Anxiety runs deep in Saudi Arabia these
days. A SARS-like disease that kills a third of those it infects is suddenly,
and mysteriously, surging inside the kingdom. The country is struggling for
answers -- and so are its neighbors.
It's called the Middle East respiratory syndrome
(MERS), and though the majority of the cases have been found in Saudi Arabia,
14 other countries have reported instances. Make that 15: Egypt just reported a
case at the end of April.
The virus first emerged in the eastern
oasis town of Al-Ahsa in the spring of 2012. But not until April 2014 did it seem
likely to be a pandemic: That is to say,
nearly half
of all cumulative cases since 2012 have occurred in Saudi Arabia in April 2014.
As of April 29, the kingdom
reported a
total of 345 cases since the virus first emerged -- 105, or 30 percent, of them
have proved fatal. Seventy-three cases
have been reported outside Saudi Arabia, and nearly all those cases have been
linked to travel to the kingdom.
Among those cases, at least two were among
religious pilgrims: The first pilgrim, from
Malaysia,
reportedly drank camel's milk in Jeddah before returning home, and the second
pilgrim, from Turkey, died last week in Mecca. But a considerable number of
cases -- nine out of the 14 reported in April -- have included foreign workers,
such as nurses, domestic workers, and oil industry employees. Most of these
workers have stayed in Saudi Arabia for their treatment, though the Philippines
issued a
health alert after an
infected nurse
returned to Manila.
And this sudden surge -- both inside and
outside Saudi Arabia's borders -- has put pressure on the Saudi government. Health
Minister Abdullah al-Rabeeah
was fired on
April 21, replaced by Labor Minister
Adel Fakeih,
who now leads two ministries. In keeping with his labor portfolio, Fakeih
immediately
expressed
special concern about the disproportionate toll the SARS-like virus is taking
among health-care workers, ordering transfer of all the kingdom's MERS cases to
King Saud
Hospital in north Jeddah, where they will be treated under severe
infection-control conditions. Between March 20
and April 26, some 29
percent of Saudi MERS cases and deaths were among health-care workers. Even King
Abdullah changed his summer plans to visit hospitalized patients in a Jeddah
hospital.
The Saudi Health Ministry has lost a
great deal of credibility, as rumors have
spread of incompetence, coverups, and lost records.
The Saudi Health Ministry has lost a
great deal of credibility, as rumors have
spread of incompetence, coverups, and lost records. (And much of the
information has
moved through
social media. I've even received
tweets from people all over the
world claiming that Saudi health officials have documented MERS cases as "
heart attacks" and that nurses fear
for their safety amid stock-outs of protective gear.) Local physicians began
reporting a surge in Jeddah and Riyadh as early as April 1, but then-Health Minister
Rabeeah issued this
unequivocal statement: "Jeddah: the novel coronavirus situation is
reassuring and thankfully does not represent an epidemic." The
daily tolls
of cases and deaths have been increasingly confusing, as outside
health agencies and
reporters
struggle to make sense of updates
from Riyadh.
Recently the
Washington Post's editorial
board cried out for accurate, transparent information from the kingdom.
The elevated concern in the kingdom reflects
a significant jump in the number of cases between April 15 and 21, when 49 new
MERS patients were hospitalized, mostly in the city of Jeddah. The World Health
Organization (WHO) issued a
statement of "concern" noting:
"Approximately 75% of the recently reported cases are
secondary cases, meaning that they are considered to have acquired the
infection from another case through human-to-human transmission," WHO Regional
Director for the Eastern Mediterranean Dr Ala Alwan said. "The majority of
these secondary cases have been infected within the healthcare setting and are
mainly healthcare workers, although several patients are also considered to
have been infected with MERS-CoV while in hospital for other reasons."
According to the WHO, cases have now been
found in Jordan, Kuwait, Oman, Qatar, the United Arab Emirates, France,
Germany, Greece, Italy, the United Kingdom, Tunisia, Malaysia,
Yemen, and
the Philippines. Egypt also reported its first case in April.
