27 countries have seen a MERS-CoV case with Bahrain's addition...

13 of those 27 have had local transmission.

The Bahrain-diagnosed infection was likley acquired from a camel in his dromedary camel farm in Saudi Arabia.

Click to enlarge.

Colombia...no recent confirmed Zika virus positives or reporting lag or...?

UPDATE #1: 24APR2016

Okay. Let me rephrase an issue I had from one of my posts yesterday-the one looking over the Colombian data. The relevant text was...

"I'm still not clear how the tally of confirmed cases is rising, but not showing up on the Colombian NIH graph (the red bars; the grey ones are clinical suspected cases). 

I've excised and posted the Colombian NIH graph to the left. 458 cases this week should show up clearly using that axis - it was the second biggest tally, just below Week No. 8 (also missing?) and 1.6X bigger than Week No. 4 which has been plotted and shows up clearly. I'm just assuming that the graph person has forgotten but would love to know if there is something else going on."

Below I've excised the relevant graphs from the most recent epidemiology report (Week No. 13 [2]) and also the one that first plotted confirmed alongside suspected Zika virus (ZIKV) cases (Week No. 11 [1]).

You can in fact see that the red bars have grown over the 3 week period - but that none of the 700 confirmed cases reported over that time have visibly made it into a bar after Week No. 5. So my question is whether that means:

1. no newly confirmed ZIKV cases have been detected/become ill during the past 8 epidemiology weeks (keeping in mind that Week No. 13's report only reports data to 02APR2016)
2. there is an 8-week lag in getting lab data into these reports?
3. Someone forgot to update the graphs
4. Colombia is no longer testing for ZIKV

 ..or perhaps something else altogether?

Week No. 11.
Data from [1]

Week No. 13.
Data from [2]

The lag seems to be the leading theory so far (see Tweet below)...but that's quite a lag. 

@MackayIM @INSColombia graph reflects adjusted reported cases per wk. not #s on table. "New" confirmed may be old. Wk12 only 1,100 on graph

— Gabby Molinolo (@gabby_molinolo) April 10, 2016

I find it strange that no-one seems to be critical of the testing lag here and yet it was the topic du jour for MERS in the Kingdom of Saudi Arabia. 

Is it simply about the perception of resources - the Americas are perceived as resource-poor and the Saudis as resource abundant? 

In the area of lab testing, I'm not at all convinced that the Saudis were at all resource rich though. I don't think they were in any better position at the start of their outbreaks. Especially if the resource we measure is understanding about testing to understand the aetiology of an emerging infectious disease.

References...

1. http://www.ins.gov.co/boletin-epidemiologico/Boletn%20Epidemiolgico/2016%20Bolet%C3%ADn%20epidemiol%C3%B3gico%20semana%2011.pdf
2. http://www.ins.gov.co/boletin-epidemiologico/Boletn%20Epidemiolgico/2016%20Bolet%C3%ADn%20epidemiol%C3%B3gico%20semana%2013.pdf

Updates...

1. Added a new 3rd option which was not carried over from the orginal post 10APR2016  - and pushed the previous 34rd to 4th

Middle East respiratory syndrome coronavirus kicks off...

Click on it.
It gets bigger!

The next wave of MERS-CoV cases is well underway in the Kingdom of Saudi Arabia (KSA). 

Since 2012, 1,702 MERS-CoV detections have been reported in humans from 26 countries around the world.

Click to expand.
Graph captured from [3]

The first reported MERS cases appeared on our radar via an eMail to ProMED sent September 20th 2012.[1] That person became ill in April 2012 and some others, found later, were ill in March 2012 [2] - so we're smack dab into our 4th "disease onset birthday" right now. 

Each year we news and number watchers, wonder aloud about the course that MERS-CoV might plot. We don't predict it though - that would be dumb. No-one can know where things may go because that's all based on human behaviours, oversights and mistakes. And who knows how, how many, how often, why or when those will occur?

MERS-CoV is very much a human problem - it's a particularly opportunistic virus which causes it's biggest impact when we create the conditions for it to spread among vulnerable people in health care settings.  Whether or not that whole process will play out again in 2016 is anyone's guess. As I noted in my last post, it has already happened to some degree in Buraidah in the Al Quassim province of KSA. The KSA is - if you are new to MERS-CoV - the country in which 80.4% of infection have been acquired. Word oen the Tweet is that the outbreak is under control now.

@HelenBranswell Because I am closely following the situation as general director of IPC. No evidence of transmission for several days.

— هايل العبدلي (@habdely) March 13, 2016

I've updated my graphs, tallies and charts with the latest numbers now, so feel free to click on the MERS-CoV tab above to see where we're at.

And don't forget - an outbreak of an infectious disease in one country has the potential to be an outbreak in any country. Just add human behaviour.

