MERS-CoV numbers-where are we at?

As the dust settles from several days of new cases, and deaths and retrospective case identifications, I sit waiting for some caped crusader (no capes!) to step from the shadows and announce "I have the numbers you seek!" Okay, I'm a sucker for a caped crusader.
Alas, there are no such wonderful heroes to help fill the data gaps we lack among the MERS-CoV case data. There are plenty trying though. And so we watch the numbers climb, the cases spread, then contract (depending on which reliable source of information is speaking) and we wait for the likely spike in new cases due to the upcoming Hajj which, even with calls to reduce numbers, will likely go ahead as a mass gathering that puts MERS-CoV transmissibility to the test.

Sometimes we seem to hear a proposed new case or a death, and then we hear no more. 

Where is this virus coming from - animals, are older males with underlying conditions (and what precisely are all these conditions?) getting it from Pipistrellus sp. or perhaps Rousettus aegyptiacus bats via contamination of dates, date products of palm sap-derived drinks/alcohol? How can the world prepare, or understand whether it needs to prepare, for a novel virus when the region of its apparent origin (we don't know that either) has trouble sorting out whether members of its own populace are positive or not? A rough - what else can there be - count shows at least 23 dates of onset missing, 9 dates of death, 10 ages, 67 dates of hospitalisation and 11 sexes undefined for around 72 cases.

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Isothermal DNA MERS-CoV test

Laurie Garret noted this article about a new, relatively easy to use bedside test to be described at the upcoming Abu Dhabi Medical Congress.

The key piece of information here, as it sometimes is with bedside (Point of Care or POC) testing, is how its real-world (using clinical samples) sensitivity ranks against other testing methods. False negatives provide a sense of false security that can be disastrous for infectious disease management. Also, the types of sample that can be collected at the bedside are presumably weighted towards easier-to-access upper airway secretions. That will not play well for any virus that may be found more often in the lower airways at presentation.

Let's hope the test fits the bill. Fast, sensitive, specific and reasonably priced testing would make great inroads into infectious disease control. Time, and more information, will tell.

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Hanni Stoklosa, Bangkok, Thailand, Post-Natural Disaster Human Trafficking Prevention in Thailand

Blog Entry #2: Hanni Stoklosa, Bangkok, Thailand, Post-Natural Disaster Human Trafficking Prevention in Thailand
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Conducting interview

  With our strong team of researchers, we were able to interview a number of UN agencies, local Non-governmental organizations (NGOs), international NGOs, and Thai governmental agencies working in disaster response and anti-human trafficking. While analysis is ongoing, preliminarily we have seen some interesting trends.

 

Populations which are vulnerable to human trafficking at baseline include migrants from Burma, Cambodia, and Laos as well as Thai children and Thai minority groups. The flood water resulted in the closure of many factories where these marginalized groups typically work. As such, the floods caused major shifts in the labor market, leaving these already vulnerable groups open to exploitation, with reports of near-bondage labor conditions in some industries. Families were geographically fragmented. Undocumented status may have left certain groups further exposed to exploitation, as they were less likely to receive benefit from social safetynets available to the general Thai population. Communication via social media was a helpful, protective tool for many communities with access to internet. There were no mentions of explicit human trafficking prevention efforts among relief organizations during the flood time. While we continue to analyze our data, looking to the future, a population-level study based on the sample frames defined during this study will help to further elucidate the impact of disasters on human trafficking and thereby inform future prevention and protection measures.

Thai Red Cross

As my trip comes to a close, I want to thank the Harvard Humanitarian Initiative (HHI), the Asian Disaster Preparedness Center (ADPC), the Institute for Population and Social Research (IPSR) at Mahidol University, my residency program, Harvard Affiliated Emergency Medicine Residency, and the Partners Healthcare COE Global and Humanitarian Health Scholarship Program for making this important research on human trafficking in disaster contexts possible.

Members of our research team and partner organizations, HHI, ADPC & IPSR

 

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Hanni Stoklosa, Bangkok, Thailand, Post-Natural Disaster Human Trafficking Prevention in Thailand

Blog Entry #1: Hanni Stoklosa, Bangkok, Thailand, Post-Natural Disaster Human Trafficking Prevention in Thailand

 

 

The United Nations de?nes traf?cking as the recruitment, transportation, transfer, harboring or receipt of persons, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, or deception, of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or bene?ts to achieve the consent of a person having control over another person, for the purpose of exploitation. ?

Here I am training our Thai research assistants

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The International Labor Organization and the U.S. Department of State have long recognized Thailand as a hub of traf?cking in southeast Asia. Economic disparity in the region helps to drive signi?cant migration into Thailand from its neighbors, presenting traf?ckers opportunities to exploit those desperate for jobs.  Traf?cking is a serious risk that is heightened when people are displaced, families separated, children orphaned, and livelihoods destroyed. Specifically, natural and man-made disasters may increase the risk of human trafficking by increasing their vulnerability by these means.  

