cites areas that still need work, and makes recommendations for moving forward.


Excerpts from a much longer report follow, so click the link to read it in its entirety.

WHO’s high-level mission to Saudi Arabia on Middle East respiratory syndrome coronavirus (MERS-CoV) 11–14 January 2016

Executive summary

Background

Since its emergence in 2012, cases of Middle East respiratory syndrome (MERS) continue to occur in countries of the Eastern Mediterranean Region signifying that the global threat of MERS has not yet subsided. Last year, the outbreak in South Korea was a strong reminder that MERS-CoV remained an international health threat and could cause severe disruption to health, economic and social services if health systems remain unprepared. It also became evident last year that hospital outbreaks of MERS in Saudi Arabia could escalate both nationally and internationally into a perpetual global health threat. In view of this, it was necessary to assess and understand what progress has been made in Saudi Arabia, where over 80% of laboratory-conformed cases of MERS have occurred, in controlling the virus, including preventing its international spread. 

(SNIP)

The objectives of the current mission, which was conducted in Saudi Arabia from 11 to 14 January 2016, were to:

• review the ongoing MERS situation;
• assess progress in implementing previous mission recommendations;
• identify main areas of public health research to better address remaining knowledge gaps; and 
• agree on a joint operational plan for WHO and the Ministry of Health of Saudi Arabia for collaborative work and research to prevent and control MERS-CoV.

(SNIP)

Summary of findings and observations

The mission noted the substantial progress made in the control of MERS-CoV in last 12 months, including in:

• accumulating knowledge and learning lessons to control hospital outbreaks and  and applying evidence-informed hospital infection control measures to prevent hospital outbreaks of MERS;
• establishing a mechanism to monitor compliance by hospitals in implementing appropriate infection prevention and control (IPC) measures;
• improving collaboration between the human and animal health sectors;
• establishing an electronic surveillance system for MERS and real-time mechanism to track and respond to cases or outbreaks;
• conducting research to evaluate information gaps identified during previous WHO missions, and 
• establishing a mechanism to support and fund priority health research on MERS to address key knowledge gaps. 

Surveillance for human infections from MERS

The mission acknowledged that the surveillance system for detecting and monitoring both suspected and laboratory-confirmed cases of MERS has improved through the establishment of the Health Electronic Surveillance Network (HESN). All suspected and laboratory-confirmed cases of MERS are now entered into this web-based surveillance system, which is accessible to most health care facilities and facilitates for the Ministry a real-time alert, investigation and response. However, the surveillance systems remain “responsive” in detecting suspected cases early. It is important to establish a sentinel-based surveillance system for severe acute respiratory infection (SARI) in the countrywhich would facilitate identification and systematically testing for in order to identify and test systematically for MERS-CoV any cases that present to health facilities with pneumonia or pneumonia-like syndromes and to monitor testing rates in order to reduce the risk of missed cases. Other challenges  include a shortage of human resources, especially a trained public health workforce for joint animal/human investigation and contact tracing.    

(SNIP)

Conclusion and recommendations 

The mission acknowledged that the first phase of the MERS response was designed to respond to acute events, such as the repeated nosocomial outbreaks. The country is now ready to move to the next phase, which is to focus on preparedness to respond to and prevent primary infections in the community and future outbreaks in hospitals. 

Therefore, the mission recommended to scale up the following strategic actions in leadership, coordination and operational areas.

1. Expand the national strategic plan for control of MERS with a strong focus on preventing primary cases in the community, as well as stopping rapidly the nosocomial transmission in hospitals through involving all concerned ministries in the country. The plan will require identification of a leader with necessary authority, responsibility and accountability and allocation of appropriate human and financial resources for the plan's effective implementation.  

2. Scale up engagement with other sectors, such as the Ministry of Agriculture, Ministry of Municipalities, etc. in preventing community-acquired infections. Of particular importance would be to reinforce and systematize joint investigation by both the animal and human health sectors of each reported case of community-acquired infection. Such joint and collaborative investigation and control efforts under the “one health” approach could effectively contribute to preventing human infections acquired in the community.

