1 of these papers is pretty much exactly like the other...[UPDATED #2]

This is a strange one. 

Today, a New England Journal of Medicine (NEJM) paper [2] came out and received a vast amount of media coverage. 

It seems as if all the other recent press, the camel kissing videos, camel advocates decrying the link between MERS-CoV and their beauties and camels being included in risk assessments...have just primed the world for the next scientific paper. 

And then this new paper came out showing MERS-CoV infection of a farmer and of his camels and a likely direction to that infection of camel >> farmer. And, it came out in the highly prestigious NEJM - this folks, is one part of what a high impact factor is all about - wide exposure and broad coverage. You really get your research out there.

Apparently neither of us are actually
Jeddah camels 'cause we're wearing too
much bling.

Twitter and the mainstream media have lit up with lines like "direct evidence that MERS comes from camels", "new report offers strongest evidence yet that MERS virus spreads from camels to people", "1st evidence that a new deadly virus has been transmitted from a camel to people".
There is a problem though. It's not reeeally any of those things.

These are both studies of what looks to be the same infected human (a 43-year or 44-year old man depending on which report), hospitalised at King Abdulaziz University Hospital in Jeddah on 3-November-2013, owner of a herd of 9 camels, some of whom were sick, sampled at around the same time (I presume, otherwise why sampled at all?).

The only major differences (there are smaller differences) between the 2 reports is which camel yielded sequence - it seems to have been Camel G for Drosten's lab and Camel B for Madani's - they even seem to have used the same identification scheme for the camels! The NEJM paper also has some human serology data that were absent from Drosten's study; determined using an immunofluorescence assay, although not confirmed as MERS-CoV specific using the more specific neutralization test.

Oh, one other big difference.

Memish, Drosten and colleagues got their paper out online around 20-March-2014 (2-months 15-days earlier [UPDATED]).

But let's also look at the sequence release/modification date too. This is the date when the researcher's virus sequence data, submitted to the public sequence database GenBank prior to the paper being published, is available. For Azhar and Madani and colleagues, that date was 1-May-2014 (sample taken 5/8-Nov-2013) and for Memish and Drosten and colleagues, 24-March-2014 (could only access 3 fragments; sampled 9-November-2013).

NOTE: This Editor's Note was added (9-June) to the NEJM paper:

The patient and camels discussed in this article are also described in Memish ZA, Cotten M, Meyer B, et al. Human infection with MERS coronavirus after exposure to infected camels, Saudi Arabia, 2013. Emerg Infect Dis 2014;20:1012-5.

I'm sure there are at least 2 very interesting stories behind this little event.

References...

1. Human Infection with MERS Coronavirus after Exposure to Infected Camels, Saudi Arabia, 2013
   Ziad A. Memish, Matthew Cotten, Benjamin Meyer, Simon J. Watson, Abdullah J. Alsahafi, Abdullah A. Al Rabeeah, Victor Max Corman, Andrea Sieberg, Hatem Q. Makhdoom, Abdullah Assiri, Malaki Al Masri, Souhaib Aldabbagh, Berend-Jan Bosch, Martin Beer, Marcel A. M�ller, Paul Kellam, and Christian Drosten
   Emerging Infectious Diseases
   http://wwwnc.cdc.gov/eid/article/20/6/14-0402_article.htm
2. Evidence for Camel-to-Human Transmission of MERS Coronavirus
   Esam I. Azhar, Ph.D., Sherif A. El-Kafrawy, Ph.D., Suha A. Farraj, M.Sc., Ahmed M. Hassan, M.Sc., Muneera S. Al-Saeed, B.Sc., Anwar M. Hashem, Ph.D., and Tariq A. Madani, M.D.
   New England Journal of Medicine
   http://www.nejm.org/doi/pdf/10.1056/NEJMoa1401505

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MERS-CoV charting on hold after 113 new cases reported without details...[UPDATED]

With the announcement overnight that a bunch (133 detections including 92 fatal cases) of old laboratory confirmed MERS-CoV detection had been found, but without any specific data to identify them, I will not be posting any further MERS-related charts. I believe there is a big WHO Disease Outbreak News update coming soon and it will provide all the detail - we bloggers will need to take a week off from our day jobs to add this detail to our line lists - but I'll resume charts some time after those data appear.