References...

1. http://www.promedmail.org/direct.php?id=20120920.1302733
2. http://www.zeit.de/wissen/2014-05/mers-fall-2012-paper.pdf
3. http://virologydownunder.blogspot.com.au/2014/08/mers-cov-daily-monthly-and-cumulative.html

Tread carefully when MERS-CoV stirs in hospitals as it can spiral out of control quickly..

In 2014 a stepwise increase in Middle East respiratory syndrome coronavirus (MERS-CoV) cases preceded the largest healthcare facility outbreak of MERS to date. 

If you look at the most recent daily Kingdom of Saudi Arabia (KSA) Ministry of Health report below,[1] you could be forgiven for thinking that there is currently a threatening rise in cases which could easily spiral out of control once again unless it is quickly stepped on.

Adding fuel to the fire is the fact that in Buraidah, in the province of Al Quassim , there has clearly been a healthcare-associated outbreak ticking over since November 2015 - patients, healthcare workers and relatively little camel contact make for a pretty clear picture.
When these fires are let smoulder in this way, they can quickly spread embers across the region and then cases fly out to other ports.

A week ago there were 8 cases reported in a day. That's far from the biggest reporting day we've seen in 3 MERS years (around 31 cases in a day n April '14), but it's still high. There have been 11 consecutive days with 2 -8 cases reported each day. The region in the map above has been the hotspot, but in the 12-March report there were 4 cases, each in a different city. 

There have also been an usually high number of camel mentions so far this MERS season. We do not usually see so many consecutive cases reported to have some form of camel contact. These are from cases across the KSA but also from United Arab Emirates- and Oman-acquired cases too. Is this because of a better understanding and acceptance of the role of camels in spreading MERS-CoV to humans, after research really hammered home the facts, or is it that more camels are infected, or there are more infected herds this season, are other animals becoming infected, or is it that, for some unknown reason, there is more contact between humans and infected camels/other animals this season?

There have been no viral gene or genome sequences from 2016 arriving on the interwebs yet, so we are left with a few of the old questions...again

• is this all normal or is something different this time around?
• has this season's MERS-CoV undergone a significant genetic change(s), affecting stability, tropism or transmission?
• has infection control and prevention slipped again?
• is there more contact with infected camels this year?
• are increased camel descriptions an indication of better surveillance and questioning about camel contact?

Time to start watching and plotting MERS-CoV again.

References...

• http://www.moh.gov.sa/en/CCC/PressReleases/Pages/statistics-2016-03-13-001.aspx

It was the camel, in the library, with the MERS-CoV...

In a paper out overnight, which is assigned to the January 1st 2016 edition of Emerging Infectious Diseases (why do you do this to us EID?!), Alraddadi and colleagues (overwhelmingly from the Kingdom of Saudi Arabia with help from the Centers for Disease Control and Prevention in the United States) have published Risk Factors for Primary Middle East Respiratory Syndrome Coronavirus Illness in Humans, Saudi Arabia, 2014. 

This is a long awaited case control study. Long awaited.

From [2]

It tells us that direct contact with dromedary camels (including the act of milking them) in Saudi Arabia, in the 2 weeks prior to symptoms ascribed to a confirmed MERS-CoV infection, is a significant risk factor for developing Middle East respiratory syndrome (MERS) disease. Cattle contact also fell out as a significant risk. 

However, cases were no more likely than controls to report exposure to bats, goats, horses, sheep or consumption of fruits, vegetables, or animal products, including uncooked meat, unpasteurized animal milk, or dromedary urine. 

The study also reminds us that the host factors of diabetes, heart diseases and smoking are associated with MERS (the disease, not how likely you are to get infected). If you do not have these then you may be more likely to have mild or asymptomatic outcomes if you were to be exposed and infected by MERS-CoV.

These are astounding findings that will take many by surprise and revolutionize out understanding of MERS (the disease) and MERS-CoV (the virus) throughout the Arabian Peninsula. 

Said no-one. Ever.

Ridiculous sarcasm aside though, much kudos to the Saudi research community! This case-control study, a long-awaited piece of work, was a camel that had to be broken by them for them, and now it has been. A win for science and for the region's science.

I hope the study helps to confirm the sizable pool of research that has come before.

But let's not lose sight of the camel in the room; most human cases of MERS come from other human infections closely associated with healthcare settings.

Defeating MERS and MERS-CoV requires battles on many fronts. As usual for any emerging viral disease. 

But then, it's a OneHealth kinda world.

References...

1. http://wwwnc.cdc.gov/eid/article/22/1/15-1340_article
2. http://virologydownunder.blogspot.com.au/2014/05/camels-at-centre-aerosol-all-around.html

Can MERS-CoV be found in the upper and lower respiratory tract of infected camels? You bet your single hump it can!