3. Identify and implement research to address the key public health questions on MERS that remain unanswered to date. Based on the list of research questions recommended in the last international scientific meeting organized by WHO in Cairo on 5–6 May 201 , the mission recommended that, in consultation with WHO, the new research body King Abdulaziz City for Science and Technology prioritizes research areas to be funded and calls for researchers across the world to submit their research proposals based on this prioritized list. 

4. Document and share widely, both nationally and internationally, institutional lessons learnt in the Kingdom in the areas of IPC measures to prevent nosocomial outbreaks of MERS. Such lessons should capture the risk factors for hospital outbreaks and the institutional lessons learnt on best ICP practices for controlling outbreaks of MERS.

5. Elevate the CCC into a multisectoral body, able to effectively coordinate and collaborate with other ministries and sectors involved with any important aspect of MERS-CoV, especially the Ministry of Agriculture, veterinary services, and wildlife sector. Such a multisectoral body could ensure a consistent government policy and communications on all cross-sectional issues related to MERS-CoV and should direct and guide an effective and coordinated response to an outbreak through optimizing communications and collaboration with all government and nongovernmental sectors and agencies involved in a response operation. 

MERS remains a global health concern. The scaling up of preventive and control efforts of MERS in the Kingdom of Saudi Arabia, where the majority of global cases have so far occurred, would effectively contribute to enhanced global response to this health threat. It would be a collective responsibility to prevent escalation of any event related to MERS-CoV. In the next course of action, WHO would like to work collaboratively with the Ministry of Health to develop an action plan with time sensitive and achievable goals, in accordance with the agreement reached during the meeting of the mission members with His Excellency the Minister of Health to implement the mission’s recommendations.

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RESEP LUMPIA SEMARANG ISI REBUNG SAUS MANIS PEDAS

Resep Lumpia Semarang Isi Rebung Spesial - Lumpia goreng isi yang enak dan renyah ini sangat sedap disantap dengan variasi aneka isi di dalamnya yang gurih, serta paling enak disajikan bersama cocolan sausnya yang mantap. Terdapat beberapa variasi isi lumpia semarang asli, di antaranya adalah lumpia isi rebung, telur, ayam atau udang beserta spesial kombinasinya yang dapat kita olah menurut kreasi sendiri di rumah.

Cara membuat lumpia yang merupakan kuliner populer khas Semarang kali ini cukup praktis dengan pemakaian kulit lumpia siap pakai. Bahan isi lumpia semarang spesial yang terdiri dari perpaduan rebung, udang dan daging ayam bahkan ayam kampung akan sangat terasa gurih dan lezat. Di samping adonan isi, cocolan saus kentalnya juga sangat mempengaruhi keistimewaannya. Saus gula merah sederhana bercita rasa manis pedas sebagai pilihan selain saus tauco ini akan dapat menambah istimewa menu cemilan bersama keluarga.

Persiapan Bahan dan Bumbu Lumpia Semarang

• 400 gram rebung direbus lalu potong-potong kecil
• 150 gram udang giling
• 150 gram daging ayam giling
• 20 lembar kulit lumpia
• 5 siung bawang putih dicincang kasar
• 1 sdm ebi
• 2 batang daun bawang diiris kecil-kecil
• 1/2 sdt merica bubuk
• 1/2 sdt garam
• 3 sdm kecap manis
• 150 ml air
• 2 sdm tepung terigu dilarutkan sedikit air untuk perekat
• minyak secukupnya untuk menumis dan menggoreng

Bahan Saus Lumpia Semarang

• 50 gram gula merah
• 10 buah cabe rawit merah diiris kecil-kecil
• 1 siung bawang putih digeprek
• 1/2 sdt garam
• 300 ml air
• 1 sdm tepung maizena dilarutkan dengan sedikit air

