Jeddah changed the MERS-CoV age:sex landscape...

Note. Not every death or case is listed.
See bottom-left corner for breakdown.
Click on charts to enlarge.

I've broken down the age and sex in these charts.

As usual, it's mostly about males and older people until we get to the Jeddah outbreak.

In the top pair of charts (note the different scale used here compared to that used in the charts below) we see the breakdown for all MERS-CoV detections to date on the left and the fatal cases from among those on the right. 
An apple in terms of people shapes.

In the middle pair of charts we look at all cases form 2012 up until the day before the Jeddah outbreak. The total case pyramid shows an older age bulge but the deaths look very similar to those for all fatal outcomes. M:F is similar to the total case charts above.

In the bottom pair of charts we're looking at what happened from the beginning of the Jeddah outbreak until now. We see a marked change in distribution with many more younger adults being positive for MERS-CoV. We also see a major shift towards more females than we'd seen beforehand. All the result of more widespread testing and a greater healthcare worker contribution I presume. Strangely though, given the younger adult demographic here, we see no accompanying jump in numbers of children. Are they not subject to testing? Are the younger adults often foreign workers who do not have children/children with them with them? There is no reason for children to test any less frequently MERS-CoV-positive and they are also just as likely as healthy adults to get mild or asymptomatic disease (as far as we know). If positive, children will have an important potential role in the MERS-CoV transmission story, especially when visiting elderly relatives.

The recent Al Qunfudhah teacher who is MERS-CoV just reinforces that children are shaping up to be a strange data gap. Yeah. I know. Another one.

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Snapdate: MERS-CoV detections near 500...

MERS-CoV detection by day; Jeddah outbreak.
Click on image to enlarge.

Welcome to the beginning of MERS-CoV's 112th week (2.15 years). We sit at 497 cases (probably over 500 if the United Arab Emirates would confirm their cases with some extra data that made them more identifiable and "real". For now, I'm not including them after the recent issue around theUAE12. For now my count says at 497 with ~131 deaths (26.3%).

Judging by tonight's announcement of only 3 cases (only 1 with an onset date which was 24-Apr), let's hope this is the week where the Jeddah outbreak gets put to bed.

MERS-CoV detection by week 2012-present.
Click on image to enlarge.

Also, make this the week that the Kingdom of Saudi Arabia's(KSA) Ministry of Health adds some consistency to its releases. They've been doing a 100% improved job in the past weeks, adding much more detail, but it needs to be the same detail for every case, every day. And the listing of deaths and recovered cases is also great; but is currently not able to be linked to the original announcements so we don't know where they these people were from, comorbidities, HCWs etc as there are often 2 or more people from the same region with the same age. A date of affliction is needed to permit the linkage between original announcement and death/recovery. Just 1 more variable guys. Pleeease.

Nonetheless the dailies seem to be slowing, although the cumulative average still strolls upwards but in a linear, not exponential manner.

We stay tuned.

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MERS-CoV detection: Cases by week and cumulative average still rising thanks to 2 healthcare clusters

Click on image to enlarge.

This chart, cases by week, really tells the story of a super-cluster driven by Jeddah's hospitals. Why this is still rolling along is unclear.

Perhaps, just perhaps (and I'm hand waving here), we can say that because MERS-CoV cases are not popping up all over Saudi Arabia, and because it seems, so far, that the contacts of the imported Malaysian (ex Jeddah) and Filipino (ex UAE) cases are testing negative for MERS-CoV, that a significant change to create MERS-CoV MkII may not have occurred. If it had, seeing positive test results among contacts and family members would be a good indirect alarm bell. But we have not seen much of that in cases to date, and in past umrah and Hajj pilgrimages. 

The clock on the maximum incubation period has probably run out for the Malaysian fatal case who became ill 4-April. The Filipino case may also have run down his clock. He tested negative for MERS-CoV 11-days after his exposure in the UAE. As far as we know there are no positive contacts or family members from these 2 exported cases.


But then there was SARS....

@MackayIM Hey, remember they guy with SARS who got on plane from China to Singapore, plane had to stop in Vietnam, & he died in Vietnam 1/2
� A biologist (@influenza_bio) April 19, 2014

@MackayIM That was 2/2003. No one on plane apparently got SARS, but HCWs in Vietnam did. & that was SARS -we may not be there yet with MERS.
� A biologist (@influenza_bio) April 19, 2014

.@MackayIM @EllenKnickmeyer @Fla_Medic transfer of undetected #MERS patients between hospitals could really fuel spread. Seen in SARS.
� Helen Branswell (@HelenBranswell) April 19, 2014

If we could for a minute use that absence of new cases in those new international sites (also watching Greece now) to cross off viral change (still need to see viral sequences to be able to do that conclusively; Spike please!), that could leave us to focus on a breakdown in infection control and in the prevention of infection in hospital settings. 

