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Wednesday, October 16, 2013
Biological Alert: As Saudi Arabia hosts the Hajj, a Look inside the Battle against MERS/Co-V | TIME.com
Biological Alert: As Saudi Arabia hosts the Hajj, concerns remain over the effectiveness of the mitigation of #MERSCo-V (Coronavirus)
What does this mean for us Stateside, Preparedness and Prevention?
It's up to YOU. Catch #SitPrep tonight 6p EST on #USAEBN:
"Saudi Arabia has been criticized for its slow response to #MERS, but
so far the world has been lucky. The disease has yet to really break out
of the Middle East and threaten the world like the H1N1 flu in 2009 and
#SARS six years earlier. SARS, which killed 744 of the 8,098 people who
contracted it, earned a rare global travel warning to affected hotspots
like Hong Kong and caused some $40 billion in economic damages. But that
could change this week with the #Hajj, the world’s largest annual
gathering, which typically draws millions of Muslims to Saudi Arabia to
trace the footsteps of the Prophet Mohammed between holy sites in Mecca,
Mina, Mount Arafat and Medina."
As the Hajj Unfolds in Saudi Arabia, A Deep Look Inside the Battle Against MERS
For more than a year, Saudi Arabia has struggled
to control the new disease MERS. Now, with millions of Muslim pilgrims
descending on the country, the challenge will get that much tougher.
A
Muslim pilgrim wears a mask as she walks to Mecca's Grand Mosque to
perform evening prayers on Oct. 8, five days before the start of the
annual Hajj pilgrimage.
In the sci-fi thriller Contagion, a new virus emerges from
wildlife and jumps into human beings, wreaking havoc around the world.
Millions die and society all but shuts down. The plot is frightening
because it’s realistic—there are viruses out there in the animal
population that, with the right genetic mutation, can jump the species
barrier and infect us. If virulent enough and able to spread easily
between people, we might find ourselves living in a real-life horror
movie.
The film is loosely based on what the deadly but limited Nipah
virus—the bat-to-pig-to-human infection identified 14 years ago in Malaysia—would
look like if it could have easily spread around the world. Now we’re
seeing a sequel of sorts. Some scientists who tackled that virus are
battling a new coronavirus called Middle East Respiratory Syndrome (MERS-CoV). The symptoms appear gastrointestinal (abdominal pain,
diarrhea) or flu-like (fever, shortness of breath, heavy cough), but
can worsen into severe pneumonia. It has killed 60 of 138
laboratory-confirmed patients since it first emerged in Jordan in April
2012. The majority of cases and deaths have appeared in Saudi Arabia;
others were reported in Qatar, Tunisia, the United Arab Emirates and
Western Europe, where some patients sought better care or returned from
visits to the region.
The world’s top virologists have struggled to uncover the origin of
MERS and predict its path. Many believe it’s carried by bats—the
reservoir for a number of new pathogens, including its distant cousin
SARS. But since people rarely interact with bats, it may be introduced
to humans through an intermediary animal. In August, European
investigators suggested in the Lancet that
camels could be the middlemen after blood tests of retired racing
dromedaries in Oman and ones used for tourism in the Canary Islands
found antibodies—proteins made by the immune system to fight
infection—that indicate prior exposure to MERS or a close relative. A Eurosurveillancereport
weeks later stoked that suspicion, as most of the dromedaries sampled
from Egypt had similar results. They earned equal parts promise and
skepticism.
So did an Emerging Infectious Diseasesstudy
in late August that named bats as the likely ultimate source of the
virus. “Finally, we nailed it,” says Peter Daszak, president of the EcoHealth Alliance,
a New York-based organization that patrols the animal-human health
border. EcoHealth collaborated on the study with the Saudi Ministry of
Health and Columbia University’s Center for Infection and Immunity.
Researchers matched a fragment of viral RNA from a fecal pellet of the
insect-eating Egyptian tomb bat to a sample from the first human case in
Saudi Arabia. One problem: the genetic fragment was too small to be
certain that it was indeed from the MERS virus. Researchers in Sydney
added to that lead in October with a report in Virology Journal that
suggested bats haven’t just fought the virus, but evolved a way to
escape it. It’s all the strongest evidence scientists have yet about the
source of this new disease—and it still doesn’t add up to much.