Cara Membuat Lumpia Semarang Saus Manis Pedas

1. Panaskan sedikit minyak, tumis bawang putih dan ebi serta aduk-aduk hingga harum. Masukkan udang dan masak hingga berubah warna. Masukkan daging ayam, aduk rata serta masukkan irisan daun bawang, lalu masukkan air dan rebung, aduk rata. Tambahkan garam, merica dan kecap manis lalu aduk dan masak hingga kering serta bumbu menyerap, matikan api dan sisihkan.
2. Siapkan kulit lumpia, setiap lembarnya diberi isi tumisan rebung tadi. Lipat dan gulung dengan rapih, kemudian rekatkan dengan larutan terigu.
3. Panaskan minyak goreng, lalu goreng lumpia hingga kuning keemasan. Angkat dan tiriskan dari minyak, lalu siap untuk disajikan dengan saus manis pedas.
4. Cara membuat saus lumpia : Didihkan air, selanjutnya masukkan gula merah, irisan cabe rawit, bawang putih dan garam. Aduk dan masak hingga tercampur rata serta mendidih kembali, tuang larutan maizena lalu aduk hingga mengental, angkat dan saring.

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EID Journal: HPAI H5N8 Reintroduced Into South Korea By Migratory Waterfowl

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Given all that has happened with the evolution of new HPAI H5 viruses around the world, it is hard to believe we only just passed the 2 year anniversary of the emergence of HPAI H5N8 in South Korea last week (see Jan 17th, 2014 report Media Reporting Korean Poultry Outbreak Due To H5N8).

Up until that time, H5N8 was normally only seen in a low pathogenic form (although one HPAI H5N8 sample had been previously described in China).

Since then we've seen HPAI H5N8 turn up in China, Russia, Europe, Taiwan, and North America. It has spawned multiple high path reassortant viruses in Taiwan (H5N2, H5N3) and North America (H5N1, H5N2), as well as evolving into several genetically distinct clades.

Today the CDC's EID Journal carries a dispatch which finds the H5N8 viruses that returned via migratory birds for the winter of 2014-2015 were different from the ones that had continued to spread through Korean poultry during their absence. 

 
In addition to giving us new insight into the evolution of the H5N8 virus, and its ability to thrive and evolve in the wild aquatic bird population, this is a reminder that the HPAI viruses we know today have the potential to mutate and evolve in faraway nesting grounds and then return the following spring or fall changed in some way.

Change isn't always bad, of course.  Viruses can diminish their virulence over time or even fade away completely, crowded out by other - more fit - viruses. 

But unlike the ads for Las Vegas, what goes on in avian nesting grounds doesn't necessarily stay in avian nesting grounds. Hence the call for better global surveillance of wild and migratory birds, else we risk being blindsided (again) by a new and potentially virulent avian flu virus.


I've only posted some excerpt, follow the link to read the report in its entirety. 

Volume 22, Number 3—March 2016

Dispatch

Highly Pathogenic Avian Influenza A(H5N8) Viruses Reintroduced into South Korea by Migratory Waterfowl, 2014–2015

Jung-Hoon Kwon¹, Dong-Hun Lee¹, David E. Swayne, Jin-Yong Noh, Seong-Su Yuk, Tseren-Ochir Erdene-Ochir, Woo-Tack Hong, Jei-Hyun Jeong, Sol Jeong, Gyeong-Bin Gwon, and Chang-Seon Song 

Abstract

Highly pathogenic avian influenza A(H5N8) viruses were isolated from migratory waterfowl in South Korea during fall 2014–winter 2015, a recurrence after initial introduction in winter 2014. These reappeared viruses were phylogenetically distinct from isolates circulating in poultry farms in South Korea.

Since the Asian-lineage subtype H5 highly pathogenic avian influenza (HPAI) virus was first detected in China in 1996, outbreaks of infection caused by this virus in poultry have been continuous. The HPAI (H5) viruses have evolved and continue to evolve into many genetic lineages and multiple clades (1). In January 2014, novel reassortant HPAI viruses of subtype H5N8, clade 2.3.4.4, were detected in poultry and wild bird carcasses in South Korea (2). Closely related viruses were also detected in Japan (3) and China (4). Genetic analysis showed that this virus was generated by reassortment of HPAI viruses of eastern China. 

