Friday, April 18, 2014

Saudi MOH Announces 6 More MERS Cases In Jeddah (1 Fatal)


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This is the second update today from the Saudi MOH, which when added to the earlier one (see Saudi Arabia Announces 6 More MERS Cases – In Riyadh), makes an even dozen new coronavirus cases out of Saudi Arabia today.


Three are listed as asymptomatic, including 1 health care worker (age 26) and a 13 year-old.  A second health care worker (age 60) is listed in stable condition, while a 49 year-old is in intensive care.  The fatality is listed as as being 53 years of age.


Based on FluTracker’s MERS Case Line Listing, this brings to 51 the number of cases in this cluster, along with 8 deaths (or 52 and 9 if you count the religious pilgrim who died this week in Malaysia with recent travel history to Jeddah.)   Additionally, 22 (42%) are described as being Health Care Workers.



Health: Registration 6 cases of infection (Corona) new in Jeddah


In the context of the work of epidemiological investigation and ongoing follow-up carried out by the Ministry of Health for the virus, "Corona" that causes respiratory syndrome Middle East MERS-CoV, the ministry made ​​public for the registration of six new cases of the virus in Jeddah.

The first resident at the age of 53 years old has passed away, may he rest in peace.

The second citizen at the age of 49 years old and receiving treatment for intensive care, asking God his healing.

The third citizen working field of health at the age of 60 years, and his condition is stable.

The fourth resident operates the domain of health and at the age of 26 years, and has no symptoms.

The fifth resident to contact with a confirmed case at the age of 38 years, and has no symptoms.

The sixth resident Mkhalt of confirmed cases at the age of 13 years, and has no symptoms.

In this context, and in order from the Ministry of Health to provide all Avradalmojtma media and social networking guidelines of health and medical advice on HIV corona virus that causes AIDS Middle East, respiratory, and inform them of the developments around it, they invite everyone to access the link on the disease through the Ministry's website www / coronanew, or communicate via toll-free phone 8002494444 or 937 center or through the expense of the ministry in saudimoh @ Twitter

We wish for all health and safety.

KSA: Red Crescent Orders Ambulances & ERs To Accept MERS Cases



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Over the past several days there have been reports (mostly on twitter) indicating that some hospitals and/or ambulances were refusing to accept  patients with MERS-like symptoms.  Most of these tweets have been cryptic and difficult to verify, but today we have a report that appears to validate at least some of these reports.


Saudi Arabia’s Red Crescent Authority has issued orders to ambulances and emergency rooms that they must accept MERS cases, and render appropriate care. 


Unless they are attempting to solve a problem that doesn’t exist, it is reasonable to assume that there have been  at least some instances where people have been refused medical care over fears they have the MERS coronavirus.


Two reports, the first one from the Saudi Press Agency.


Red Crescent: Corona virus from within the emergency situations that must embrace.

Riyadh 18 jomada Al-akhera 1435 Ah April 18, 2014 s.p.a.

Saudi Red Crescent Authority confirmed that one of the functions of the emergency teams and centres in all regions of the Kingdom were directly infected by HIV cases/SK/so classified by the Board under emergency situations that must be carried out and provide treatment services are either on site or through transport until the injured to hospital.

The body said in a press release issued today that this action comes within the medical Protocol and emergency centres core business of body without exception.

It said the circular was all the difference in ambulatory centres or advanced air ambulance teams need to deal with all situations that are dangerous to human life and provide appropriate treatment by ambulatory teams directly, stressing that these cases can be diagnosed only after laboratory tests in the hospital.

He revealed that will stop any patient transfer ambulance squad reject suspected flu/SK/and referred for investigation and appropriate action will be taken after the completion of the investigation and announce it via the media.

He noted that emphasis was placed on all branches in the Kingdom to provide consumers and equipment such as masks and gloves and sterilization of the paramedics of the Red Crescent ambulance service to emergencies, whether a citizen or resident.

The body said in a statement that the goal is to detect any false or incorrect information is disseminated through the media or social media/new media/.


12: 17 pm


Another version of this story comes from Al Jazeera Online.



Red Crescent: We will stop work for any paramedic refuses to transfer the case of crowns

April 18, 2014 Last Updated 18:23

Stressed the Saudi Red Crescent Authority that it will halt any paramedic refuses to transfer a patient suspected wound infection (sk) from work and turn it to investigate and take appropriate action to them after the completion of the investigation with them and the declaration of the piece through the media.

