MERS is a disease we spread...

There is little doubt now that Middle East respiratory syndrome  (MERS) disease outbreaks are triggered by sporadic zoonotic transmission of the MERS coronavirus (MERS-CoV) from an infected camel to a susceptible human. 

Little doubt to anyone who has followed the story of MERS at all, anyway.

But that's just the tip of the iceberg. 

The majority of human cases that have contributed to those steep rises in the cumulative MERS-CoV detection graph below are there because humans have infected other humans while in or associated with a healthcare facility. A telling picture when you consider that MERS-CoV is not a great transmitter. We've done much to make something from what should have been nothing.

Can we vaccinate against lapses in infection prevention and control?

There (might be) something in the air tonight... [UPDATE]

UPDATE No.1 06SEPT2016

One of the early pieces of science-based news to come out of the May-2015 Middle East respiratory syndrome coronavirus (MERS-CoV) outbreak in South Korea was a June-2015 piece asking whether air conditioning may have played one (of many?) key role in facilitating the spread of virus from infectious patients, within healthcare facilities.[1]

In a publication that came out in April 2016 (yes, the literature did not see much detail on the South Korean outbreak for quite some time), authors described a study to collect and test air and swabs from surfaces in and outside patient's rooms, and their restrooms, in 2 hospitals that housed 3 male cases of MERS pneumonia.[2]

Whenever RT-PCR is used for this sort of work, it brings with it the question of whether infectious virus-containing droplets were captured, or only bits of non-infectious RNA viral genome was detected. This group, like those in the last post (who did not collect air samples), attempted to grow infectious virus. They could confirm that it was infectious virus by observing cell changes in infected laboratory cultures which were also RT-PCR positive. Also the same approach as that described by the South Korean study reviewed in the last post.[3] Additionally, the infected cell cultures also reacted to an anti-Spike protein antibody in a fluorescent test and they even saw some actual virus from swab cultures (not captured air samples?) using electron microscopy.

Some interesting findings from the use of these test on air and swabs samples included:

• All air samples from both hospitals were RT-PCR positive and these included the detection of MERS-CoV of RNA in room, restroom and common corridor air. Infectious virus was grown in cells from from 4 of 7 (57%) samples.
• 42 of 68 (62%) surface swab samples tested positive for MERS-CoV RNA by RT-PCR and included elevator button and rails, doorknobs and handrails inside and outside a patient's room, telephone button, toilet seat, call button, patient pillow, nasal prong, toilet seat, TV, keyboard, stethoscope and air exhaust dampers. Infectious MERS-CoV was isolated from 15 swabs of some of these items including an elevator button, nasal prong, patient pillow, TV, bed handrail, keyboard, stethoscope, toilet seat and an air exhaust damper

This study really addresses three big issues. 

Firstly MERS-CoV from very ill patients late in their disease course, thoroughly contaminates a hospital room and its surrounds - not just with detectable genetic material, but with infectious, viable MERS-CoV virus. 

Secondly, surface contamination was detected from swabs collected 3-7 hours after daily room cleaning suggesting either that cleaning was insufficient or that new virus was quickly laid down on cleaned surfaces (with no lasting anti-viral effect from the cleaning solution). 

Thirdly, the capture of infectious virus from the air implies that the virus maybe present in droplets or droplet nuclei with implications for the level of personal protective equipment required for healthcare workers and visitors to an infected person bedside. It also pertains to the distance away from a case that is considered "safe" for an uninfected person to be. Six feet may not be nearly enough distance, at least if that is a prolonged period in a room.

This provides some more data to explain how MERS-CoV may be associated with hospital outbreaks. Why it has been allowed to get away with this is a matter for infection prevention and control specialists in each and every healthcare facility to address.

UPDATE.

After this was published, Van Kerkhove and colleagues wrote a letter to the editor to make some points about the study noting:

• an absence of negative control sampling from areas where MERS-CoV patients were not housed.
  Absolutely. I'd even suggest a few different sites in very distant hospital areas from where MERS patients were housed, given the possible human-spread of virus around a facility during and the possibility of silent or subclinical infection in patients admitted to hospitals for other reasons during times of outbreak. This will explore whether false positive laboratory results are occurring.
• other studies have reported surface contamination that did not yield viable virus. Van Kerkhove note that these negative findings need to be published to balance the literature. Always.
  However, it's well known that virus culture is insensitive compared to RT-PCR methods so it may fail to detect infectious virus which may be enough to infect a human . It may also be that infectious virus capable of infecting another person who comes into contact with it is not always present in the air or on surfaces. It may be that the surfaces often simply have non-infectious "bits" of virus detected by RT-PCR -these cannot cause a new infection. But in this study infectious virus was able to be isolated from air and surfaces...unless Van Kerkhove and colleagues are implying contamination of the cultures in some way.
• the need to replicate these findings in other studies.
  Always.
  But as is often the case, let's not wait on those findings to recognise that infectious droplets and contaminated surfaces now have some more data to support them and that they fit nicely into a picture of hospital transmission. Precautionary principle.