This is all obviously being dumped at the feet of the stood-down Deputy Minster of Public Health whose reputation for total control was well reported. Let's not forget that the Minister, Abdullah al-Rabeeah, was stood down 21-April by King Abdullah. If Prof Memish, who had been moved off the advisory committee when the new Acting Minster of Health took the reins, had the total responsibility (that many attribute to him) of ensuring every lab result was identified and reported and he was in charge of overseeing and releasing those data - then blame away! But that would also mean that the Ministry of Health is not a Ministry, but a one-manistry. I'd like to  believe that was not the case. Was the Ministry really under the complete control of just one Deputy Minister? It's never that simplistic.

This latest event, 6-weeks later and including cases from 2013/2014, points to reporting systems and data collection and collation pipelines that failed miserably. Given the inconsistencies of case reporting by the MOH, I don't have much trouble believing this is not a cover up but an administrative stuff-up. 

Sounds like I'm defending Prof. Memish too - which is not my intention. I do not know the facts. But I'm not sure anyone outside the KSA MOH does. Wouldn't it be great to live in a world where someone came out and just told it like it was? While Prof Memish obviously loved a good paper, and that was his chosen method of science communication (I've talked about that as a less-than-ideal route for public health matters), I personally have no evidence for or against the scope of his control over this latest debacle. 

Highlights of 113 retrospectively added (orange)
laboratory-confirmed detections of MERS
(including 92 deaths)
added to the cases already knwon (blue)
Chart from KSA MOH CCC [3]

A final note. These data [3] are presented on the new-look Ministry of Health's Control & Command Center (CCC).[1] It's a new website address so update your links. 

Let's wait and see whether the CCC lives up to it's name.

References..

1. Saudi MERS data review shows big jump in number of deaths
   http://in.reuters.com/article/2014/06/03/us-health-mers-saudi-idINKBN0EE1N820140603?feedType=RSS&feedName=health&utm_source=dlvr.it&utm_medium=twitter&dlvrit=309303
2. Kingdom of Saudi Arabia Ministry of Health Command and Control Center (CCC)http://www.moh.gov.sa/en/CCC/PressReleases/Pages/default.aspx
3. Update in Statistics: Ministry of Health Institutes New Standards for Reporting of MERS-CoVhttp://www.moh.gov.sa/en/CCC/PressReleases/Pages/mediastatement-2014-06-03-001.aspx

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MERS-CoV by week...good luck Professor Memish

We are now in the 116th week since MERS-CoV caused known illness in a  human; a week that has seen the loss of Professor Ziad Memish from the frontlines of the war on MERS. 

Thankfully it was not a physically fatal loss, but rather a "standing down". Not only is Prof. Memish the father of Mass Gathering Medicine, but he has been the public and global face for the mischief caused by MERS since the beginning.

Insights from the Front Lines. UPMC Center for Health 

Security presentation by Dr Ziad Memish on MERS-CoV.

August 21, 2013

I tip my hat to a very prolific and expert writer who has in his time covered every aspect of the emergence of this virus. He has produced about 40 journal articles on MERS-CoV in just 2-years..so far. 

I and others have been critical of the speed with which information about MERS and the MERS-CoV has materialized and I stand by that. But I admit to never having walked a mile in Prof. Memish's shoes so that may be unfair.

I also realize that this one person had a lot to do. He bore the brunt of being the front man, the scientific communicator, the collaborative nexus and also the punching bag for the hits that came when things didn't go well or go fast enough; today's announcement is probably the culmination of those hits. Whether or not Prof. Memish was adequately supported in his role, I have no idea, but I personally feel The Ministry of Health needed more engagement with it's stakeholders, the people of the Kingdom, but also with the world at large. I don't know that any one person can adequately do all those things nor should he be blamed for all those failings. 

