Sweeping surge in MERS cases due to infection control problem in Saudi hospitals

TORONTO -- The sweeping surge in MERS cases over the past five weeks appears in large measure to be due to problems with infection control practices in some Saudi Arabian hospitals, the World Health Organization suggests.

A senior official of the Geneva-based agency says a team of WHO experts that recently returned from that country toured hospitals in the city of Jidda, one of the current MERS hotspots. What they saw pointed to lapses that have allowed the virus to spread among patients and health-care workers.

"One of the things that we can already conclude is that the infection control practices were not optimal and they have to improve," Dr. Keiji Fukuda said in an interview.

The silver lining of that reality is that better infection control should help the Saudi health system control spread of the MERS coronavirus in hospitals, says Fukuda, who is the WHO's assistant director-general for health security.

Stringent infection control measures were critical to the effort to stop the 2003 SARS outbreak, caused by a virus from the same family as the MERS coronavirus. And good infection control practices extinguished a 2013 MERS outbreak in hospitals in and around Al Ahsa, Saudi Arabia, he notes.

The sharp increase in infections in Saudi Arabia since early April has again raised concerns that MERS is on a similar trajectory as SARS, which also spread well in hospitals. About 20 per cent of the roughly 8,500 probably SARS patients were health-care workers, and people in hospital for other health ailments also made up a substantial portion of SARS sufferers.

Many of the recent Saudi cases are people who entered hospital for one health problem and contracted the infection during their stay.

"A lot of people are wondering and worried about whether we are seeing a SARS-like scenario unfold," Fukuda acknowledges.

"I think the good thing here is that with SARS and with the MERS virus, I think that the preponderance of the evidence is that infection control at the right level really can stop it in hospitals."

Fukuda says the WHO team is still sorting through data shared by Saudi Arabia's ministry of health. But it seems clear that a recent change in the policy of who to test for MERS infection -- not just sick people, but seemingly healthy contacts as well -- is also inflating the country's MERS tally. This testing change is identifying significant numbers of people who are infected but have mild or no apparent symptoms.

The case count climbs daily, sometimes multiple times a day. On Wednesday, 28 new cases -- and six deaths -- were reported on the Saudi health ministry's website. By end of the day, the country's count stood at 449 cases and 121 deaths, about 80 per cent of the global total. But those numbers are likely already out of date.

Despite these explanations for the surge, Fukuda says it also seems to be true that there has been an increase in MERS cases in the community, among people not thought to have been infected in hospitals. What's behind that rise, which may be seasonal, is not currently known.

The WHO is keeping a close eye on the pattern of community cases, looking to see whether there is any evidence that the MERS virus is becoming more adept at transmitting from person to person. So far, Fukuda says, "We don't see that."

He says the WHO team received good co-operation from Saudi officials, who have been faulted in the past for failing to share information or pursue the types of studies needed to figure out how people are becoming infected with the new virus.

When case numbers started to soar in April the health minister was fired and replaced by the labour minister. The change in leadership in the health ministry has lead to an apparent change in heart about information sharing and the country's willingness to seek help from the WHO.

"I think that this big upsurge in cases has really made the Saudi ministry of health and the authorities there very aware that they don't have the situation fully under control and that they have to improve infection control, they have to step up on some of the investigations being done," Fukuda says.

"And I think they're also very aware about how worried other countries are ... they know how worried everybody is and I think that they're pushing pretty hard to improve in all of those areas."

The steep climb in cases alone would have been enough to garner the attention of public health officials globally. But added to that has been the fact Saudi Arabia and the United Arab Emirates -- which is also experiencing a sizable jump in cases, though not to the same degree -- have been exporting MERS cases.

Malaysia, the Philippines, Jordan, Egypt and Greece have all recently reported diagnosing MERS in people returning from Saudi Arabia or the U.A.E. Last Friday the United States disclosed it had found its first MERS case, in a U.S. citizen who lives and works in the health-care sector in the Saudi capital of Riyadh.

With the start of Ramadan -- the Muslim month of fasting -- only seven weeks away, the reminder of the potential for exported cases is a timely one.

Muslims visit their religion's holiest sites, Mecca and Medina, all year round in a pilgrimage called Umrah. But performing Umrah during Ramadan is considered to be almost as important as having done the Hajj, the major pilgrimage all able-bodied and financially able Muslims are meant to do at least once in their lifetimes.

Fukuda says the WHO has discussed the looming influx of pilgrims with Saudi Arabian officials.

"The Saudis themselves are extremely aware of the issues," he says.

"And so they're very conscious that they want to make sure that people coming to visit and people leaving are not either posing a danger to other pilgrims in Saudi Arabia or not spreading infection to the rest of the world. I think they're very conscious about that, and very responsible about that."

"But it's a difficult situation, because people want to go on pilgrimages," he continues.

"And those are particularly important to a very large number of people. So balancing all of those things requires some careful thinking and discussion about how to get that balance right. And I do think the Saudis do try very, very hard to get that balance right."