The political stakes are high for King
Abdullah and the Saudi royal family as they are the keepers of the most sacred
sites of Islam: Mecca, Medina, and Jeddah. Every year, starting in late spring
and extending roughly to October, millions of Muslim pilgrims descend upon the
sacred cities for the religious observances of
umrah and the hajj. It is the duty of the king and his royal family to provide safe and
healthy passage to all pilgrims. In addition, Saudi Arabia is absolutely
dependent on foreign workers to sustain everything from basic construction and
household labor to the advanced engineering of the kingdom's petrochemical
industry and oil fields. According to the
International
Labor Organization, in 2006 the kingdom
had a total workforce of about 7.5 million, 54 percent of whom were foreign. In
2013, however, the Saudi government expelled thousands of foreign workers, so
these numbers may not reflect current trends.
Worry in the Philippines since the return
of an infected national has grown high enough that the government has issued
"do not panic" bulletins in
Manila. Nevertheless, fewer Filipinos are reportedly
applying for Saudi jobs. And
on April 14, after five Filipino nurses were quarantined in the
United Arab Emirates following
their exposure to a MERS patient, the Philippines' Department
of Foreign Affairs urged Filipinos in the Middle East to "take precautions."
The sharp
rise in cases has scientists and Saudi authorities asking a raft of the
usual outbreak questions:
Has the virus changed, adapting genetically to the human
species in a way that makes it more infectious?
Has the virus changed, adapting genetically to the human
species in a way that makes it more infectious? Is this surge due to laboratory
artifacts or some changes in testing practices in Saudi Arabia?
Verification tests in Europe of the Saudi diagnoses
rule out
laboratory error or changes
in
diagnostic methods as explanations for the surge. On April 26 a German team completed genetic
analysis of strains from three patients diagnosed in the new surge, comparing
those genomes to earlier MERS strains. No significant differences were
found -- certainly none that could lay responsibility for the surge on
viral mutation. Nevertheless, many
news organizations and individual scientists have speculated, without evidence, that the
spike in cases signals viral adaptation to the human species.
The WHO has
offered to mobilize an
international team of scientists to assist the Saudis in doing the
detective work to determine why this surge is unfolding and what can be done
about it. To date the Saudi government has
frustrated many outside scientists who have
tried to help on the ground or offer epidemiological insights from afar. But the
sorts of data the scientists say they
need -- such as the
occupations of infected individuals, travel details prior to infection, details
regarding possible exposure to camels or other animals -- the Saudi government
has not provided for most cases. Even leading Saudi news organizations have
called for greater transparency from government officials. "What has been shocking and extremely disturbing are the
countless stories and rumors that have spread just as quickly and just as
aggressively as the virus itself," an author
wrote
in the
Saudi Gazette.
***
So why is the surge happening now? MERS
is a coronavirus, part of a family of microbes that includes SARS (severe acute
respiratory syndrome). Clues to the
largely mysterious natural history of MERS, how it spreads, and where it comes from may
well lay with the SARS saga. The SARS virus is a fruit-bat microbe that causes
no harm to the flying animals. The 2002 and 2003 human epidemic was preceded in
the late fall of 2002 by an outbreak in captive
civets, sold for exotic meals in live-animal
markets throughout China's southern Guangdong province. It is not certain how
the civets originally acquired SARS, but animal hunters and smugglers commonly
caged their prey beside one another, possibly putting bats and civets side by side.
