Health authorities around the world are on high alert after a sudden spike in the incidence of a deadly Middle Eastern flu-like bug that began in Saudi Arabia but has now spread to Asia and the USA.
As of 4 May, the Kingdom had recorded 411 cases of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) and 112 deaths in two years.
Almost a third of these cases have emerged in the past two weeks, the biggest single surge of MERS-CoV since it was discovered in April 2012, prompting questions about whether the virus has the potential to escalate into a pandemic similar to Severe Acute Respiratory Syndrome (SARS), which swept through Asia in 2002-3, killing over 700 people.
Beyond Saudi Arabia the virus has a significant caseload in the United Arab Emirates (UAE) and in the past week other cases have been discovered in the US, Greece and Egypt for the first time, with 12 countries in total now affected.
“This is a key moment in the MERS-CoV timeline,” Sofian Ragab research director at IDPH Research Group, a London-based but Middle East and North Africa-focused think tank, told IRIN. “Unless it is brought under control and kept that way, we could see an exponential increase in incidence.”
Ragab, who has been mapping MERS-CoV since it first appeared, noted that while the “pandemic potential” remained “low”, he said: “We still have to be concerned, and infection prevention and control measures should be implemented and maintained.”
The good news is that so far the genome structure of MERS-CoV does not appear to be mutating as it passes from person to person, unlike SARS, which makes it less virulent and unpredictable, and easier to treat.
But while several studies have identified camels to be the likely source of MERS-CoV, scientists remain unsure about how the virus is moving from animals to humans.
“Until we better understand how the virus transmits from camels or the environment to a human, we are likely to see more cases,” said Jaouad Mahjour, director of the Department for Communicable Diseases at the World Health Organization (WHO)’s Eastern Mediterranean Regional Office (EMRO) in Cairo.
Mahjour, a medical doctor who has just led a WHO fact-finding and risk assessment mission to Saudi Arabia, added: “Understanding this link is key to limiting the outbreak. There is an urgent need to conduct an in-depth epidemiological study of known cases to get this knowledge.”
Two weeks on a ventilator
Forty-seven-year-old Saudi consultant Ismael Qushmaq, one of a number of healthcare workers to be infected with the virus in the Kingdom in the past month, is recovering after two weeks on a ventilator in the ICU department he runs at King Faisal Specialist Hospital and Research Center in Jeddah.
His sister, Nahid Qushmaq, who works as a doctor in infection control at another hospital in the city, told IRIN that her brother had been exposed to MERS in early April while treating a patient, who it later turned out had the disease despite having atypical symptoms.
“It’s important that we control this as soon as possible. It’s not a chronic disease, it’s an acute infection of the respiratory system and it can be contained,” she said.
Some parents in Saudi Arabia have called for schools to close early for summer due fears of an outbreak, but Qushmaq said she was still sending her children to class because she was confident that adequate surveillance measures were in place.
“People are obviously concerned and are asking a lot of questions”, she said. “But… I wouldn’t say there has been a lot of panic, not as much as I thought there would be. People are still going about their lives, though you do see some people in masks in shopping malls and other crowded areas.”
Saudi Arabia had come under fire for its handling of MERS, with some accusing the government of opacity and trying to cover up the infection rate in order to limit reputational damage.
Last month, in what was read as a response to those negative headlines, King Abdullah removed the country's health minister, Abdullah al-Rabiah, and appointed Adel Faqih as his “acting” replacement.
The Kingdom’s Ministry of Health now has a dedicated and regularly-updated MERS section on its website. A 10-person medical advisory council made up of leading health experts has also been put in place and three hospitals in the Kingdom are designated specialist MERS-CoV treatment centres.
“The previous minster didn’t seem to want to talk about the numbers and he kept telling people to keep calm and not panic,” said Ahmad Qushmaq, a brother of the recovering ICU consultant.
“But now there seems to be a lot more information available and more discussion, which is good,” he added.
Although the details of how the virus is passing from animals to humans is not clear, the Saudi Health Ministry has now reiterated WHO advice about contact with camels and consumption of the animal’s meat and milk - controversial in a country where camels are revered for their beauty and considered prized possessions as well as part of the traditional diet.
A number of the healthcare staff in Saudi Arabia who have fallen ill with MERS-CoV have been migrant workers from Asia, fuelling concerns about the virus being transported around the world.
Last month some 400 passengers from an Etihad flight from Abu Dhabi to Manila were called in for testing by the Philippines Ministry of Health after it was discovered one person on board had been diagnosed with MERS-CoV in the UAE, but had left the country before his results were known.
Like many countries supplying workers to the Gulf, the Philippines government has sent information on MERS-CoV to all its embassies, consulates and overseas labour welfare organizations; their websites now carry large banner reminding people about hand hygiene and what to do if symptoms develop.
In the UAE, the death of a Filipino paramedic, 45-year-old Abundio Verzosa Esporlas, in the city of Al Ain in April sparked a flurry of concern on social media sites.
In recent weeks some Filipinos in the UAE have been seen wearing protective masks while travelling on public transport and the health authorities have stepped up awareness campaigns, running “advice clinics” on social networking sites like Twitter.
A bigger worry is the millions of Muslims who travel to Saudi Arabia every year on religious pilgrimages to Mecca and Madinah, particularly the Hajj pilgrimage in October.
Malaysia recorded its first case in April when an infected man returned from pilgrimage to Saudi Arabia. Press reports say the country will now be screening all passengers landing at Kuala Lumpur airport.
The Saudi government has advised against elderly people, pregnant women and those with underlying health conditions (all more vulnerable to MERS-CoV) from taking part in pilgrimages, advice reiterated by Egypt as well.
Nevertheless, in spite of the increase of MERS-CoV cases since the start of 2014 and the widening global spread of infections, WHO has not declared a Public Health Emergency of International Concern (PHEIC).
It has recommended “increasing efforts to raise awareness of MERS among travellers going to and travelling from MERS-affected countries,” but said it did not “advise special screening at points of entry with regard to this event nor… does [it] recommend the application of any travel or trade restrictions.”