Saudi Arabia has been criticized for its slow response to MERS, but
so far the world has been lucky. The disease has yet to really break out
of the Middle East and threaten the world like the H1N1 flu in 2009 and
SARS six years earlier. SARS, which killed 744 of the 8,098 people who
contracted it, earned a rare global travel warning to affected hotspots
like Hong Kong and caused some $40 billion in economic damages. But that
could change this week with the Hajj, the world’s largest annual
gathering, which typically draws millions of Muslims to Saudi Arabia to
trace the footsteps of the Prophet Mohammed between holy sites in Mecca,
Mina, Mount Arafat and Medina.
The journey is a notorious hotbed of infectious disease, as pilgrims
from every corner of the planet often trek around barefoot in demonic
heat and share tight sleeping quarters. On Oct. 15, the Kingdom announced there
are 1.38 million pilgrims from 188 countries, down 21% from last year
due to health concerns and a steep reduction in visa quotas as the
expansion of the Grand Mosque in Mecca continues. There are 57% fewer
domestic pilgrims, too, tallied at about 600,000. But while the ministry
claims it’s more prepared than ever, with 22,500 health-care workers
offering free medical care to those in need, it’s the aftermath that has
experts worried.
In a conference call with reporters on Sept. 25, Keiji Fukuda, the
World Health Organization’s (WHO) assistant director-general for health
security and environment, said the current level of surveillance for
MERS was “suboptimal.” The average MERS incubation period of five days
to two weeks leaves plenty of time for pilgrims to return home infected
but not yet obviously ill, potentially seeding the virus
internationally. The WHO’s emergency committee expressed concern that
nations in sub-Saharan Africa lack the proper lab facilities and ability
to track cases and infection patterns if the virus appears there.
We still don’t know exactly how the virus is contracted, or whether
it has adapted to our bodies well enough to pass efficiently between us,
or how to stop it. Those answers could have enormous impacts on humans,
and they’re certain to involve wildlife. In his book Spillover: Animal Infections and the Next Human Pandemic,
the writer David Quammen described the relationship well, calling
animal and human diseases “strands of one braided cord.” HIV, Nipah
virus, SARS—they all jumped from wildlife to people. And we’re just
getting started.
A recent EcoHealth study in mBio estimates
there are at least 320,000 viruses in mammals awaiting discovery. About
70% of these are believed to be zoonoses, or ones that cross from
animals to humans. That’s why independent laboratories, universities and
governments are investing so heavily in early detection programs, to
stop emerging pathogens like MERS before they become global killers.
When each new virus can set off a pandemic, Daszak says, “we’re in a
race against evolution.”
The Outbreak Begins
In June 2012, a Saudi businessman died at the Dr. Soliman Fakeeh
Hospital in Jeddah, an urban hub on the bank of the Red Sea. His
physician, Egyptian microbiologist Ali Mohamed Zaki, couldn’t identify
the man’s respiratory infection and sent a sample to the Saudi Ministry
of Health. But dissatisfied with its negative tests for flu and other
viruses, he mailed another sample to Ron Fouchier, a virologist at
Erasmus Medical Center in Rotterdam. The lab grew the virus’s full
genome sequence and the two researchers concluded it was a new
coronavirus. On Sept. 20 that year, Zaki—unable to report the finding to
the WHO without going through government channels—posted to
ProMED-mail, an Internet forum that tracks emerging diseases. That
prompted a London hospital to test a Qatari patient, who had recently
visited Saudi Arabia. He was positive for a closely related virus.
One case tosses up a flag, but when there are at least two cases,
three months apart, in two different countries, “then you know there is
trouble,” says Fouchier. The ministry was enraged with Zaki for sending a
sample outside the country unauthorized and reportedly forced hospital
brass to fire him, sending him back to Egypt. But within days of Zaki’s
post, Ziad Memish, the Saudi deputy minister of public health, reached
out to W. Ian Lipkin, the epidemiologist and famed ‘virus-hunter’ at
Columbia. (It was Lipkin who was hired as a consultant to help make Contagion realistic.)