I understand that healthcare workers don't walk around in full gloves, goggles, gowns and N95 masks for their entire shift (fyi, as lab researchers, we have to wear gloves, safety goggles and back fastening lab coats while we work in a PC2 laboratory environment with these viruses which we handle in a Class II Biosafety Cabinet), but I do wonder why we have guidelines for managing patients with certain signs and symptoms, if, and emphasise if, they are not to be followed. 

Such a guideline can be found in the very comprehensive publication listed below [1]...Table 1 about handling SARS patients seems particularly relevant. I wrote about this publication back in August 2013 [3], with the help of Mike Coston who has an extensive range of expert information on preventing infection over at his Avian Flu Diary blog.[2]

The recent spate of MERS-CoV cases is a grim but timely reminder of why HCWs need to be extra cautious when dealing with respiratory infection cases; you never know what might come through the door.

References..

1. Infection prevention and control measures for acute respiratory infections in healthcare settings: an update | Seto et al | Eastern Mediterranean Health Journal
   http://applications.emro.who.int/emhj/v19/Supp1/EMHJ_2013_19_Supp1_S39_S47.pdf
2. Avian FLu DIary | search for N95
   http://afludiary.blogspot.com.au/
3. Infection Prevention and Control measures for MERS..mostly as per other ARIs
   http://newsmedicalnet.blogspot.com.au/2013/08/infection-prevention-and-control.html

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MERS-CoV cases continue steep climb thanks most to 2 healthcare-related clusters...

Click on image to enlarge.
Data are for lab-confirmed cases only, and 
from FluTrackers, Ministries of Health
and the World Health Organisation Disease Outbreak
News reports.

The Jeddah cluster | Jeddah | Kingdom of Saudi Arabia. 

It is the biggest of any of the clusters of MERS-CoV cases within the Kingdom of Saudi Arabia, MERS-central (0 to date. It has seeded at least 2 internationally exported cases (a fatal case in Malaysia and now a case in Greece). It totals 53 cases so far; the tally for this cluster began after the onset of illness in the first case, 6-Apr.

The paramedic cluster | Abu Dhabi | United Arab Emirates

Happening simultaneously and right next door is a cluster of cases that began 28-Mar. It stands at 14 cases as I compose this; most recent with an onset of 14-Apr.

These dates, starting points and information are all up in the air of course. 

There have been no solid answers from either site on how each cluster commenced, so we don't know the actual 1st case nor how they became infected, what their status is or what type of contact occurred (animal or human-to-human). 

We don't know how many cases are linked together or even whether the 2 sites are linked. We don't know whether these focal outbreaks are ongoing nor just how so many healthcare workers (HCWs) can be infected by a respiratory virus that was already well known to the region and its hospitals (Wk 109, 2.1 years since first MERS cases). 

We don't know if this outbreak is just bad infection prevention and control at some hospitals/among some people. We are all wondering how this has continued among HCWs as it seems to be? After a couple of confirmed cases wouldn't masks and gloves and gowns be standard fare - if they weren't already in the management of unknown acute respiratory disease cases? Whether a "super spreader" is involved or not, such measures should have prevented so many healthcare workers becoming infected shouldn't they? 

Is this MERS-CoV Mk II - now with the ability to transmit efficiently and rapidly (before extra prevention measures are in place)? We have no MERS-CoV sequences to answer that. Spike gene sequences would at least help us understand he virus aspects? I don't really care about complete genomes-they are for phylogeny more so than public health; changes in Spike yielded information of value in the SARS-CoV event and for coronavirus in general, and could do so again. Just sequence that region guys! Do it quickly and release that info now. It's something informative. Don't wait for a scientific paper. Start a blog and put the results on there. Not just in Arabic and then in English some time later; with Yemen, the Philippines, Malaysia and Greece picking up cases in the past week, these 60+ cases are not just a Saudi thing (although the case numbers say otherwise-but you know what I mean), it's global village thing. Just tell us what's going on with the virus! 

So many things we don't know. "So what?" you ask Go and Google "MERS SARS" and limit it to the past 24-hours. That's so what. The media are starting to heavily lean towards the "MERS is the next SARS" story again and that stirs up concern at many levels. Is that concern justified. At the moment who the heck knows??? If there is no change in Spike, while not the be-all and end-all for change in the virus, it will allow the experts to make comments that inform the media that may calm a rapidly progressing situation with economically damaging potential for the world, and the region.

For crying out loud Ministry of Health|Saudi Arabia, get ahead of this thing.

Sources...

1. The world's greatest resource for tracking MERS-CoV cases, the FluTrackers line list
   http://www.flutrackers.com/forum/showthread.php?t=205075

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