Subsequently, HPAI (H5N8) viruses spread to Europe and North America and were then reintroduced into South Korea and Japan (5). The HPAI (H5N8) viruses identified in South Korea in early 2014 were divided into groups A (A/Baikal teal/Korea/Donglim3/2014 strain-like) and B (A/breeder duck/Korea/Gochang1/2014-like). Group A viruses further evolved into 3 distinct subgroups: icA1 (Europe/Japan), icA2 (North America/Japan), and icA3 (South Korea/Japan) (5). Wild birds were suspected of being a source of intercontinental transmission because the timing and direction of the outbreak coincided with the migratory route of wild birds (5,6). 

We sequenced and genetically analyzed the complete genomes of 11 HPAI (H5N8) viruses isolated from wild migratory waterfowl in South Korea during December 2014 and February 2015 and compared these isolates with other HPAI (H5N8) isolates, including isolates identified from South Korea poultry farms in late 2014.

(SNIP)

Conclusions

These results suggest that HPAI (H5N8) viruses circulated in wild bird populations and evolved into subgroups during the breeding season. Detection of subtype H5N8 viruses in healthy wild birds (12,13; this study) and subclinical infection with viral shedding among migratory waterfowl experimentally infected with HPAI (H5N8) viruses (11) support the theory of long-term circulation of HPAI (H5N8) viruses in wild bird population.

This study also found that subtype icA3 viruses, derived from HPAI (H5N8) viruses from South Korea and reintroduced by migratory waterfowl, were genetically distinct from the HPAI (H5N8) viruses that continued to circulate in poultry farms. In the previous 4 HPAI (H5N8) virus outbreaks in South Korea and Japan, migratory waterfowl were identified as the source of HPAI outbreaks (14,15); however, related HPAI viruses were not reintroduced into South Korea and Japan after the initial outbreak season. The phylogenetic analysis described here shows that HPAI (H5N8) viruses isolated from migratory wild birds in the winter of 2014–15 are phylogenetically distinct from isolates from South Korean poultry farms. HPAI (H5N8) viruses thus independently evolved in wild bird populations and poultry farms in South Korea until late 2014.

Our results indicate that HPAI (H5N8) viruses have been circulating in wild waterfowl population since early 2014. Enhanced global active surveillance is needed to monitor the spread of these viruses through wild birds. Such efforts could clarify the epidemiology of HPAI virus and facilitate early recognition of novel genotypes.

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WHO SEARO Statement On Thailand's Imported MERS Case

MERS Exported Cases As of October 2015 - Credit ECDC

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While MERS activity has been on the decline the past few months, last summer in Our Global Game Of Whac-A-MERS we looked at the ongoing threat of seeing MERS infected travelers arriving unannounced anywhere in the world.  

As the ECDC map above illustrates, while MERS cases have all originated from the Arabian peninsula, its prolonged (up to 15 day) incubation period allows those exposed ample time to board a plane and unknowingly transport the virus globally (see Why Airport Screening Can’t Stop MERS, Ebola or Avian Flu).

In Korea, a single introduction last May led to 185 additional infections, and 36 deaths, spread across a dozen or more medical facilities.  By contrast, the following month a single infected traveler arrived in Thailand, and was quickly diagnosed and isolated, preventing further spread.

Once again Thailand is dealing with an imported MERS case (see yesterday's Thailand Reports 2nd Imported MERS Case From Oman), and while it is too soon to know if they have contained the threat, they appear to have acted quickly once again.

First a statement from WHO SEARO (South-East-Asia Regional Office), then I'll be back with a bit more on containing the spread of MERS.