Within days, Lipkin was on the ground in Bisha, the arid town in the
southwest where the businessman had lived. Vishal Kapoor, a senior
researcher and colleague at Columbia, joined him. So did two members of
EcoHealth: Kevin Olival, a bat specialist, and Jonathan Epstein, a
veterinarian and its associate vice president for conservation medicine.
Bisha was desolate but more modern than the desert outpost they
expected. The group met the man’s family, seeking to learn about his
health and lifestyle, and to gauge his interaction with wildlife like
bats. None, they were told. That wasn’t surprising. Bats typically roost
in non-descript cracks or crevices and emerge after dusk. If you don’t
know to look for them, you may never see them. They also visited the
man’s hardware store. The eureka moment, Epstein recalls, came when they
found bats foraging around the sheds out back. This was a critical
contradiction of the family’s claim, and a welcome clue. Now they just
needed to catch the bats.
The researchers were eventually led to abandoned ruins on the hem of
town, where Epstein says they found the “needle in the haystack”—a roost
with hundreds of bats. Over three weeks at various roosts, they caught
and released 96 bats, each sampled for their blood, saliva, feces and
urine—the four conventional ways a virus can escape their bodies.
Plastic tarps were also placed at roosts to collect their pellets. The
samples were stored in liquid nitrogen, then packed in dry nitrogen and
sent back to the U.S. for testing.
They would later preliminarily find that the virus, thought to travel
through bats’ gastrointestinal tracts, might be found in the pellets
and that a human or another animal could inhale the pathogen if the
pellets were crushed and aerosolized. But the researchers couldn’t say
for certain. Since the virus was found in feces, a bat might have
dropped infected pellets on another animal, or it could have been
ingested from another source altogether. It didn’t help that the samples
were delayed leaving Saudi Arabia and that U.S. border protection
officers ended up opening the containers, causing them to thaw. Still,
Lipkin’s lab subjected the degraded samples to polymerase chain
reaction, a biochemical tool that quickly copies RNA millions of times
and sows them into a segment. But the output wasn’t long enough. “You
need big chunks of RNA to start out with in order to get big chunks
later,” says Olival.
In April, Lipkin, Kapoor and Olival returned to Saudi Arabia to
collect more pellets, sample other domestic animals and widen their
ground search. By then, a cluster of cases from a Jordanian hospital a
year earlier had been linked to the virus and there was a new hospital
outbreak in Al-Hasa, in the oil-rich eastern province. The infection
would spread to three other hospitals as patients went elsewhere,
sickening others. Memish, in charge of the response, invited in Western
academics and clinicians—including SARS veterans—to help with the
epidemiology.
Around their arrival in May, the International Committee on Taxonomy
of Viruses—yes, it exists—decided on a name that was catchy, informative
and geographically sensitive: MERS. Three members of that international
team said most of their work involved streamlining clinical chart
reviews, aiding health care workers with infection control practices and
working to define which patients needed to be tested for MERS. Writing
in the New England Journal of Medicine, they found that the infection had moved between patients in hemodialysis units.
Medical tests in general are skewed toward the seriously ill, who are
more likely to have higher concentrations of a virus and therefore more
likely to turn up positive. Only “unexplained” cases of pneumonia were
being examined and patients must have hailed from (or visited) the
Arabian Peninsula to qualify for MERS testing. That’s why the mortality
rate hovered around an alarming 50%—doctors were likely only catching
the sickest of the sick. But the experts urged for an expanded spectrum
of symptoms worthy of testing to spot milder cases, who could
conceivably still transmit the virus. That would eventually happen. And
when they looked harder, they found more.