In February 2003, when I reached the animal market in Guangdong's megacity, Guangzhou,
where the epidemic was spawned, I found thousands of caged, miserable animals
stacked atop one another, defecating and urinating upon each other. Moreover, animal
dealers -- who would blithely grab animals at customers' requests -- handled
the civets, possibly cross-contaminating cage after cage. I tracked down the
first cluster of SARS cases, centered on a restaurant famed for its civet
meals. The people became infected through the handling, slaughter, and cooking
of the animals. In the earliest stages of the epidemic in 2002, all human cases
were linked to civets or to individuals who handled civets. Once the primary
cases entered the hospitals, however, infection spread like wildfire from person
to person across the wards and through the health-care worker populations.
In the case of MERS, there is now
plentiful evidence that its primary host is another fruit-bat species, the
Egyptian tomb bat. Nobody knows why the bat virus only emerged into people in
2012. But it seems that it originated in the Al-Ahsa date-growing oasis town in
eastern Saudi Arabia, where the bats nest atop the palm trees. In April 2014, an
international research team
published
evidence that bats may be able to carry dangerous viruses like Ebola, SARS, and
MERS without harm to themselves because the physical action of flight elevates
their metabolism and innate immunity. More sedentary animals -- camels and
humans, for example -- lack the same elevated metabolic impact on their immune
systems.
In some manner the bat virus
spread to camels, which can be considered the MERS equivalent of civets in the viral
chain of transmission. And some of the human MERS cases have been linked to
camels. For example, the Malaysian pilgrim who succumbed to MERS
visited a
camel farm and drank camel milk before taking ill. During the last week of
March, an
animal trader
from Abu Dhabi came down with MERS after visiting a camel farm. A Saudi man who
contracted MERS was infected with a strain that proved a 100 percent genetic
match to the virus extracted from one of his
personal
camels. And laboratory analysis of
camels' milk
samples has found many contaminated with the virus, which appears to be
harmless or cause only mild illness in the animals. This week the new Saudi minister
of health urged residents of the kingdom to
shun camel milk
consumption.
Very recently scientists discovered that
camels from as far away as Tunisia, Nigeria, Ethiopia, and Sudan
test positive for MERS
infection. The geographic area encompassed by these MERS-infected camels perfectly
overlaps the North African terrain of Egyptian tomb bats. It would seem that
the bat and camel connection for MERS is an ancient one that may have led to
the occasional human case -- even death -- over the centuries, occurring
sporadically but undetected.
Finally, on the camel front, it must be
noted that only a small minority of MERS patients have had histories of contact
with the animals or consumption of their milk. While the camel connection may
explain sporadic cases, the vast majority of MERS cases seem to have been
acquired by other means.
***
Al-Ahsa, where MERS emerged, is
surrounded by desert. Where there is spring water, orderly and
well-tended
palm orchards stand, without
competition from other vegetation. Date farming is an enormous business for
Saudi Arabia, with farmworkers shooing away bats to tend to the trees at key
points in the growing season. In April, date farmworkers scale the trees,
reaching the very tops to carry out
pollination
work, a labor-intensive activity that
entails removing the male components of the plant, shaving out the pollen,
sprinkling pollen on the female portions of the tree, and tying and clipping
the now-fertilized sections in a manner that increases fruit yield. If
MERS-infected Egyptian tomb bats or their leavings are present, the workers
will likely be exposed. Late March and the month of April comprise a time of
especially intense work in the date palms and potential exposure to the bats
and their leavings.
Remarkably little is known about the
behavior of these bats, though it seems April and May is
breeding season
for the animals and
June is birthing time, when a
single progeny per female bat is born, and fiercely defended.
Farmworkers will return to the treetops
in June, as the fruits are getting larger, to fend off bats and other pests and
to wrap the fruit clusters in protective mesh. And their third potential period
of exposure to bats will come in late summer and early fall, for the harvest.
There was no surge in MERS cases in 2013
at this time, but that may reflect labor issues in the kingdom. Early in 2013,
Saudi Arabia enacted a tough new labor law and tossed thousands of workers out
of the country. Hardest hit was the
agricultural sector, which relied heavily on foreign migrant labor. The labor crunch for
the date industry was so acute that the entire harvest of 2013 was threatened
and last fall a 30-day amnesty was decreed specifically for date workers. The
action came too late for the full range of activities necessary for an ideal
yield, including the April pollination work, and date prices soared. This year
date growers lobbied hard for early labor exemptions, hoping to bring in a large
harvest.