Map of Thai flood water progression from disaster response organization

 

I am here in Thailand to explore the relationship between the devastating 2011 Thai flood and human trafficking, thereby informing prevention and protection efforts against trafficking in future disaster scenarios.

Canal community affected by Thai flood

 

Through a partnership with Harvard Humanitarian Initiative, the AsianDisaster PreparednessCenter in Bangkok, and the Institute for Population and Social Research (IPSR) at Mahidol Universityin Thailand I am leading a team of researchers in a qualitative research study on Post-Natural Disaster Human Trafficking Prevention in Thailand. Through rigorous semi-structured interviews with established disaster response and anti-human trafficking NGOs in Thailand, we will explore relationships between a natural disaster and human trafficking.

 

 

  
  

 

One of our partner organizations, the Asian Disaster Preparedness Center

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Stuff from the literature: Don't judge a virus by its worst case [UPDATE].

This article, a Letter in the Journal of Clinical Virology (2013 Sep; 58(1):338-9) is one from our own keyboard. It is entitled Avian influenza A (H7N9) virus: Can it help us more objectively judge all respiratory viruses? Unfortunately it s behind a paywall, but I do not have the funds (they all go into the research) to pay for open access publication.

We try and make the point that every respiratory virus can be found in severe, moderate, mild cases or even asymptomatic people - H7N9 in a young child earlier this year being an example - but no particular portion of a given virus's clinical severity spectrum should be used to define that virus.

The risk of future prejudgement is real. For example, not all influenza-like illness (ILI) is due to influenza viruses. Expecting it to be so leads to confusion and misunderstanding. But on the other hand, screening for every likely viral culprit in every patient during a pandemic is impractical - or at least, it creates a bottleneck that slows result reporting and infection control. At some stage we'll have better, faster higher-throughput tech to do this, but we're not there yet - so we have to pick and choose.
In the meantime, old labels like the "common cold" virus (human rhinoviruses and coronaviruses) have done little to help anyone really be aware of what a virus is capable of. You may argue they have slowed research into their other roles to the detriment of public health. I do. These labels will never be shaken off. Yet we now know that most asthma exacerbations are triggered by infection with one of these 200 or so little packets of mischief.
Apart from naming viruses to avoid geopolitical, and personal sensitivities, it is also important not to label viruses which at one time may be innocuous...and at another, deadly.

Viruses pack a lot of potential into a small shell-and do a great job of running us in circles.

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Cumulative MERS-CoV Cases by area.

This is the latest chart (a cumulative epidemic curve) for my MERS-CoV page

Its a lacking some cases (57 of approx 64 cases are depicted below) - you may have head, data are sometimes hard to come by for the MERS-CoV outbreak. Still, it gives one a clear idea of where most of the cases have been occurring and how quickly they have accumulated.

Of particular interest is the take-off point which occurred from the week beginning April 14th. Over 30 of KSA's reported cases ~49 cases occurred from this point onwards - the exponential part of the red line.

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MERS-CoV cases and deaths rising.

FluTrackers report on 3 new cases of infection and 4 deaths among existing MERS-CoV cases.

The numbers are changing rapidly (cases being released in several batches of 3 doesn't help).

Currently there are at least 64 total cases and 34 deaths among people with MERS-CoV. Most cases are in people with underlying chronic medical conditions. The Saudi Arabian Ministry of Health (MOH) regularly accounts for this clinical feature in each press release.

You can get a feel for the spread of MERS-CoV cases on this map

The following sites are useful to keep a check on numbers:

• The FluTrackers case list
• CIDRAP news gives nice, timely summaries of events
• The US CDC site has a good table of cases
• The Kingdom of Saudia Arabia MOH site
• The WHO Global Alert and Response (GAR) updates

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MERS-CoV infection control: the French connection.

A Eurosurveillance article by Mailles and colleagues describes the procedures used to lock down spread of MERS-CoV once confirmed.

Confirmed cases were isolated in negative pressure rooms (they suck air in, instead of pushing air out of a room as usually occurs in an air-conditioned room, ensuring virus-laden particles cannot escape) with dedicated staff using contact and aerosol precautions (e.g. personal protective gear which may have included back fastening gowns, disposable gloves, filtering masks, glasses etc).

A close contact was asked not to return to work and to wear a surgical mask when with other people. Other close contacts had to carry a ask and do nit if they developed symptoms, but could otherwise continue with life as usual.

Airborne transmission was strongly suspected but other routes, including the possible contamination of surfaces from the stools of the index case who initially presented with diarrhoea.

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