Today's review is of a paper listed as published in Emerging Infectious Diseases in July 2015, authored by Khalafalla and colleagues from King Faisal University in the Kingdom of Saudi Arabia and from the CDC in the United States of America.[1]

Al Omran City (also Al Umran) city is located 
just adjacent to Al Hofuf on this map.

The introduction tells us that bats "seem to be the reservoir host" but are not the likely ongoing source of human Middle East respiratory syndrome (MERS) cases in the KSA. An assumption based on the finding of 1 small yet diagnostic MERS-CoV sequence in 1 bat from 1,003 samples, once.[5,6] It also reminds us that up to this point in time, camels were mostly sampled from the nose and eye during MERS-CoV investigations. We still didn't know whether other parts of the camel respiratory tract could test positive for MERS coronavirus (MERS-CoV). This is important knowledge as it pertains to virus transmission from camel-to-camel and camel-to-human.

This study focused on the dromedary camel (DC; Camelus dromedarius) collected samples
from around the Al-Ahsa area. These comprised two sample populations collected during a year (April 2013-May 2014):

1. Tissue from at least lung lobe of camels slaughtered at the Al Omran Abattoir, Al Omran City. Animals were kept in groups of 10-15 for up to 4 days in stock markets prior to slaughter
   ..8 batches of samples were collected (a batch every 1-2 months) from 91 carcasses in total
   ..28 young animals (<4 years of age) and 63 adult animals (4 or more years old) were sampled
2. Over the same period, age-matched nasal swab samples were collected from Al Omran abattoir, Al Ahsa livestock market and the King Faisal University veterinary hospital
   ..96 animals were swabbed; 36 young animals and 60 adults
   ..only 2/94 animals were visibly unwell - the 2 had nasal and lacrimal discharge

Samples were tested by a pancoronavirus conventional RT-PCR assay [4] as well as two real-time RT-PCR assays [2,3] No culture of virus was attempted so we must extrapolate from the RT-PCR findings to assume a positive finding of MERS-CoV RNA represents replicating virus-at some point during the infection anyway (a safe assumption).

The findings...

• 84 of 187 DCs (44.9%) tested positive, most often during the cooler months (NOV2013-JAN2014) and more often from young camels than adults
• 59 of 91 (61.5%) DC carcasses had MERS-CoV RNA detected
• 28 of 86 (29.2%) nasal swabs were positive
• 4 samples yielded a spike gene sequence-these differed from each other but clustered with other human and camel MERS-CoV spike gene sequence

The authors are clearly not exuberant that their findings have shed much new light on the camel>human debate and call for longitudinal studies to better understand how MERS-CoV spreads among DCs. A good suggestion indeed. 

Nonetheless, this study adds pieces to the story; DCs appear to be infected throughout their respiratory tract, not just at the openings usually swabbed. And if the seasonality of MERS-CoV in DCs hinted at by this study at this locale, does not overlap perfectly with human cases at the same time and place, that is most likely because camel>human infections are very rare. Also this mismatch is likely because most human infections are not due to camel/human interactions, but are acquired from human-to-human infections, thanks to errors in the management of a sick index case. That case's uncontrolled infection is what usually results in many other patients, healthcare workers and visitors becoming infected. 

That's the camel in the room that seems to be overlooked so frequently. 

Another thing that seem lost in translation - MERS itself is a relatively rare human disease and when you consider that camel>human transmission is only a fraction of that.... 

Some seem to think that lots of infected camels must equate to lots of infected humans if this crazy theory about camels being the source of human cases is to be believed. Sorry. Not the case (unless reported contacts are much more frequent than we are being told). 

There are definitely human MERS-CoV infections who only had DC, not infected human, exposures. Unarguably we do need to do better to try and catch transmission 'in the act' and show how it happened in order to dot the 'i' and cross the 't'. The same also applies to a lot of zoonoses. Until those breakthroughs though - we have a lot of data which can be used to better protect people from getting infected by MERS-CoV. 

Seems pretty dumb to wait on more convenient data while people still get infected, become sick and often die.
On balance, separating camels from humans, being better protected when in contact with camels, and improving infection prevention and control in hospitals may even obviate the need for vaccination. Gasp.

References...

1. MERS-CoV in Upper Respiratory Tract and Lungs of Dromedary Camels, Saudi Arabia, 2013–2014Abdelmalik I. Khalafalla, Xiaoyan Lu, Abdullah I.A. Al-Mubarak, Abdul Hafeed S. Dalab, Khalid A.S. Al-Busadah, and Dean D. Erdman
   http://wwwnc.cdc.gov/eid/article/21/7/15-0070_article
2. http://www.ncbi.nlm.nih.gov/pubmed/23041020
3. http://www.ncbi.nlm.nih.gov/pubmed/24153118
4.  http://www.ncbi.nlm.nih.gov/pubmed/19057882
5. http://wwwnc.cdc.gov/eid/article/19/11/pdfs/13-1172.pdf
6. http://virologydownunder.blogspot.com.au/2013/08/mers-cov-genetic-sequences-found-in.html

MERS and the media in Saudi Arabia - a match that fuels confusion....