Since April, the number of cases has more than doubled and other
outbreaks—one included a Filipino health care worker—have blossomed
throughout Saudi Arabia. In Hafr al-Batin, a remote town in the
northeast where 11 cases were confirmed, there were four deaths in one
family. The brothers of Fahd al-Sahly, 39, a government employee and
part-time camel trader, told the Wall Street Journal he
fell ill in August after buying a young camel that became sick. He
cared for the animal, then sold it. Thirteen days later, he was dead.
His mother and two other relatives would die, too. One brother, Jawal,
recalled hospital workers told Fahd “you’re making a big deal out of
nothing.” Memish, who coauthored a study
that found several strains of the virus had been swirling as a common
ancestor as early as mid-2011, insists the ministry has appropriately
increased its information campaign with television and newspaper ads.
Jawal said the family wasn’t aware MERS had even existed, let alone how
to avoid it.
Blaming the Host
No search for an emerging disease is free of criticism, and Saudi
Arabia has received a lot of it. In June, Tareq Madani, an infectious
medicine professor at King Abdul Aziz University in Jeddah, accused
the ministry of poorly informing citizens about how MERS spreads. In
September, Michael Osterholm, director of the University of Minnesota’s
Center for Infectious Disease Research and Policy, called
the lack of epidemiology surrounding the outbreaks “absolutely
unacceptable.” Larry Anderson, the scientist who led the SARS response
for the Centers for Disease Control and Prevention and who now teaches
at Emory University, recently told the
Canadian Press it’s “concerning and sad” that more was known about SARS
just weeks after it was found than what’s known now about MERS.
Memish has pushed back, asking critics to put the virus into the
perspective of something like the seasonal flu, which annually kills
between 250,000 to 500,000 people worldwide. He says case information,
while limited, is posted online before being sent to the WHO and that
testing has been expanded to anyone who’s been in contact with known
MERS carriers. On Oct. 2, he said
hospitals along the Hajj route are screening pneumonia patients for
MERS using tests that produce results in six hours. He also confirmed
that pilgrims have been advised to wear surgical facemasks and a
case-control study, which compares sick and healthy people to look for
possible sources of infection, would begin at a future date. Critics
have wanted this standard for months*. “It’s not that we don’t have
resources and it’s not that we don’t have brains, and it’s not that we
don’t have the capacity,” Memish told TIME, “but there’s always the
critic[s] who say we should know in a day what’s going on.”
That never happens. Laurie Garrett, a senior fellow at the Council on
Foreign Relations, says the blame isn’t Saudi Arabia’s alone. The
exorbitant cost of ground-level research and surveillance, in desolate
parts of a country that tends to be hostile to non-academic Westerners
but which lacks scientific resources of its own, at a time when funding
is low and millions of foreigners could become carriers and return home
to countries incapable of combatting it, has created “a perfect storm.”
By the end of the month, we could see a menial rise in the number of
regional infections, or we could see the bloom of the next big pandemic.
Like Garrett, William Karesh, executive vice president for health and
policy at EcoHealth, says there aren’t any “bad guys.” He believes the
Saudis were right to be cautious and avoid the possibility of mass
hysteria. “There’s a lot of potential risk in saying the wrong thing and
then, of course, there’s a potential risk of not doing the right
thing,” he adds. “There’s a dilemma, and that’s not uncommon.”
Karesh recently returned from Saudi Arabia as part of a two-week
mission with the U.N.’s Food and Agriculture Organization. At the
invitation of the Ministry of Agriculture, the country’s legal authority
for domestic animals, the team was asked to strategize how to identify
the virus in animals. To date, not one has been found sick with it.
Karesh recognizes that Saudi officials haven’t prioritized animal
testing the way they have for human cases—now ramped up to hundreds of
samples each week—but insists there’s a desire for it.
New cases, and sometimes deaths, are being reported as testing widens
and researchers try to define the elusive path of transmission. There’s
still no vaccine, either, which isn’t surprising—they’re not typically
made for viruses with few cases due to the immense time and money needed
to create, test and distribute one. The ministry hasn’t reported
Hajj-related cases, but if they do appear the international response
could shift into overdrive when the WHO emergency committee meets again
in November. Until then, we wait. “There’s nothing to suggest at present
that we need to go on high alert,” says Lipkin. “We’re yellow, not
red.”
