Hajj and the Middle East Respiratory Syndrome (MERS)
By Dr Zafar M. Iqbal
TCCI, Chicago, IL
Those considering Umrah this Ramadan or Hajj in October would have to worry about something they never had to before: a previously unknown virus (a coronavirus) that causes an acute respiratory illness, observed mostly in the Arabian Peninsula. So far, out of 80 cases identified in just a year, 44 (or over 50% ) were fatal, and 65 of these cases with 38 deaths have been reported from Saudi Arabia alone.
Considering its geographic presence and impact, WHO has officially named it recently as the Middle East Respiratory Syndrome Coronavirus (MERS-CoV), after it was rather non-scientifically alluded to in the social media and elsewhere as ‘Saudi’ Severe Acute Respiratory Syndrome (SARS). Although a few cases have also been reported from nearby areas like Qatar, Jordan, UAE, Tunsia (and in about seven visitors from UK, France and Italy) but none so far from the US. Most of them got infected while visiting the region and brought the virus back to where they resided and would spread it further.
MERS, as it is commonly called, was first isolated in the Fall of 2012 by an Egyptian virologist, Dr Ali Mohamed Zaki, from the lungs of a 60-year-old patient in Jeddah, with acute pneumonia who died of renal failure (June, 2012). Dr Zaki shared a virus sample with Ron Fouchier, a noted virologist at Erasmus Medical Center, Rotterdam, the Netherlands, whose team then successfully sequenced its genome, published it in the Fall, and acquired a patent on it. [By the way, for this apparently unauthorized sharing, poor Dr Zaki lost his job, as reported in The Economist, though the Rotterdam Center took pains to clarify that the patent would not interfere with the public health research on the virus, and it did supply those who requested the necessary ingredients and reagents, free of charge.]
Coronaviruses belong to a large family of viruses that cause illnesses from common cold to SARS. MERS is a distant relative of SARS coronavirus (both belong to the genus, betacoronavirus). SARS first appeared in S. China in 2002/2003 and spread to three dozen countries, infected 8,000 people, killing over 770 (less than 10%). MERS, like other coronaviruses, is considered mostly an animal virus that sporadically infects humans, and spreads slower and is less transmissible than SARS but, given the over 50% fatality, deadlier.
MERS is reported to have an incubation period of about 12 days. Those infected develop in about two weeks increasingly severe acute respiratory illness, with fever, cough, and shortness of breath, along with some secondary complications such as renal and multi-organ failure, consumptive coagulopathy, GI trouble and diarreah. The median age of the patients is reported about 56 years, a large majority (72%) of them male, who may have had a direct or indirect link or travel-related experience with the Middle East.
While it took just months for SARS to become a pandemic, MERS has been circulating in humans for a year without any noticeable mutation into any pandemic form yet. What is to come during the hajj this October with nearly three million pilgrims from around the world is a matter of growing concern to WHO and health agencies in US, UK and other European countries, besides Saudi Arabia and its neighbors.
Dr Margaret Chan, WHO Director General, said MERS-CoV virus is a "threat to the entire world." She added , "We understand too little about this virus when viewed against the magnitude of its potential threat. We do not know where the virus hides in nature. We do not know how people are getting infected. Until we answer these questions, we are empty-handed when it comes to prevention. These are alarm bells. And we must respond."
A WHO team of experts went to Saudi Arabia this month to make a risk assessment ahead of the hajj, and suggest ways to minimize the risks. WHO's assistant director-general for health security and environment, Keiji Fukuda, MD, announced last week the formation of the emergency committee which has now been holding tele-conferences. The new committee is the second emergency panel the WHO has set up under the International Health Regulations (IHR). The first time the WHO took the step came during the 2009 H1N1 influenza pandemic, Fukuda explained. Fukuda sees two main patterns of MERS cases: sporadic cases in communities, from sources unknown, and cases resulting from person-to-person transmission among close contacts, mostly in families and hospitals.
"We really want to be in position to be ready for any possibility,” Fukuda added, “and we want countries to be ready for any possibility...If we see some future explosion or outbreak, we'll already have a group of emergency committee experts who are already up to speed. We just want to make sure we can move as quickly as possible if we need to move in the future in any major direction."
Fukuda said the Saudis have generally done a good job of responding to MERS, such as sending health experts into communities, investigating hospital outbreaks, stepping up infection control precautions in hospitals, and providing information to the Saudi public. Many have complained though that the government information is too sketchy and too little; more detailed information is needed about the overall situation.
Some groups organizing hajj pilgrimage are increasingly worried about the MERS outbreak. The Association of British Hujjaj (Pilgrims), the Birmingham-based group, is warning prospective travelers to take special precautions during the Hajj.
Khalid Pervez, general secretary of the organization said, "We would like to warn those people who have low body immune systems that they should not attend this year's hajj. And for the rest of the people, we would strongly recommend that they [check their health with] their doctor before their departure."
Ian Jones, a professor of virology at the University of Reading, UK, says, "My advice for the hajj at the present time is ....what I would recommend for large gatherings, and that is that personal hygiene should be as good as possible. You should take care of food hygiene, of course, and you should generally avoid situations which seem to be suspicious in terms of the cleanliness of the establishment. So, don't put yourself at obvious risk. But that would apply to a number of communicable diseases, not only this one."
John Oxford, a professor of virology at Queen Mary College in London, cautioned that the first cases of MERS infection were discovered before the last hajj, in October 2012. But there was no explosion of infections among participants, which sounds ominous for hajj this October.
Experts generally suspect that the hosts of this virus are Middle Eastern bats but how the virus gets transmitted from bats to humans is not known. Possible routes could be eating contaminated food products or handling intermediary animals such as goats and camels bitten by bats and fallen sick.
For background information and FAQs on MERS, clinical aspects and public health issues, these links from WHO and various public health agencies are very helpful:
http://www.who.int/csr/disease/coronavirus_infections/MERS_CoV_investigation_guideline_Jul13.pdf
http://en.wikipedia.org/wiki/Middle_East_respiratory_syndrome_coronavirus
http://www.cdc.gov/coronavirus/mers/faq.html
http://www.cdc.gov/coronavirus/mers/infection-prevention-control.html
http://www.cdc.gov/coronavirus/
http://www.guardian.co.uk/science/2013/may/13/new-coronavirus-mers-cov
http://www.phac-aspc.gc.ca/tmp-pmv/notices-avis/notices-avis-eng.php?id=108
http://www.sciencedaily.com/releases/2013/06/130619194957.htm
Rocky Mountain Laboratories, National Institute of Allergy and Infectious Diseases, NIH. The Middle East Respiratory Syndrome virus, MERS, or CoV
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