We shall see how Prof Memish's successor goes. I'd personally hope that they start a dedicated media Unit that can become a more public face for MERS and other health issues in the Kingdom. I'd instruct that Unit to have an active presence on Twitter. But not just on Twitter ; engaged with Twitter. Many people have ideas that could help inform and educate-listen and learn from them. And update the Coronavirus website with some "work in progress" banners. I think some official hints or comments about what is coming down the pipeline would be very useful and calming. And try find some mainstream media writers who will do the occasional 1 on 1 interview - sometimes the quick grabs can be a killer for trying to get the bigger picture out into the world. Plus, a lot of people like knowing more about "that person over there". Its a big media-driven world out there. Use it. Be novel and innovative with it. You've cleaned out your house now. Do something new and exciting with your abode.

So, to wish Prof Memish the best, I post a chart. I can't buy him a coffee from my chair on the other side of the world far away from all the action-but I would if I could. I'd love to sit and have a chat with him about it all. I also very much hope he has someone he can he can vent to, or with, at the end of the day. I know that without my family, I'd have gone mad many years ago! 

This is not a new chart to anyone who reads these pages. And it's not one that screams of an outbreak out of control. It's a chart that shows the continued cessation of an outbreak. In fact, one that seems to be under control, at least for now. And given that the biases in reporting are probably no different now from what they were 6-weeks or 18-months ago, I tend to trust that it is under control. 

Perhaps this is a fitting send off for a man who seems like he just wanted to do the best he knew how to, to help his people. I hope he can still do that in whatever role is next up for him. Just as I've always hoped for that for Prof Zaki as well.

Now to see what comes next for MERSville.

A chart for Professor Ziad Memish.
Click on chart to enlarge.

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MERS-CoV detection and age...

Just a few different ways of looking at age of living and deceased MERS-CoV people, globally, since 2012.

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The International Health Regulations (IHR) 2005...

I've heard a lot about the IHR but I have not read the entire document. 

This post is just to note which States are considered to be a party to them and what they mean in general terms.

 A blog-friendly reformatted excerpt from the Foreward (highlighting is mine)...

"The purpose and scope of the IHR (2005) are �to prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade.� The IHR (2005) contain a range of innovations, including: 

• (a) a scope not limited to any specific disease or manner of transmission, but covering �illness or medical condition, irrespective of origin or source, that presents or could present significant harm to humans�; 
• (b) State Party obligations to develop certain minimum core public health capacities; 
• (c) obligations on States Parties to notify WHO of events that may constitute a public health emergency of international concern according to defined criteria; 
• (d) provisions authorizing WHO to take into consideration unofficial reports of public health events and to obtain verification from States Parties concerning such events; 
• (e) procedures for the determination by the Director-General of a �public health emergency of international concern� and issuance of corresponding temporary recommendations, after taking into account the views of an Emergency Committee; 
• (f) protection of the human rights of persons and travellers; and 
• (g) the establishment of National IHR Focal Points and WHO IHR Contact Points for urgent communications between States Parties and WHO."

This was taken from the PDF of the IHR2005 [1]

References...

1. International Health Regulations 2005
   Second Edition
   http://whqlibdoc.who.int/publications/2008/9789241580410_eng.pdf?ua=1

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MERS-CoV detected in 21st country....no party ensues

Algeria has reported 2 cases of MERS-CoV infection among two men (66 and 59-years of age) returning from performing Umrah in the Kingdom of Saudi Arabia (KSA).[1,2] 

No indication of any local transmission as yet. Seems the pilgrims arrived with signs and symptoms of disease so, as Crawford Kilian asks[6], just how carefully are authorities at KSA exit points examining departing people for signs of respiratory disease? 

Click on image to enlarge.