If this cycle is, indeed, at the root of
this year's seasonal surge in MERS, it mirrors what has been seen with another
bat disease, Nipah, in Bangladesh. I visited a Bangladeshi village that had
been hard hit by the disease in 2010. Grieving parents whose children died of
Nipah showed me where the bats nested high in the palm-oil trees, sucking sweet
oil from the catch devices farmers hung -- something like maple tree taps.
During the day the family's children climbed up to drink the sweet oil,
becoming infected by contacting parts of the tree the bats had defecated and
urinated on.
***
By all accounts, King Fahd Hospital in
Jeddah was the scene of chaos and hysteria on April 1.
By all accounts, King Fahd Hospital in
Jeddah was the scene of chaos and hysteria on April 1. That day, six ailing nurses and a physician were diagnosed
with MERS, sparking an outcry from the entire hospital staff. One of the nurses
came down with the disease just days after his wedding, leading authorities to
insist the source of the cluster of cases was not the hospital, but the feast.
The accusation only fanned the fire, and some
physicians quit their jobs, decrying unsafe working conditions for those
treating MERS patients.
Clusters like this of transmission are
surfacing inside hospitals in Saudi Arabia, with some 75 percent of cases in
the April surge being human-to-human transmission, about a third of them health-care
employees. Nearly all public information about hospital spread has come from
the Ministry of Health hospitals -- public facilities that service foreign
workers, migrant laborers, and average Saudis. But ministry facilities account
for less than half of the MERS cases. On April 15, for example, the Health Ministry
released this breakdown for then-hospitalized MERS cases:
Ministry of Health hospitals: 72
Department of Defense hospitals: 39
National Guard hospitals: 30
Security forces hospitals: 4
Saudi Aramco hospitals: 14
Private hospitals: 20
University hospitals: 5
King Faisal specialist hospitals in Riyadh and Jeddah: 10
Total: 194
Combined, the military, security forces,
and royal family facilities accounted for 83 cases, about which little is
known. If MERS is spreading within the security and military ranks, Saudi
national security would be an issue, but almost nothing is known about these
cases.
On April 15, the National
Scientific Committee for Infectious Diseases issued its
verdict on the
Kang Fahd outbreak and escalation of cases in Jeddah: "The clustering of cases
found in the city is actually in line with the nature of the disease, which
tends to affect an aggregate of cases, and the infection pattern of the virus
does not differ from that in the rest of the kingdom. The members also added
that the preparedness of hospitals and health-care facilities follows national
and international infection control standards and does not need any additional
preparation, as all necessary machines and supplies required to treat cases are
available."
The patent fallacy of the committee's statement
would be revealed in a few days, as MERS case numbers soared.
Some Saudi experts have insisted that
proper
face masks,
alone, reduce transmission risk by 80 percent. The SARS experience would argue
against such assurance, as many masked doctors and nurses were infected. The
virus spreads via hands, surfaces, stethoscopes, used latex gloves, even contaminated
contact lenses. Hospitals in
Hong Kong and Singapore
stopped the spread of SARS by compelling all staff to work in teams, donning
and removing their protective gear under the watchful eyes of co-workers to be
sure each step was executed perfectly. On a less sophisticated level, the SARS
outbreak in Hanoi was stopped when all patients were removed from the higher-tech
French Hospital and placed in the aging, warfare-damaged Bach Mai General
Hospital. French Hospital had air-conditioning and high-tech instruments, while
Bach Mai's windows were open, overhead fans moved the muggy tropical air
around, and the most acute cases were tended to by SARS survivors.