I'm interrupting my reviews on MERS and camels to briefly critique a recent media article published in the Arab News, Wednesday 14th of October. This was also on camels, but a view into the other side of this story.

The title of the article: ‘No conclusive proof’ camels spread MERS: Expert.[1]

There are two trains of thought here - and perhaps I have not clarified them so far. The first train doesn't believe that camels have a role in human cases of MERS-I disagree completely with the sentiment here. The second train of thought wants more testing of more and different animal species. I agree with this wholeheartedly. And those who can do this should be getting on with the job of doing it or organising those who can do it instead of wishing the data we absolutely do have, were different.

Let's keep in mind that seeking out other sources is a research endeavour. You cannot write public health messaging around things for which you have absolutely no supporting evidence. You can't protect your population, especially those most at risk, if you don't have proof to support how they are at risk. Looking after the public's health requires data. Research gets those data. Support the research. Look at those data instead of ignoring them because they scare you, point a finger at your favourite animal or conjure fears of an animal-driven negative economic impact. 

Distancing humans from infected camel vectors is a here and now action. It is not the result of a future research study. Finding ways to act on the data may have an impact on cases. 

Rather than guess at what people's concerns are - let's have a read of some key sections of this article, and comment as we go.

"There is no conclusive evidence that shows camels are responsible for the spread of the deadly Middle East Respiratory Syndrome coronavirus (MERS-CoV), according to research conducted by a Saudi expert at King Saud University in Riyadh."

• This is plain wrong. There is considerable body of peer reviewed scientific literature providing evidence both for spread among camels and between camels and humans, even data strongly suggesting that direction (camel>human). A review I co-authored last year goes into a lot of that detail - it has a huge table on the camel related literature.[2]

“All the studies published in scientific journals do not at this stage show that the blood samples taken from camels have the virus present."

• This is an English language article so I am going to take that at face value. Virus in the blood, or viraemia, is not considered a major concern for spread human or camel MERS-CoV infection - the real and larger concern is virus, in high amounts, that is regularly identified in the nose of infected camels. This is quote is not evidence of an expert comment.

"The reality is that more than 80 percent of the tested samples prove that camels’ blood carry protective antibodies against the virus,” he said."

• Again, this comment highlights a lack of expertise in virology or immunology. Fields important for this discussion. The camels have antibodies because they have been previously infected. Research has found that camels seem capable of being reinfected - infected again even when they already have antibody from a previous infection. These camel antibodies may not be protective. Cell mediated immunity (h/t @MarionKoopmans) may be an important study subject here to better understand what happens in camels.

"He said some studies have found that 5 to 6 percent of shepherds and persons dealing with camels carry antibodies against MERS, and do not have the virus itself."

• This is where a science reporter would have been really helpful to Arab News. Shepherds (camel herders?) don't have the virus by the time they develop antibodies because, like many viruses, MERS-CoV causes a short-lived, or acute, infection in humans and camels. Those few percent of shepherds with antibodies were previously infected and the virus was subsequently cleared by their immune system, usually near to or before those antibodies develop.

“In our previous studies we found out that Heavy Chain Antibodies are present in the blood of camels and are carried out with its milk. This research was published in the Journal of Proteomics. This in itself proves that immunity is transferred from camels to humans,” he said."

• This does no such thing at all. This shows that antibodies are in camel blood and milk - if indeed that was what was found. What are the previous studies that showed these antibodies were ingested by humans and survived the digestive tract to remain effective against MERS-CoV? There are none that I have read but I'd be interested in seeing them.

Science tests and measures, it calculates and concludes. Very little of that process is evident here, but a sense of the confusion around this topic is. These stories should be great starting points for the Saudi Ministry of Health to work up local, relevant and specific answers, (more) factsheets or Ministry-involved media interviews and internet posts to help educate those with concerns about there camels. Listen, communicate, take feedback, re-tune, communicate, listen....

References...

1. ‘No conclusive proof’ camels spread MERS: Expert
   http://www.arabnews.com/featured/news/820181
2. Middle East respiratory syndrome: An emerging coronavirus infection tracked by the crowd.
   http://www.ncbi.nlm.nih.gov/pubmed/25656066

Corona counts continue to clarify...