A second letter was also written by Myoung-don Oh,[7] noting:

• few infected cells in the cultures / slow growth.
  This isn't too surprising, it may just reflect that there was a low amount of virus in the air, added to the cell cultures compared to that used from the control virus (cell adapted?) stock.
  This may mean that the risk from airborne transmission in these rooms is low. However, since we don't know what amount of MERS-CoV is required to start a new human infection, this is a moot point.
• the sequences of the room samples were too different from each other.
  This is a bit surprising since within an outbreak, MERS-CoV doesn't usually vary much at all. I'll have a look at how much South Korea's MERS-CoV Spike gene sequences varied and come back to this point.

Both letters were replied to.[8]

References...

1. Did poor ventilation lead to MERS 'superspread' in Korea?
   http://www.sciencemag.org/news/2015/06/did-poor-ventilation-lead-mers-superspread-korea
2. Extensive Viable Middle East Respiratory Syndrome (MERS) Coronavirus Contamination in Air and Surrounding Environment in MERS Isolation Wards
   http://cid.oxfordjournals.org/content/early/2016/06/08/cid.ciw239.abstract
3. Korea contamination: Middle East respiratory syndrome coronavirus in the room..
   http://virologydownunder.blogspot.com.au/2016/09/korea-contamination-middle-east.html
4. Interpreting Results From Environmental Contamination Studies of Middle East Respiratory Syndrome Coronavirus
   http://cid.oxfordjournals.org/content/early/2016/08/09/cid.ciw478.full.pdf
5. STABILITY OF MIDDLE EAST RESPIRATORY SYNDROME CORONAVIRUS (MERS-COV) UNDER DIFFERENT ENVIRONMENTAL CONDITIONS
   http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20590
6. Transmissibility of Middle East Respiratory Syndrome by the Airborne Route
   http://cid.oxfordjournals.org/content/early/2016/08/09/cid.ciw479.full.pdf
7. Interpreting Results From Environmental Contamination Studies of Middle East Respiratory Syndrome Coronavirus
   http://cid.oxfordjournals.org/content/early/2016/08/09/cid.ciw478.full.pdf
8. Reply to Kerkhove et al and Oh
   http://cid.oxfordjournals.org/content/early/2016/08/09/cid.ciw480.extract

Update...

1. Added in detail on letter by Van Kerkhove and colleagues [4], and rebuttal authors [5]

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

MERS-CoV: Saudi Arabia still tops the chart..by a long way

A quick reminder that MERS and the MERS-CoV remain a thing of the Kingdom of Saudi Arabia from where 80% of detections have been reported.

South Korea's hospital outbreak comprises 11% of all reported detections.

Whether MERS-CoV spreads or stops is entirely up to the hospitals...

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MERS simmers down in South Korea...did we learn anything this time?

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Tracing the MERS-CoV cases in South Korea...

The Korean Broadcasting System (KBS) News channel has made an awesome "bump map" or force diagram (thanks @Casillic) showing the layout of cases and the hospitals they passed through or were admitted to or transferred to.[1] It shows sex, deaths (9 across multiple facilities), profession, rounds of transmission and some dates (written as month.day)

Unfortunately for some of us, it's in Korean. If you, like me, are having trouble remembering your grade school Korean, I'm here to help (a little).

I've put together a screenshot of this awesome map as of today's count of  - no doubt the values will change tomorrow - and added onto it the hospital names in English. I highly recommend you visit the actual site though - the map is scalable and interactive. This snapshot does not do it justice and won't be updated like the map seems to be.

I've interpreted the hospital names by eye from the Hong Kong Centre for Health Protection's (CHP) excellent multi-lingual list of all the "MERS hospitals" released by the Korean health authority.[2,3] They may not be perfect and I'd be happy to take any suggestions and corrections (including what is in the orange boxes).

The index case, #1, is shown in green and is linked here to 2 clinics and a hospital - which differs a bit from the WHO story which includes a final move..."whereupon he was transferred to the nationally designated treatment facility for isolation".

The most recent additions seem to have a pulsing arrow (only visible at the source).

Made using a combination of sources. [1,2]
Click on image to enlarge.

References...

1. http://dj.kbs.co.kr/resources/2015-06-04/
2. http://www.chp.gov.hk/files/pdf/distribution_of_mers_cases_en.pdf
3. http://www.chp.gov.hk/files/pdf/korean_hospital_list.pdf

The crowded virus escapes from Hofuf?

While MERS-CoV (f. HCoV-EMC) cases have been detected in the UK (3-2 fatal), Jordan (2-both fatal), the United Arab Emirates (1, fatal) and Qatar (2) since April 2012, it has been the Kingdom of Saudi Arabia (22 cases-13 fatal) that is the current hot zone. 

These cases are from 5 different clusters according to the FluTrackers. 

The latest news paints a bleak picture. According to the Wall Street Journal, Al Moosa General Hospital is not the only hospital treating patients from the current outbreak. 

Given that human-to-human transmission has been noted for MERS-CoV, this may nor bode well for containment.