Thailand confirms MERS CoV in traveler, WHO cautions against continued risk of importation

SEAR/PR/1618

New Delhi, 24 January 2016: Thailand today confirmed Middle East respiratory syndrome coronavirus (MERS CoV) disease in a traveler, the second such case in the country in the last seven months, as WHO cautioned other member states in its South-East Asia Region against the continuing risks and the need to remain vigilant.

“The new case of MERS CoV is a reminder of the continued risk of importation of the disease from countries where it still persists. All countries need to further enhance surveillance for severe acute respiratory infections, focus on early diagnosis, and step up infection prevention and control procedures in health-care facilities to rapidly detect any case of importation and effectively prevent its spread,” Dr Poonam Khetrapal Singh, Regional Director, WHO South-East Asia Region, said.

A 71-year -old national from Oman, who arrived in Bangkok, Thailand for treatment on 22 January, and was admitted to a private hospital, tested positive for MERS CoV. He has since been transferred to the Bamrasnaradura Infectious Disease Institute. Measures are being taken to trace all those who could have been in his contact during his journey to Thailand, and within Bangkok.

This is the second MERS CoV case in Thailand and in the WHO South-East Asia Region. Earlier, on 18 June 2015 another Omani national who arrived in Bangkok for treatment, was tested positive for MERS CoV.

In the recent past, countries in the WHO South-East Asia Region have been reviewing and strengthening preparedness to respond to MERS CoV.

WHO has been strongly advocating for strengthening health systems and ensuring strict infection control measures are in place in countries to respond to infectious diseases such as MERS CoV.

In the Region, WHO is supporting Ministries of Health to build capacities and strengthen preparedness as required under the International Health Regulations (2005) to effectively detect and respond to outbreaks and other hazards.

MERS CoV is caused by a virus. Typical symptoms include fever, cough and shortness of breath. Pneumonia is common, but not always present. Gastrointestinal symptoms, including diarrhea, have also been reported.

Due to the risks of seeing imported MERS, Ebola, or Avian flu cases, last summer TFAH Issue Brief: Preparing The United States For MERS-CoV & Other Emerging Infections, looked at the steps that governments, healthcare facilities, and public health departments around the world need to take in order to prepare for the arrival of MERS and other Emerging infections.


While most imported MERS cases around the world have been quickly identified and isolated, in Eurosurveillance: Estimating The Odds Of Secondary/Tertiary Cases From An Imported MERS Case, we looked at modeling that put the odds of seeing at least one secondary case derived from an imported MERS case at 22.7%, while the odds of seeing at least one tertiary case is 10.5%.  

Based on their models they calculated the odds of seeing at least 8 cases as the result of a single importation at a non-trivial 10.9%.

 
Reason enough to take calls for better surveillance, diagnosis, and infection control for MERS (and other emerging infectious diseases) seriously.

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PAHO Statement On Zika Transmission & Prevention

Epi Week 3 - Credit PAHO

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On December 1st, 2015 PAHO (the Pan American Health Organization) issued its first epidemiological alert on the Zika virus (see  Neurological syndrome, congenital malformations, and Zika virus infection. Implications for public health in the Americas – Epidemiological Alert).

At the that time, only 9 nations in the Americas had reported local transmission of the virus; Chile (on Easter Island), Colombia, El Salvador, Guatemala, Mexico, Paraguay, Suriname, and Venezuela.

Seven weeks later, that number has climbed to 22 nations, and the virus seems poised to spread to wherever the Aedes mosquito is present. 

While most people experience a mild, self-limiting illness - a concurrent rise in microcephalic birth defects in Brazil and neurological disorders like Guillain-Barre Syndrome in El Salvador and French Polynesia, have scientists frantically looking for a link.

Ten days ago the CDC issued a Level-II travel advisory to affected regions, and last week we saw a detailed CDC MMWR Early Release: Zika Spread & Possible Association With Microcephaly outlining what we know - and don't know - about this viral threat.

 
Below you'll find PAHO's most recent statement on the Zika Virus, and their interim recommendations.