The
guidelines for
SARS infection control in clinical settings are well known, detailed, and
internationally recognized. Among the WHO recommendations is: "Turning off air conditioning and opening
windows for good ventilation is recommended if an independent air supply is
unfeasible," a tough requirement in the Saharan desert heat.
Half of the roughly 8,500 SARS victims in 2002 and
2003 were health-care workers, but the rates of hospital infection varied
widely, depending on the physical conditions of the facility (French Hospital
versus Bach Mai in Hanoi) and the institutions' long-standing infection-control
standards.
***
The question now is: Will the virus go global? MERS is at least
three times more lethal than SARS. About 31 percent of MERS patients have
eventually succumbed versus 8 percent of SARS cases.
SARS spread to 31
countries, causing serious epidemics and spectacular economic stress in half of
them, especially China, Singapore, Hong Kong, Canada, and Vietnam. In Canada,
where
40 percent of the 375 SARS cases were hospital personnel, the globalization of SARS was
especially sobering: One of the wealthiest, most advanced nations on Earth
struggled mightily to stop the virus's spread. The also technically advanced
Chinese University hospital in Hong Kong was ripped apart by grief, with
three of its staff sickened by the disease in the first two months of the
region's epidemic.
The specter of a SARS-like, 31-nation, 8,500-patient MERS
pandemic is three times more horrible, due to the greater virulence of the
virus.
Without knowing the relative roles date palm farming, Egyptian tomb
bats, camels, hospitals, and other possible factors play in the spread of MERS
in Saudi Arabia, it is extremely difficult to predict the pandemic potential of
this disease. Clearly, spread inside hospitals is transpiring and must be
stopped before the world can possibly breathe a sigh of relief. This will
require a great deal more than face masks and the scanty patient information
released to date by Saudi authorities.
But the vast majority of MERS cases remain mysteries: How did patients
get infected? What were their professions, living conditions, recent travels,
and family situations? Have there been clusters of transmission outside clinical
settings, such as within households, workplaces, military barracks, or schools?
Saudi health authorities
simply must
find and release far more detail on the known patients and their contacts.
Parallels with the ongoing Ebola epidemic in Guinea and Liberia
abound. In both cases the virus spreads easily inside health-care settings,
putting other patients and doctors and nurses in peril. Both viruses can be
protected against, however, with fairly basic infection-control procedures and
quarantine. Ailing patients with both viruses are limited to palliative care,
as no magic-bullet drugs or vaccines exist for either virus. And in both Ebola
and MERS scenarios, a poorly understood cycle of transmission from bats to
intermediary animals and then to humans is responsible for introducing the
virus -- perhaps repeatedly -- to our species. Mysteries abound.
But one crucial difference between MERS and Ebola must be underscored:
the respective settings of the outbreaks. Today, Ebola is unfolding in one of
the poorest, remotest, most difficult locations on Earth, one rarely visited by
tourists, traders, or travelers. It is highly unlikely that an infected Ebola
victim will have the capacity to board a jet headed to nearby Nigeria, much
less London, Paris, Beijing, or Los Angeles.
But MERS is unfolding in one of the wealthiest countries on the
planet, in an unusual kingdom built on black gold, dependent on the labors of
tens of thousands of foreigners, and host to one of the modern world's most
holy set of shrines, visited by more than a million people annually from nearly
every country on Earth. And it is a kingdom nestled in the midst of the world's
most difficult, war-torn region, where hundreds of thousands of refugees live
in danger and squalor, riots and civil tension periodically erupt, mass
migrations of populations are routine, and governance cooperation between
nations is nearly absent, for everything, even public health.
*Correction, May 2, 2014: The two charts and one map used in this article are from the European Centre for Disease Prevention and Control's Rapid Risk Assessment of April 24, 2014. The original version of this article did not include the source. (Return to reading.)
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Source: European Centre for Disease Prevention and Control, 
Source: European Centre for Disease Prevention and Control, 
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