While we await confirmation that all the laboratory "I"s have been dotted and "T"s crossed, I wonder if there was any camel/animal contact or if these men visited a hospital while there? If the answer to these questions is no, then we're left to suspect that there may be a lot more community transmission going on than we are getting wind of. 

Daily total MERS-CoV detections have dropped to low levels and healthcare worker involvement no longer noted (i. because there are none or ii. because profession is no longer considered valid demographic detail for public consumption), so if not from animals or hospitals...then from where?

Less speculative is that we're also waiting on scrubbed detail from the WHO on hundreds of KSA cases, a Philippines case and detail about what is happening in Iran too. We've been waiting a while for some of that.

hat-tipping @crof, @Fla-Medic and @FluTrackers 

References...

1. http://www.tsa-algerie.com/2014/05/31/coronavirus-deux-cas-confirmes-en-algerie/
2. http://www.aljazeera.com/news/middleeast/2014/05/algeria-confirms-first-mers-cases-201453118430877511.html
3. http://www.flutrackers.com/forum/showthread.php?p=536454&posted=1#post536454
4. http://afludiary.blogspot.com.au/2014/05/algerian-moh-statement-on-two-mers-cases.html
5. http://www.sante.dz/communique_coronavirus.pdf
6. http://crofsblogs.typepad.com/h5n1/2014/05/algeria-a-very-litte-more-about-the-two-mers-cases.html

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Mental Health Inequality in Chiapas, Mexico

This is the room where a man has been incarcerated for five years, without ever leaving.  I don't call him a patient because I didn't meet him personally, but his story churns my stomach.  He is somewhere around 60 years old, and developed schizophrenia when he was 18.  He was odd but functional for many years, but in later years grew increasingly aggressive and threatening both to his family and to people in the community.  He had one psychiatric hospitalization, where they used injection medications that aren't available in the community.  Once he was discharged back home, he refused to take oral medications.  After he attacked his family, they decided he needed to be locked up, for the safety of everyone.  It took eight men to restrain him and secure him in the above room and he hadn't left this room in five years.  

Note the rope that is tied to the metal door... That is to keep it locked.  There is a hole where they pass him food and he uses the floor to go to the bathroom.  No shower, no grooming in five years.  As we walked near the house, it smelled of filth.  He yelled for his mother repeatedly and said that he wanted us to go away, whoever we were.  I don't know if he meant us or voices he was hearing, although we're the most likely culprits.

We were there to try and convince the family to let Compa�eros en Salud try and get an injectable antipsychotic in the community that lasts for a month, in the hopes that it will make him calm enough to be able to come out of his locked room.  The proposal was that we get the police and lots of back up, open the door, sedate him, clean him and bathe him, give him the medication and return him to the room after it has been cleaned.  The hope is that he may be able to be calmed enough that he won't have to stay a prisoner for the rest of his life. 

His family was hesitant; they'd had lots of doctors try to fix him, and all of them had demanded large sums of money.  They also didn't want to be hurt.  Another big concern...  We would need to destroy the metal door, which had been solderd shut and they didn't have money for a new door.  But the seed has been planted, and hopefully they will make it happen.

The situation makes me feel physically ill. There is nothing humane about what is being done to him, which I say even as I understand why his family is doing it.  There simply are not places for people like this man to go in the long term in rural Mexico.   With only one psychiatric hospital, there are long wait times for a place in the hospital, and there are no discharge locations where patients who need interim care can go. While his family was trying to mitigate the harm he could cause, I can't imagine a more terrifying situation for a paranoid patient than to be locked in solitary confinement, essentially forever.  People of sound mind go crazy under those circumstances, let alone people with his degree of illness.  

I say this with deep respect for each of the individual players, who are doing their best in a terrible situation.  And yet the horrific inequality of how impotent we were in the face of this awfulness shows how large the problem looms.  And it is a hard measure of how well they are able to take care of the mentally ill, some of society's most vulnerable.

-Sarah Kimball, PGY-3

Internal Medicine, Brigham and Women's Hospital

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