Influenza/PandemicQuickKit - Contagion EDC at NebshipShop
Flying Blind
We’re still new at this. We may beat back one pathogen, but another
can reappear and take its place. Several SARS cases have popped up since
the outbreak a decade ago, and an alert was recently issued in
Madagascar amid new cases of the bubonic plague. Much of today’s health
research is fueled by the need to respond to new outbreaks, rather
than averting a crisis before it hits. With MERS, scientists at the CDC
have aimed to remedy this by developing and distributing molecular
diagnostics to state agencies so they can tell whether any of the
estimated 11,000 Hajj pilgrims from the U.S. return infected. None have
yet, but this regional strategy shows that we’re running out of time to
change our global approach.
EcoHealth’s Daszak likens the response to what happens in the wake of
earthquakes: “We go in there, we deal with it after it’s happened, we
dig people out of the rubble.” Karesh agrees: with so many unknown
infectious diseases out there, medicine needs the equivalent of tougher
building codes and the technologies to predict outbreaks before they hit
so we’re not spending crucial time and resources to rebuild.
Preemption, not reaction, would go a long way.
So why hasn’t that changed? We have the technology needed to identify
most emerging viruses and their origins, speeding up recognition and
intervention, but we stall. The answer is simple: politics and money.
In Wired, the writer Maryn McKenna explains
that governments almost always seek to evade blame for global health
threats within their borders rather than promote transparency:
“Information can outrun deadly new diseases, but only if it’s allowed to
spread.” These threats are expensive to find, test and contain. And
even if labs have the time, they’re short on personnel and cash.
Sequestration in the U.S. hasn’t helped. Automated federal spending cuts in 2012 reduced
the National Institutes of Health’s annual budget by 5.5%, to $29.1
billion. Labs have felt the pinch of fewer research grants, with
directors ending half-completed projects, foregoing others altogether
and trying to keep their staffs relatively intact. That was all worsened
by the government shutdown on Oct. 1, which also marked the start of
flu season. About 9,000 of the CDC’s 15,000 workers have been
furloughed. Thomas Frieden, the CDC’s director, tells TIME that several
staffers are still working in Saudi Arabia, but the lack of resources
back home is inhibiting their research.
Frieden’s tone is anguished. The shutdown hasn’t just “derailed” the
agency’s capacity to find, stop and prevent health problems, but
“undermined” its ability to work with local and state authorities.
Bi-weekly calls with state health agencies about global threats have
stopped and concern is high that should an emergency come up, any
response would be delayed. Illustrating the impact, he likens the CDC to
a ship lost at sea. “You can go a day or two without your navigation
system—you won’t get too far off-track,” he says. “If you go a week or
two, you could end up in very dangerous waters.” Now his biggest worry
is what they’re missing: “We can respond to emergencies, but we don’t
have our systems to find them reliably.”
Lipkin, who advises the NIH director, puts it bluntly: “There’s no
money for science in the United States.” It’s hard to see effects on his
office-lab setup at Columbia—the floors buzz with white coats handling
vials or waiting for costly machines to spit out results as others slog
away on computers. Sequestration forced him to reallocate other funding
to MERS research and pushed back the hire of another researcher, but the
shutdown means new tests on ungulate samples—he says the surveillance
focus should shift to livestock and wildlife—will be outsourced through
mobile labs he’s helping send to Saudi Arabia. “We’re wrestling with
these challenges of trying to find ways to do as much, if not more, with
less,” he says. “And it’s tough.”
In the meantime, doctors are keeping up with threats as best they
can. This virus isn’t a pandemic yet, and some believe that MERS may
lack the ability to truly threaten the world. But the potential is
there. “If it does,” says Connie Price, the infectious disease chief at
Denver Health Medical Center who aided epidemiology efforts in Al-Hasa,
“I guess it’s on us.” And the generations that come after us.
*[UPDATE: The original version of this
story reported that Ziad Memish confirmed a case-control study had
begun. Memish hasn't provided a start date and couldn't be reached for
comment on this matter.]
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