A team of experts from the World Health Organization (WHO), the UN’s Food and Agriculture Organization, the World Organization for Animal Health and Institut Pasteur, France concluded a mission to Saudi Arabia on February 23 to assess the current situation of the Middle East respiratory syndrome (MERS-CoV) following a surge of cases in the past few weeks, and to make recommendations for improving the surveillance, prevention and control of the virus.
Already this month, more than 50 cases have been reported in several locations in the Saudi Arabia, including infections acquired in health facilities (called nosocomial infections) in Riyadh, Qassim Region and Damman City, eastern region.
MERS-CoV is a viral respiratory disease caused by a novel coronavirus that was first identified in Saudi Arabia in 2012. MERS-CoV cases continue to occur, with sporadic cases and clusters of cases in communities and healthcare settings.
In total since the emergence of the virus in April 2012, 1,026 laboratory–confirmed cases of MERS-CoV, including at least 376 deaths have been reported to WHO. More than 85 percent of these have been reported from Saudi Arabia. There is no cure or vaccine at present, and WHO has expressed concern about the possibility of international spread. There is no evidence of sustained human-to human transmission although a small number of cases have been exported by travelers.
Members of the joint mission held discussions with high-level representatives from the Saudi Ministry of Health, visited the Command and Control Center that has been leading all activities related to the control of the MERS-CoV, and toured the emergency and isolation facilities of the Prince Mohammed Bin Abdulaziz Hospital. Government officials and the WHO-led mission shared their concern about the rising number of MERS-CoV cases in recent weeks and in particular in healthcare facilities.
“The Kingdom did a lot to control the MERS-CoV. We want to hear WHO experts’ feedback on the Kingdom’s progress, but also where we can improve," said Ahmed Bin Aqeel Al Khateeb, the Saudi Arabian Health Minister who also stressed the need to enable any hospital, whether government–run or private, to handle a MERS-CoV case. "The government is fully committed to implementing the right control and prevention measures and also to funding any activities needed to control this disease."
Although data collection and surveillance have improved globally in recent months, critical gaps in knowledge remain,and several challenges in the country will require further work.
For example, how and why infections occur in the community is yet to be understood, and this is critical to stopping the outbreak. In addition, cases that occur in healthcare settings require further analysis to fully understand what steps are needed to ensure infection prevention and control measures are adequately implemented.
The fact that infections are still occurring in some healthcare settings but not in others indicates that current infection control measures are effective but not implemented.
“When health workers are infected at work, this puts other healthcare workers at risk, but also can be a risk to all other patients who seek care for other health conditions," said Dr. Keiji Fukuda, WHO Assistant-Director General who led the mission to Saudi Arabia. "Understanding where the breach in these measures is occurring and taking the steps needed to fully implement infection prevention and control measures can put an end to these nosocomial infections."
Besides implementing good infection control and prevention measures, efforts to educate professionals and the public are urgently needed. There are also significant gaps in community engagement to fully understand routes of infection and the preventive steps that should be taken.
Defining groups that are most at risk, such as the elderly and those with underlying medical conditions, and how to target these groups with the right health messages remains a challenge.
The mission, along with the Saudi Arabian health authorities, identified main areas that should be urgently addressed:
- Understanding the animal/human interface, that is, modes of infection and transmission;
- Filling critical knowledge gaps in the science and epidemiology of MERS-CoV by conducting further research studies and by sharing the findings widely and rapidly;
- Improving disease prevention, especially in health facilities that continue to experience avoidable infections; and
- Intensifying social mobilization, community engagement activities and communications. The mission also stressed the need for intersectoral cooperation and coordination, especially between health, agriculture, and other sectors.
Additional information from research studies is also required to better understand the risk factors for infection and transmission. Results from case-control studies from affected countries are urgently needed, in particular, from Saudi Arabia.