PAHO Statement on Zika Virus Transmission and Prevention

24 January 2016

Zika is a mosquito-borne virus that is new to the Americas. Since Brazil reported the first cases of local transmission of the virus in May 2015, it has spread to 21 countries and territories* of the Americas (as of 23 January 2016).

There are two main reasons for the virus's rapid spread: (1) the population of the Americas had not previously been exposed to Zika and therefore lacks immunity, and (2) Aedes mosquitoes—the main vector for Zika transmission—are present in all the region's countries except Canada and continental Chile.

PAHO anticipates that Zika virus will continue to spread and will likely reach all countries and territories of the region where Aedes mosquitoes are found.

The most effective forms of prevention are (1) reducing mosquito populations by eliminating their potential breeding sites, especially containers and other items (such as discarded tires) that can collect water in and around households; and (2) using personal protection measures to prevent mosquito bites (see also recommendations below).

The role of Aedes mosquitoes in transmitting Zika is documented and well understood, while evidence about other transmission routes is limited. Zika has been isolated in human semen, and one case of possible person-to-person sexual transmission has been described. However, more evidence is needed to confirm whether sexual contact is a means of Zika transmission.

Zika can be transmitted through blood, but this an infrequent mechanism. Standard precautions that are already in place for ensuring safe blood donations and transfusions should be followed.

Evidence on mother-to-child transmission of Zika during pregnancy or childbirth is also limited. Research is currently under way to generate more evidence regarding perinatal transmission and to better understand how the virus affects babies.

There is currently no evidence that Zika can be transmitted to babies through breast milk. Mothers in areas with Zika circulation should follow PAHO/WHO recommendations on breastfeeding (exclusive breastfeeding for the first 6 months, followed by continued breastfeeding with complementary foods up to 2 years or beyond).

Other PAHO recommendations:

To prevent or slow the spread of Zika virus and reduce its impact, PAHO recommends the following:

• Mosquito populations should be reduced and controlled by eliminating breeding sites. Containers that can hold even small amounts of water where mosquitoes can breed, such as buckets, flower pots or tires, should be emptied, cleaned or covered to prevent mosquitoes from breeding in them. This will also help to control dengue and chikungunya, which are also transmitted by Aedes mosquitoes. Other measures include using larvicide to treat standing waters.
• All people living in or visiting areas with Aedes mosquitoes should protect themselves from mosquito bites by using insect repellent; wearing clothes (preferably light-colored) that cover as much of the body as possible; using physical barriers such as screens, closed doors and windows; and sleeping under mosquito nets, especially during the day when Aedes mosquitoes are most active.
• Pregnant women should be especially careful to avoid mosquito bites. Although Zika typically causes only mild symptoms, outbreaks in Brazil have coincided with a marked increase in microcephaly—or unusually small head size—in newborns. Women planning to travel to areas where Zika is circulating should consult a healthcare provider before traveling and upon return. Women who believe they have been exposed to Zika virus should consult with their healthcare provider for close monitoring of their pregnancy. Any decision to defer pregnancy is an individual one between a woman, her partner and her healthcare provider.

PAHO is working with its member countries to strengthen vector-control, communicate the risks of Zika and promote prevention, and establish or improve surveillance of both Zika virus infections and suspected complications, such as microcephaly, Guillain-Barre syndrome, and other autoimmune and neurological disorders.
* Barbados, Bolivia, Brazil, Colombia, the Dominican Republic, Ecuador, El Salvador, French Guiana, Guatemala, Guadeloupe, Guyana, Haiti, Honduras, Martinique, Mexico, Panama, Paraguay, Puerto Rico, Saint Martin, Suriname and Venezuela.

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Saudi MOH: Two Asymptomatic MERS Cases With Camel Contact

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Two days ago the Saudi MOH reported a symptomatic MERS case in Jeddah, a primary case linked to camel contact.   Today they report two asymptomatic cases - also linked to camel exposure - in Alkhumra (which appears to be Al-Khumra, a sub district of Jeddah). 

