Only a few months ago, the threat from Middle East Respiratory Syndrome (MERS) in large parts of the Gulf region appeared to be growing. Dozens of new cases were being reported every month and a key panel set up by the World Health Organization (WHO) advised that the “situation had increased in terms of its seriousness and urgency.”
Yet in recent weeks that threat has seemingly fallen away - with only two new cases in the last six weeks in Saudi Arabia. While seasonal changes may have had some effect, Saudi Arabia’s shifting strategies towards the disease also appear to be bearing fruit. What has caused this drop in cases? And what lessons can be learned for other contagious diseases such as Ebola?
A slow start
MERS, a cousin of the Severe Acute Respiratory Syndrome (SARS) that killed over 700 people around the world in 2002-3, is a virus that affects the respiratory system. It was first spotted two and a half years ago and to date there have been over 800 cases worldwide, with nearly 300 deaths.
Cases have been reported across the Arabian Peninsula and in May the disease was first confirmed in the US, with two cases of healthcare workers returning from Saudi Arabia sick. As yet, there is no cure for the disease, though it can often be contained through effective control and prevention methods.
Saudi Arabia has been the base of the disease since it began - with over 50 percent of the cases occurring there. By most accounts, the country’s initial reaction to the disease was slow. Saudi authorities were accused of downplaying the threat or not taking it seriously enough, with experts suggesting that the death toll could have been lowered had their reaction been quicker.
In particular, a high percentage of the cases were medical professionals - implying that hospitals had not put in place the right security and health mechanisms. An investigation led by WHO found that the main reason for the upsurge of MERS cases in Saudi Arabia was due to secondary - i.e. human-to-human - transmission, usually occurring in hospitals due to the implementation of poor infection control measures.
The infection mode in which the virus spreads is known as a “droplet infection” - airborne droplets of secretions from the nose, throat, or lungs. Mamunur Malik, an epidemiologist at WHO who stressed he was speaking in a purely personal capacity, said improper infection control measures among healthcare workers and visitors had helped the virus “spread fast”.
Sofian Ragab, research director at IDPH Research Group - a London-based research group that focuses on infectious diseases - agreed that the high levels of secondary transmission implied poor health standards. “It was worrying that so many nosocomial [hospital acquired transmissions] were being reported,” he said.
Likewise, critics accused the authorities of a lack of transparency. Jeremy Youde, associate professor of political science at the University of Minnesota Duluth who has done extensive research on global health governance, said openness is key to preventing the fast spread of a disease. But initially at least, he said, the Saudi government was seen to be slow and not keen enough to work with “other governments and organizations”.
Yet in recent months, the Saudi authorities appear to have shifted tactics to take the disease more seriously. In April, the minister of health and key advisers were fired, with Adel bin Mohammed Fakeih taking over the top job.
Among his first acts was to launch a council to work towards containing the disease.
Ragab praised the work of the new minister, saying Fakeih had introduced three dedicated centres in Riyadh, Jeddah and the Eastern Region to deal with MERS patients as part of a move towards openness. The government also took measures to ensure the reliability of information and the speed of reporting through developing an electronic case reporting system, as well as improving reporting mechanisms on new cases to the Ministry of Health.
Ragab said the decision to take the disease more seriously had had a huge effect “We witnessed a significant change in public health systems and a confidence-inspiring increase in effective infection prevention and control measures. The fall in disease cases can be attributed to effective epidemiology, contact tracing, disease surveillance and infection control,” he said.
There are other theories as to why the rates of disease have fallen away - foremost among them that the disease is seasonal. Malik points out that as it is believed to come from camels, it is possible that the number of cases spikes between March and May as mothers give birth. However, he said scientists are “yet to determine the seasonality of the disease”.
Likewise the drop in cases does not mean the disease is beaten. The Hajj pilgrimage in October, when over two million Muslims will descend on Mecca, could introduce new cases, Ragab said. “The crowded nature of the Hajj coupled with international diversity affords the opportune setting for the spread of infectious diseases,” he said.
However, he added that as long as “effective measures are kept in place”, the threat remains low as the cases that were reported during Ramadan and the Umrah pilgrimage this year included “only a handful of MERS cases”.
The government has also taken measures to increase awareness for those performing Hajj with doctors advising pregnant women, the elderly and children not to go. The government will also use existing health surveillance checkpoints at borders which to be on the look-out for cases.
Learning the lessons
In a world of over seven billion people, disease outbreaks are inevitable. But lessons can and should be learned from each.
The Ebola virus, recently declared an international health emergency by WHO, is a case in point. There are many similarities between MERS and Ebola. Both are believed to have come from animals and require close contact with an infected person to transmit, while neither currently has a cure. Ebola has claimed over 1,400 lives so far but the initial response was slow.
Ragab argued that the most important lessons from MERS and other diseases were “vigilance and preparedness”. While those who work in the healthcare sector know these are common issues, the slow reaction of the Saudi authorities appears to have been sadly mirrored in West Africa.
While Liberia, Sierra Leone and other countries have now declared a state of emergency, in the initial months medical professionals say they reacted slowly, with denial of the scale of the problem common.
“Outbreaks don’t just happen overnight: look at Ebola - the first cases were detected in Guinea during December 2013,” Ragab said.
While it may now be too late to contain Ebola early, MERS also shows the importance of international awareness and cooperation. All the experts IRIN spoke to agreed that limiting an outbreak is best done through openness, transparency and coordination. Malik said the best way to control outbreaks was “good collaboration and coordination with the health sector”.
Youde pointed to the SARS virus, which the Chinese government was initially keen to play down, as another example of the dangers of not taking viruses seriously enough. “It wasn’t until the Chinese government stopped trying to cover up SARS and actively engaged with the World Health Organization and other international partners that we really got a handle on the outbreak,” he said.
“Combining the resources and expertise of the international public health community allows us to leverage our collective knowledge,” Youde added, noting the importance of building up healthcare systems.
“When outbreaks occur, the healthcare system needs to be able to respond quickly… Many of these lessons apply to the current Ebola outbreak.”
While the lessons apply, critics say the response has still not been adequate. On 15 August Médecins Sans Frontières (MSF) released a damning critique of the international support to those countries affected by Ebola.
Calling the response “dangerously inadequate”, MSF called for an “immediate and massive international mobilization of medical resources - human and technical - to Liberia and Sierra Leone”.