Commission emphasized in a statement released today - Al-Jazeera received online copy of it - all the branches in the Kingdom of the importance of providing all the necessary hardware Kaloguenah gloves and tools sterilization of paramedics affiliates for the safety of workers in the field of ambulatory when directly these cases or other, indicating that they put the safety of their employees in the first place and foremost, but that does not absolve them from performing and humanitarian duty to save the lives of sick and injured with providing the best ambulance services for emergencies, both citizens and residents.

Authority said that the direct cases infected with HIV (Corona) of the functions of the difference ambulatory centers and affiliates in all regions of the Kingdom, noting that it is classified among the emergencies should be conducted and provide treatment services, both on-site or through the transport until it reaches the patient to the hospital.

Explained that it is through this press release, confirming the credibility and transparency of dealing him either with the beneficiaries of their services or media at the same time Authority aims to reveal any information "false" or incorrect and is published through the media or social media (new media

ECDC: MERS-CoV Epidemiological Update & Risk Assessment



Credit ECDC


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As part of their larger overall weekly Communicable Disease Threats report, the ECDC today has updated their assessment of the MERS outbreak in the Middle East. 


Middle East respiratory syndrome- coronavirus (MERS CoV) – Multistate

Opening date: 24 September 2012 Latest update: 17 April 2014

Epidemiological summary

Since April 2012 and as of 18 April 2014, 275 laboratory-confirmed cases of MERS-CoV have been reported by local health authorities worldwide, including 98 deaths and 64 healthcare workers. The following countries have reported MERS-CoV cases:

Saudi Arabia: 212 cases / 72 deaths
United Arab Emirates: 33 cases / 9 deaths
Qatar: 7 cases / 4 deaths
Jordan: 4 cases / 3 deaths
Oman: 2 cases / 2 deaths
Kuwait: 3 cases / 1 death
UK: 4 cases / 3 deaths
Germany: 2 cases / 1 death
France: 2 cases / 1 death
Italy: 1 case / 0 death
Tunisia: 3 cases / 1 death
Malaysia: 1 case / 1 death
Philippines: 1 case / 0 death

Fourteen cases have been reported from outside the Middle East: the UK (4), France (2), Tunisia (3), Germany (2), Italy (1), Malaysia (1) and Philippines (1). In France, Tunisia and the UK, there has been local transmission among patients who had not been to the Middle East, but had been in close contact with laboratory-confirmed or probable cases. Person-to-person transmission has occurred both among close contacts and in healthcare facilities.

In the first 18 days of April 2014, 57 cases (21% of total cases) have been reported, 29 of whom are healthcare workers (51%) and 21 are asymptomatic cases. In the United Arab Emirates, a cluster of 14 healthcare workers (including one case exposed in UAE and reported by the Philippines) has been reported during the past week. They all had had contact with a previously reported case, who died on 10 April 2014. Eight of the cases had mild symptoms and six were asymptomatic.

In Saudi Arabia, during the past week, 30 cases have all occurred in Jeddah, including 11 healthcare workers; five cases were fatal and eight were asymptomatic.

The first cases reported in Asia have occurred in people returning from the Middle East:

  • The case from the Philippines is an asymptomatic healthcare worker returning from the United Arab Emirates.
  • The case in Malaysia was in a 54-year-old man who returned from Saudi Arabia after Umrah on 29 March 2014. He developed symptoms (fever, coughing) around 8 April 2014. On 10 April 2014, he was admitted to hospital and died on 13 April 2014. The Malaysian health authorities are conducting prevention and control activities including monitoring close contacts of the case.

ECDC assessment

The source of MERS-CoV infection and the mode of transmission have not been identified, but the continued detection of cases in the Middle East indicates that there is an ongoing source of infection in the region. Dromedary camels are likely an important host species for the virus, and many of the primary cases in clusters have reported direct or indirect camel exposures. Almost all of the recently reported secondary cases, many of whom are asymptomatic or have only mild symptoms, have been acquired in healthcare settings. There is therefore a continued risk of cases presenting in Europe following exposure in the Middle East and international surveillance for MERS-CoV cases is essential. An international case-control study has been designed and proposed by WHO. Results of this or similar epidemiological studies to determine the initial exposures and risk behaviours among the primary cases are urgently needed.

The risk of secondary transmission in the EU remains low and can be reduced further through screening for exposure among patients presenting with respiratory symptoms and their contacts, and strict implementation of infection prevention and control measures for patients under investigation. The case detected in Malaysia last week had participated in the muslim pilgrimage Umrah. However, more details are needed on possible and suspected exposure events and it is possible that these cases were also infected when visiting healthcare facilities in the region.