From Mackay & Arden [1]
Click on image to enlarge

The Kingdom of Saudi Arabia's (KSA) Ministry of Health (MOH) has, over the past week, made a few changes to its Middle East respiratory syndrome coronavirus report layout. Good changes. Nice additions. And I say bravo. In fact - as we've said in the scientific literature [1] - the KSA data are far better than  those we have seen from other recent emerging infectious outbreaks. In particular, China's efforts for the avian influenza A(H7N9) virus cases over many months or Egypt's communication about its avian influenza A(H5N1) virus outbreak(s), have been relatively simplistic, uninformative and hidden from public view, by comparison.

Since the 17th of September, the reports have been undergoing constant change. These range from the subtle tweaks in colour, the addition of pie charts (I particularly like the strong colours in the latest!), inclusion of a marker to identify an asymptomatic MERS-CoV positive sample (are these now included as a "cases" by the MOH?) and the breakdown of how MERS-CoV positives were likely to have acquired their infection.  

Some things I'd still very much like to see added...

1. In the 'Deaths' table, a column for the date that the deceased person was first described by the MOH - that is, the reporting date. Currently there is not always enough information to go back and say with conviction which e.g. "60 year old male Saudi from Riyadh" died when there may have been several cases with the same description, listed over the preceding days and weeks (even months as some MERS cases have been hospitalised for a very long time before eventually dying of complications)
2. The number of samples tested each week, as listed by the Infection Prevention and Control-KSA webpage
3. Details added retrospectively for those 'found' cases. Those data are clearly in the system somewhere as they were summarised back on the 3rd June 2014 [4] and the 18th September 2014. This would be a nice 'rounding off' of all the data to date.
4. An explanation for what constitutes a "primary case". Currently, the suggestion is that over a third of cases are primary cases. To my mind, after excluding healthcare acquisition, this implies infection from animals. But only a touch over 7% (91 of over 1200 virus detections) of cases reported publicly have any animal contact described. So what does a primary case" mean to eh KSA MOH?  
5. A single, regularly updated and downloadable line list of these deidentified detections, each with a unique identifier, for all 1200+ detections (akin to what the World Health Organization did for the South Korea cases...but better). This would be a resource that could be of use to future publications (which should cite the source appropriately), conversations whereby we could all discuss the same case using the same code, for student projects and for those number nerds the world over

Screen captures from the KSA MOH Command and Control Centre (CCC)[2]
Date of report is shown below each screen capture.
Compiled using Adobe Photoshop
Click on image to enlarge

But that little wishlist aside, it is fantastic to see this response from the MOH. I have no problem at all with the formats changing, even if it is day by day by day. I'm just happy to see a responsive data sharing outlook. And the willingness to put these changes up, and leave each version in public view is also a promising sign of openness from the MOH. There is nothing wrong with showing the process.

These website is becoming a great example of how we can and should communicate outbreak data in the future.

References...

1. The Middle East respiratory syndrome puzzle: A familiar virus, a familiar disease, but some assembly still required
   Mackay IM, Arden KE. J Infect Public Health. 2015 Sep-Oct;8(5):405-8. doi: 10.1016/j.jiph.2015.07.001.
   http://www.ncbi.nlm.nih.gov/pubmed/26278813
2. http://www.moh.gov.sa/en/CCC/pressreleases/pages/default.aspx
3. http://www.gdipc.org/
4. http://www.moh.gov.sa/en/CCC/PressReleases/Pages/mediastatement-2014-06-03-001.aspx
5. http://www.moh.gov.sa/en/CCC/PressReleases/Pages/Statistics-2014-09-18-002.aspx

Happy 3rd birthday Middle East respiratory syndrome coronavirus (MERS-CoV)...

It has been 3-years since Prof. Ali Mohamed Zaki sent his email to ProMED notifying them, and the world, of a novel coronavirus (15-Sept-2012). That email was published 20-Sept 2012.[1,7,8] 

Two years ago at this time we had 138 cases and 58 deaths, last year 856 cases with perhaps 306 fatal (36%). Today, we have heard of 1,588 cases worldwide of which at least 551 (35%) have been fatal.[2,3] A higher proportion of fatal cases occur in the Kingdom of Saudi Arabia (KSA) than were recorded in the 2015 South Korean outbreak. The type and extent of a nation's community that has comorbidities may play a role in these differences. The young seem nearly untouched by MERS. To date, 26 countries have harboured a MERS-CoV infected person and 13 of those have hosted ongoing transmission.[4]

Thankfully, the diagnostic tools described very early on are as useful today as they were in 2012.[5,6]

Three years on we still see no sign of that virus patenting issue manifesting into a real problem.[3] 

For me, this past year in MERSville has been about:

• How amazing it was that MERS cases didn't occur during or as a result of one of the world's largest mass gatherings, the Hajj. Really. Amazing.
• The absence of asymptomatic cases included in reporting from KSA. The World Health Organization's (WHO) definition of a case does not rely on the presence of symptoms but on the presence of virus or past viral infection. Withholding or not seeking these data produces an overstated value for the proportion of cases that die from infection and could confound efforts to interrupt transmission during an outbreak. In reality, the higher percentages may just be what we should expect among infection of older males and females with one or more comorbidities
• The continuing appearance of large hospital-based MERS-CoV outbreaks driven by circumstances we create through unsatisfactory understanding of respiratory viruses, as well as poor preparation for their arrival in an emergency department. This occurred again in South Korea and Riyadh over the past year as it did in Jeddah the year before. In South Korea, the financial, economic, social and trust impacts were significant; communication once again a big loser from public health authorities and governmental agencies
• The big question over our MERS-CoV antibody detection tools' capabilities. Can they detect the prior presence of a MERS-CoV infection when that infection did not result in symptoms in its human hosts, or caused only very mild symptoms? A 4-week study enrolling the contacts of confirmed cases and collecting daily nose/throat swabs, weekly bloods, filling in a daily symptom and temperature diary, followed by an 8-week blood sample, would help address this I think
• Slow acceptance that camels are the main, albeit sporadic, source of MERS-CoV spillover infections of humans. Bats may have been involved in the distant past but for 30 or more years we have strong data to say that a MERS-CoV (or closely related virus) has resided in and spread among dromedary camels in Africa and or the Arabian peninsula causing mostly a 'common cold' like upper respiratory tract illness. The precise role of importation on moving MERS-CoV around the region remains poorly explored
• Other animals, on paper, look like they could host MERS-CoV, but experimental infection studies are still lacking. Similarly, a camel birth cohort study (h/t @newprof1) would add additional information to the story of how this virus spreads between camels in herds or holding pens after importation or during festivals
• We did not see any resolution to the missing data from 2014 - despite assurances from the KSA MOH.[12] Comprehensive data on cases that were just 'found' - remained incomplete.[11] Also, trying to identify deaths from among previously announced MERS cases is a task fraught with frustration, despair and dismay. And then there are the unexplained errors and differences in reporting when comparing MOH data to World Health Organization data. Yes, those cases that are reported are likely to be the tip of an iceberg of indeterminate size, but at least get right what is being reported-or...GASP...fix it up later
• It was reported that among those humans listed as being 'asymptomatic' - over three quarters of such cases, when later interviewed, recalled having symptoms.[6] This, to me, casts a darker shadow over the quality of other clinical and epidemiology data too
• We still have not seen any data from the testing of human samples, prospectively or retrospectively, from non-Arabian countries that play host to high numbers of MERS-CoV antibody-positive camels, for example, Egypt, Sudan, Somalia or Ethiopia
  
• In the past year we learned that MERS-CoV variants, like other CoV variants, can recombine when multiple variants co-infect the same host (probably in camel herds but perhaps in crowded hospital outbreaks in places like Riyadh which appears to be a nexus for mixing of variants [13,14]) producing a new variant.[9,10] To date there has been no proven impact on clinical presentation or course, virus reproduction or immunomodulation or transmission. But have wee looked hard enough lately? While it is not immediately obvious from observing whole genome sequences - most of the kind of sequencing produced since MERS-CoV was discovered - sites of recombination can be predicted when we look with more specific software tools. Yet, what happens if this recombination happens between a contemporary human/camel variant and a more ancestral camel variant? Could the resultant recombinant virus change in transmissibility or become more or less clinically severe? Is that recombination scenario even possible? Are even older bat variants too genetically distinct to allow easy recombination? It is important we find out more about the diversity of MERS-CoV and CoVs among camels outside the Arabian Peninsula and seek them out in other animals there too. Just as it is important to measure what is happening in people there
• Advances in therapeutic antibody preparations and in vaccine candidates. It remains to be seen whether camels will respond as immunologically required for a camel-based vaccine to prove effective, but as Ebola virus disease showed us, there is obvious benefit to having a ready-to-deploy arsenal of weapons in case of invasion by a viral foe that just 'shouldn't be capable of doing that thing'

It would be stupid to predict what will happen with MERS and MERS-CoV in the next 12 months. We can take some educated guesses though. 

But for now the focus is still largely on what the KSA will do about the problem on their doorstep. It may also be that MERS-CoV cases are percolating outside the Arabian Peninsula without our knowledge. Let's not leave this virus to its own device any longer. Let's act to make sure it doesn't comes back to bite us. The clues are all there. There are patterns that are clearly visible. Let's get the work done ahead of the panic for a change. How about we meet back here this time next year, same batch channel, same camel topic?

References...