These two cases were detected due to the enhanced surveillance conducted in the wake of yesterday's announcement that Camels Test Positive For MERS-CoV In Jeddah Market. 

Today they've also added a new graphic (camel contact) to their daily report. 

While asymptomatic MERS cases have been documented for several years - usually discovered during the process of contact tracing - the Saudis haven't been particularly aggressive in testing anyone without severe symptoms, and so many have gone undetected.


Last September, we saw the WHO Statement On The 10th Meeting Of the IHR Emergency Committee On MERS  chastise the Saudi Response to MERS in unusually blunt terms, specifically mentioning their handling (or lack thereof) of asymptomatic cases:
 

The Committee further noted that its advice has not been completely followed. Asymptomatic cases that have tested positive for the virus are not always being reported as required.

Timely sharing of detailed information of public health importance, including from research studies conducted in the affected countries, and virological surveillance, remains limited and has fallen short of expectations. 

The role (and incidence) of `mild’ or asymptomatic carriage and transmission of the virus remains unresolved, although the lack of identifiable exposures among many primary cases at least suggests that they may play a part in the spreading of the virus. 

In  WHO Guidance On The Management Of Asymptomatic MERS Cases, the World Health Organization strongly urges that asymptomatic PCR-positive MERS cases be isolated, and their contacts be monitored as well.

Today's announcement may be a sign the Saudi MOH is taking the WHO's advice to heart. 

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Thailand Reports 2nd Imported MERS Case From Oman

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In a report that is strikingly similar to one we saw last summer, overnight (US time) Thailand's Ministry of Health announced the detection of a second imported MERS case, and as before, it comes from an Omani businessman seeking medical care after going undiagnosed after being hospitalized at home.

According to the MOH Statement (which doesn't translate particularly well), the patient is a 71 y.o. who flew to Thailand on January 22nd after a week of being hospitalized in Oman with a fever and cough, but without improvement. 

It appears the hospital in Thailand quickly determined the patient's MERS positive status, and placed him in isolation, and he has been transferred to an infectious disease hospital.  In his travels, and before he could be tested and isolated in Thailand, the patient had contact with a number of people.


The Bangkok Post reports:

The Public Health Ministry is looking for people who had contact with the patient. They included a relative who accompanied the patient, 218 crew and passengers who are still in Thailand, one taxi driver, a hotel employee, and 30 hospital staff.

These people will be kept under close surveillance for 14 days. Of them, 37 are categorised as high-risk. They are the patient's relative, 23 air passengers, the taxi driver, the hotel employee, and 11 hospital staff.

Those with a high risk will also be quarantined.

All of this raises questions (again) over the diligence or ability of hospitals in the Middle East - which arguably should be aggressively looking for MERS cases -  to detect and isolate cases, and makes the low case counts they report to the WHO suspect.

 
Oman reported its most recent MERS case three weeks ago (see Oman: MOH Announces 7th MERS Case), which was the first new case since May of last year (excluding the exported case to Thailand last June).

Also last May, two truck drivers transporting camels from Oman to the UAE were found to be asymptomatically infected (see WHO: Asymptomatic MERS-CoV Case – UAE).

In November of 2013, we looked at a study published in The Lancet Infectious Diseases, that attempted to quantify the likely extent of transmission of the MERS virus in the Middle East. (Middle East respiratory syndrome coronavirus: quantification of the extent of the epidemic, surveillance biases, and transmissibility).

They calculated  that for every case identified, there were likely 5 to 10 that went undetected.

The assumption is that most of these are mildly symptomatic patients, not ill enough to be hospitalized and tested. But when you consider that of the 9 MERS cases known to have originated from Oman - two were hospitalized and released without diagnosis - their `capture rate'  is less than enviable.

This is also a reminder that MERS (and avian flu, Ebola, Lassa fever, etc.) can turn up at any hospital's front door, anywhere in the world, without warning.  

Which is why every health care facility – large and small - needs to plan, train and equip themselves for the possibility that the next patient that comes through the ER entrance could be carrying something considerably more exotic than the flu.

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