The Malaysian authorities have asked all passengers travelling on the flights with the case detected in Malaysia on 29 March to be screened for health complaints.

The Philippines authorities have asked all passengers travelling with the Filipino case detected on 15 April to be screened for signs and symptoms of MERS-CoV infection, while the department of health is also actively contact tracing passengers.

(Continue . . . )

Saudi Arabia Announces 6 More MERS Cases – In Riyadh




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While we’ve been focused on the Jeddah cluster in Saudi Arabia, it wasn’t so very long ago (April 9th) when the capital city was the focus of most of their recent MERS cases.  Over the past 10 days KSA has announced 39 consecutive cases from Jeddah, but today we once again turn our attention toward Riyadh.


Today’s update revolves around five cases currently in intensive care, and a single fatality.  There is no mention of onset dates, routes of exposures, or occupations in this update.


Health: Registration 6 cases of infection (Corona) in Riyadh new


In the context of the work of epidemiological investigation and ongoing follow-up carried out by the Ministry of Health for the virus, "Corona" that causes respiratory syndrome Middle East MERS CoV Ministry announces the registration of six cases in Riyadh.

The first citizen at the age of 81 years is suffering from several chronic diseases, and is currently receiving treatment in intensive care.

The second is a citizen at the age of 32 years and also suffers from several chronic diseases, and is still receiving treatment in intensive care.

The third case was a citizen at the age of 78 years, as well as suffering from several chronic diseases where currently receiving treatment in intensive care.

But it is the fourth case of a resident at the age of 52 years and also suffers from several chronic diseases, is still receiving treatment in intensive care.

As for the fifth case it is also a resident at the age of 27 years old and suffers from a chronic disease, and is currently receiving treatment in intensive care, ask God healing them all.

The sixth case and they are resident at the age of 55 years, has died Ngmayora he rest in peace, where she was also suffering from chronic diseases.

In this context and in order from the Ministry of Health to provide all Avradalmojtma, media and social networking guidelines of health and medical advice on HIV corona virus that causes AIDS Middle East respiratory and inform them of the developments around it, they invite everyone to access the link on the disease through the Ministry's website www.moh / coronanew, or communicate via toll-free phone 8002494444 or 937 center or through a link saudimoh @ Twitter to get the information required.

God save our country from all evils.

The MERS Hospital Cluster Puzzle


R0 (pronounced R-nought) or Basic Reproductive Number.

Essentially, the number of new cases in a susceptible population likely to arise from a single infection. With an R0 below 1.0, a virus (as an outbreak) begins to sputter and dies out. Above 1.0, and an outbreak can have `legs’.


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Two months ago, in mBio: Spread, Circulation, and Evolution of MERS-CoV, we looked at a study that focused on the evolutionary changes in the MERS coronavirus since its introduction to the human population, and its apparent efficiency in transmitting between humans.


At the time, based on 180 human cases reported over roughly 18 months, the authors determined that the MERS virus had an R0 of less than 1.

In other words, it wasn’t spreading efficiently enough to sustain an ongoing epidemic.

They warned, however, that over time evolutionary pressures could allow the virus to better adapt to human hosts, writing:


MERS-CoV adaptation toward higher rates of sustained human-to-human transmission appears not to have occurred yet. While MERS-CoV transmission currently appears weak, careful monitoring of changes in MERS-CoV genomes and of the MERS epidemic should be maintained. The observation of phylogenetically related MERS-CoV in geographically diverse locations must be taken into account in efforts to identify the animal source and transmission of the virus.


Fast forward 60 days, and suddenly we are seeing at least two large clusters of MERS – one in the UAE (12 cases) and the other in Jeddah, Saudi Arabia (45 cases) – and of particular note, both involve a large number of healthcare workers. 


A cohort that, at least in theory, should be practicing stringent infection control protocols. 


While we don’t have the specifics on the source of the initial infection or the subsequent chain of transmission in either cluster, their size and duration are at least suggestive of more robust transmission. 


Dr. Ian Mackay’s chart from earlier this week (see below) illustrates this sudden jump in cases counts in KSA and the UAE. 



All of which begs the $64 question: Has something changed with the virus?


It is a question raised by Dr. Michael Osterholm – Director of CIDRAP - yesterday (see Osterholm & Mackay On MERS), and one that has been on the minds of many watching the evolution of these two large clusters.