1. http://www.promedmail.org/direct.php?id=20120920.1302733
2. https://flutrackers.com/forum/forum/novel-coronavirus-ncov-mers-2012-2014/146270-2012-2015-case-list-of-moh-who-novel-coronavirus-mers-ncov-announced-cases?t=205075
3. http://www.who.int/csr/don/17-september-2015-mers-saudi-arabia/en/
4. http://virologydownunder.blogspot.com.au/2015/09/mers-around-world.html
5. http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20285
6. http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20334
7. Happy 1st birthday Middle East respiratory syndrome coronavirus (MERS-CoV)
   http://virologydownunder.blogspot.com.au/2013/09/happy-1st-birthday-middle-east.html
8. Happy 2nd birthday Middle East respiratory syndrome coronavirus (MERS-CoV)...
   http://virologydownunder.blogspot.com.au/2014/09/happy-2nd-birthday-middle-east.html
9. http://biorxiv.org/content/early/2015/06/12/020834
10. http://mbio.asm.org/content/6/5/e01280-15
11. http://virologydownunder.blogspot.com.au/2015/03/where-did-mers-cov-comorbidity-and.html
12. http://virologydownunder.blogspot.com.au/2014/09/mers-cov-data-request-response-from.html
13. http://www.ncbi.nlm.nih.gov/pubmed/24055451
14. http://mbio.asm.org/content/5/1/e01062-13.abstract

MERS around the world...

China was the 26th country to host a MERS-CoV infected person, when a 44-year old symptomatic male (onset 21-May-2015) travelled from South Korea, through Hong Kong to Huizhou in Guangdong Province,  China on 26-May-2015.[1] 

Click on it!
It gets bigger!!!

Reference...

1. http://www.who.int/csr/don/30-may-2015-mers-china/en/

Ignore mild and asymptomatic cases at your peril...

Infected but apparently well people may be key points along the transmission chain - not just in spreading infectious virus, but also in contaminating surfaces.

Or they may have no role in transmission at all.

When you have problems that weren't solved by the easy answers - look harder.

Study. Test. Find out. Communicate.

Knowing the full story of how a virus spreads is hard work. But transmission is not necessarily a simple process. Like everything biological, it may be more complex than we care to acknowledge. Such a complex scenario is shown here. Completely fictitious.
Or maybe not.
Testing can answer questions. Communication can provide answers.Click on image to enlarge.

MERS-CoV jumps a flight to South Korea...but from where?

It could be Qatar, Bahrain, the United Arab Emirates (UAE) or the Kingdom of Saudi Arabia (KSA). Any of these may have been the country of origin for the infected person who returned with a bunch of microscopic passengers, to the 24th country to host a case of Middle East respiratory syndrome coronavirus (MERS-CoV) infection - South Korea. 

The infected man then passed the spiky parasites on to his 63-year old wife and to a 76-year old man with whom he shared his hospital room. Close contact. From what we know of the MERS-CoV - it's a pretty ineffective transmitter among us humans types, preferring instead to give the hump to dromedaries.

Qatar seem less likely as it appears to have only been an airport transit point. If it's Bahrain, then we have 25 countries as Bahrain has not yet reported a MERS-CoV positive person. Both the people and the camels of the UAE and KSA are well known to this virus both in humans and camels. 

We await the clarity of the World Health Organization's analysis in a Disease Outbreak News (DON) article - although this might be a tough one to unravel.

Click on image to enlarge.

Where did the MERS-CoV comorbidity and animal contact fields go...? [UPDATED]

Is this the work of the US CDC and other visitors helping the Kingdom of Saudi Arabia (KSA) Ministry of Health (MOH) resolve their Middle East respiratory syndrome coronavirus (MERS-CoV) problem? Is it an arbitrary reporting change by the Command and Control Center (CCC)? Is it someone forgetting to unhide the relevant columns in their spreadsheet?

Changes to the KSA MOH MERS-CoV public 

reporting detail after 17-March-2015.

1. The MERS-CoV graph changed scale and caught up.

2. Three fields disappeared: pre-existing disease, 

animal exposure and contact with a known cases 

within a hospital setting

3. The promise of weekly updates was dangled-

without reference to a host site.

Click on image to enlarge.

I don't know why, but since 17th March, the KSA MOH MERS-CoV reports have stopped posting information about whether each newly announced MERS case had a comorbidity and whether they had animal contact. Granted, the last field was almost always "No" or "Under Investigation" - and thus of little use (we rely almost exclusively on the World Health Organization reports to provide useful animal data) - but I wonder why the MOH has chosen to stop posting even the heading this month? 

The much more epidemiologically significant description of whether the case was an "expat" or a "Saudi" citizen remains - whew! 