Definitive answers to that question may be some time in coming, as it will require detailed genetic analysis and an in-depth epidemiological investigation to establish the facts. It isn’t, however, the only possible explanation.

Another possibility is that we are seeing a couple of `super spreader’ events, reminiscent of what was seen in Al-Hasa a year ago (more on that later). 


During the SARS epidemic of 2003, we know that transmission of that coronavirus was typically fairly inefficient.


An infected person might only infect 1 or 2 additional people, and sometimes none.  But a small percentage of those infected were far more efficient in spreading the disease, with some responsible for 10 or more secondary infections.

This super spreader phenomenon gave rise to the 20/80 rule,  that 20% of the cases were responsible for 80% of the transmission of the virus (see 2011 IJID study Super-spreaders in infectious diseases)


Last year, for the 10 year anniversary of the SARS epidemic, the CDC authored a review of the outbreak called Remembering SARS: A Deadly Puzzle and the Efforts to Solve It.   While the whole article is a good read, I’ve lifted some excerpts from the section entitled: Solving the Mystery of “Super Spreaders”.

In the 2003 outbreak, in some instances outside the United States, a single SARS patient infected large numbers of people. At the same time, other patients did not infect people who came in contact with them. 

Researchers found that the virus was typically spread from person to person by large droplets (less efficient spread because it would be too big to linger in the air); however, at other times, clusters of illness suggested aerosol spread (where the virus can linger in the air longer after an ill person coughs) causing more spread of infections from a single sick person. 

CDC investigated the so-called “super spreaders.” They wanted to know if there were differences in when and for how long people ill with SARS might shed the virus, making them contagious to others. In the past, super spreaders had been documented during other disease outbreaks such as rubella, tuberculosis and Ebola. A common feature of super spreaders was that hospitals served as a source for the disease to widely infect others.


Last summer, in Branswell:The NEJM Saudi MERS-CoV Cluster Report, we looked at a review of the  hospital associated cluster involving 23 cases in the Al-Hasa region, occurring between April 1st and May 23rd. 


Helen Branswell’s report, which is still online, discussed the `super spreader’ angle.


Saudi MERS outbreak showed SARS-like features, including possible superspreader

Helen Branswell, The Canadian Press Jun 19, 2013 05:00:17 PM

TORONTO – A long-awaited report on a large and possibly still ongoing outbreak of MERS coronavirus in Saudi Arabia reveals the virus spreads easily within hospitals, at one point passing in a person-to-person chain that encompassed at least five generations of spread.

The study, co-written by Toronto SARS expert Dr. Allison McGeer, also hints there may have been a superspreader in this outbreak, with one person infecting at least seven others.

(Continue . . . )


As was common with SARS, and featured in the Al-Hasa report above, we are once again seeing the familiar pattern of unusually large clusters centered around health care facilities. 


Whether they signify an evolutionary change in the virus, the effects of `super spreaders’, or a combination of both  - or perhaps some other dynamic - is impossible to tell at this point.


All we can say right now is that the pattern of disease spread appears – at least temporarily, and in these two locations - to have changed in recent weeks, and that it bears watching.


As Dr. Osterholm said yesterday, we are definitely in a `stay tuned’ moment.

Thursday, April 17, 2014

Osterholm & Mackay On MERS


Coronavirus – Credit CDC PHIL


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Epidemiologist Michael Osterholm – Director of CIDRAP and Professor Ian Mackay – Virologist at the University of Queensland (and editor of VDU blog) are two of the smartest people I know when it comes to emerging infectious diseases. 


Today both voiced their concerns to AP reporter Adam Schreck, who penned a report on the growing MERS outbreak in the Middle East.


You’ll find a link, and the opening paragraph below. Follow the link to read about what Mike calls `a stay tuned moment’ in the ongoing epidemiological investigation.


Spate of Mideast Virus Infections Raises Concerns

DUBAI, United Arab Emirates April 17, 2014 (AP)

By ADAM SCHRECK Associated Press

A recent spate of infections from a frequently deadly Middle East virus is raising new worries about efforts to contain the illness, with infectious disease experts urging greater vigilance in combatting its spread.


More than 20 people, many of them health-care workers, have been reported infected with the Middle East respiratory syndrome coronavirus in two distinct clusters — one in Saudi Arabia and the United Arab Emirates — likely involving human-to-human transmission since early last week.

(Continue . . .)