And the MOH has continued to do away with all of that pesky detail that might allow an observer to link a death to a previously announced case. Thank goodness we don't have that clutter to deal with - or the details from the found113 which I presume are now completely lost in the sands of time. 

I guess the removal of these latest 2 data fields is just all part of providing the world with more of that full transparency and up-to-date information about this emerging pathogen - like the MOH "News" page - all the latest info you could want from August and earlier is to be found there. 

Oh well, at least you can get the latest from the weekly updates...if Google Translate's efforts can be understood.

It really isn't as hard as it is being made to look to get the reporting aspects right.

MERS in the UAE...

Over my weekend, the Robert Koch Institute (RKI) in Germany reported that they had a Middle East respiratory syndrome case (65 year old returning German) under their care, imported from the United Arab Emirates (UAE).[1,2]

There have been two other MERS cases hospitalized in Germany - 1 from Qatar and the other originating from the UAE, where infections are presumed to have been acquired.

This latest case is nothing astonishing but it does act as a warning that there most likely are other MERS cases circulating in the UAE. Alternatively, this person may have visited the Kingdom of Saudi Arabia (KSA) before travelling to Germany, acquiring an infection there. 

When cases emerge in other countries they can be very telling. They speak of what might be happening in the host country. The UAE has only reported (this is the important word for any outbreak observation) a single case since July last year. Was RKI just "lucky" to pick up the only other MERS-CoV case in the UAE over the past 8 months? Highly doubtful. In the absence of other information (WHO detailed data will surely follow soon), it is much more likely that MERS-CoV is circulating in the UAE, as it is in the KSA and possibly neighbouring countries, but that cases are going either undetected or unreported.

When animals were described alongside human cases.
Click on graph to enlarge.
Taken from MERS number page.

Current MERS-CoV circulation would be in keeping with the popular theory that MERS is a seasonal zoonosis (animal infection that spills over to humans causing disease on occasion), and that more primary human cases, although still relatively rare, emerge during periods when more infections are occurring in camels - which seems to occur around this time of year. That seasonality in camels has not really been established yet and still it is one popular theory among those who do not completely deny any involvement of camels in MERS whatsoever. Also worth repeating is that MERS-CoV appears to be inefficient at transmitting between people - at least so far as the testing done to date has revealed.

From the rare spillover cases acquired by humans from camels, humans proceed to do the lion's share of the work in continuing to spread MERS-CoV among humans. Yay us. 

In recent WHO disease outbreak news reports [3,4], the detailed information reveals multiple instances of cases having shared wards with laboratory-confirmed MERS-CoV cases - and despite assurances that the same healthcare workers did not attend both people, some form of contact has apparently occurred somewhere, somehow. The precise details of what that contact was, still seem to be beyond the capacity of the Saudi disease detectives to capture. But in that detail lies some important hospital (or community) transmission clues - even if those clues are as simple as revealing that the wring question are being asked, too few contacts are being tested, healthcare workers movements are not being tracked sufficiently, or finding that people (patients, contacts and healthcare workers) do not answer the question fully. 

A little thing called infection prevention and control is apparently still not being adequately adhered to in some parts of the region. 

In other words, MERS is a rare but preventable disease.

References...

1. Flutrackers post
   https://flutrackers.com/forum/forum/novel-coronavirus-ncov-mers-2012-2014/germany-coronavirus/726247-germany-reports-3rd-imported-mers-cov-case?_=1425773133137
2. Robert Koch Institute [German]
   http://www.rki.de/DE/Content/InfAZ/M/MERS_Coronavirus/MERS-CoV.html
3. WHO MERS DON 06MAR
   http://www.who.int/csr/don/6-march-2015-mers-saudi-arabia/en/
4. WHOMERS DON 23FEB
   http://www.who.int/csr/don/23-february-2015-mers-saudi-arabia/en/

A new Middle East respiratory syndrome coronavirus (MERS-CoV) table of graphs stacks up...

My new favourite graphic. 

This shows MERS-CoV detection by month since the virus was identified in 2012. Detections are further broken down by each region of the Kingdom of Saudi Arabia (KSA) in which they were reported  by the KSA Ministry of Health website here.

At the moment its highlights that the KSA has a real problem in the Eastern region (Ash Sharqiyah) and growing issue in Ar Riyad (as always with MERS-CoV detections) but that Al Quassim region is also of growing concern.

This table of graphs is part of my MERS-CoV static page to be found at... http://virologydownunder.blogspot.com.au/2014/08/mers-cov-daily-monthly-and-cumulative.html

I try and update these data as often as possible - at the moment detection are rising and February is currently the 4th largest month for new detections - updates occur every day or two.

References...

1. Kingdom of Saudi Arabia Ministry of Helath MERS-CoV data http://www.moh.gov.sa/en/CCC/pressreleases/pages/default.aspx