On 6 June 2016, a 59-year-old man from Tabuk in the north west of Saudi Arabia was admitted to hospital. Two days later he was diagnosed with Middle East Respiratory Syndrome and four days after that he passed away. Unfortunately, he will not be the last to die of MERS, as the disease is more commonly known.
The disease, which is caused by a coronavirus, was first identified in Saudi Arabia in 2012 and has since spread to 26 other countries. The World Health Organisation (WHO) says it has been notified of 1,769 confirmed cases to date and at least 630 deaths. The vast majority of these have been in Saudi Arabia, although there was a significant outbreak in South Korea in mid-2015 and there have been cases reported from the US to France to Malaysia.
There has been some criticism of the way in which the Saudi authorities handled the issue at first and how quickly it shared information with the rest of the world. This is not in itself unusual, as Dr. Keiji Fukuda, assistant director general for health security and environment at WHO, noted when talking in June 2015 about the slow response of the South Korean authorities to the outbreak there.
“In my experience in dealing with outbreaks for the last few decades, what’s true is that whenever they occur, particularly when we have new viruses and new diseases, they invariably take everybody by surprise,” he said. “They take the country by surprise, the responders and the government and there is always a period of time in which you have to get organised to deal with the outbreak… There is always a learning curve in the beginning of these outbreaks.”
It may not have helped that the Ministry of Health has been led by seven different people in the four years since the MERS outbreak began. At least some ministers or acting ministers have been dismissed due to their handling of the response to MERS, including Abdullah Al-Rabiah who lost the job in April 2014. Hospital managers have also been in the firing line. In May 2014, the then acting Minister of Health Adel Faqih replaced the director and deputy director of King Fahd Hospital. The official Saudi Press Agency said the changes were made “to better fight the corona virus,” as the disease is often known in the country.
In one sense at least, things have been getting better. In the early days of the disease, the fatality rate was running at around 60%, but it is now close to 36%. Even so, the problem is far from solved and new patients are diagnosed with the disease most weeks. Between mid-May and mid-June, five other people in Saudi Arabia were diagnosed with the condition, in addition to the 59-year-old from Tabuk, and one of them is in a critical condition. Between 16 and 20 June the numbers shot up, with 28 more cases in the country, the majority of them occurring in a hospital in Riyadh.
Most cases have been attributed to human-to-human infections, particularly in hospitals and other healthcare settings where poor hygiene standards and other problems are to blame. One recent case highlights the risks: a 49 year-old woman was admitted to a hospital in Riyadh on 10 June with symptoms unrelated to MERS and kept in a multi-bed ward. During that time, at least 50 healthcare workers and patients were exposed and at least 20 of them have since tested positive for MERS.
It is widely suspected, although not proven, that infected camels are the original source of the disease and many others who have been diagnosed with the disease have had a history of close contact with camels. As a result, WHO says people should avoid drinking raw camel milk or eating camel meat that has not been properly cooked.
MERS is a tricky condition to diagnose at first. As with other respiratory infections, the early symptoms are non-specific, including fever, coughing and shortness of breath, but some carriers of the disease are asymptomatic. Patients can go on to suffer pneumonia and organ failure, especially of the kidneys. Older people, those with chronic diseases such as diabetes, cancer and chronic lung disease, and those with weakened immune systems, are all at higher risk.
No vaccine has yet been discovered for the disease. However, moves are afoot to develop one. In the U.S., the National Institute of Allergy and Infectious Diseases reported some promising results in tests of a vaccine on mice, rhesus macaques and camels in 2015.
In December that year, a team of Dutch, Spanish and German scientists revealed, in a paper published in the journal Science, that they had developed a vaccine that makes infected camels excrete less virus, something which could help to prevent transmission to humans. “It is possible that the risk of outbreaks among humans can be minimized by vaccinating camels,” said Bart Haagmans, leader of the study and a virologist at the Erasmus Medical Center, based in Rotterdam in the Netherlands. At the time, the Erasmus Medical Center said the new vaccine could also be used to vaccinate humans, and that a fresh study was being undertaken to determine this. As yet, no results have been announced from that study.
Along with the human cost of the disease, there is also an economic cost to be borne, although to date it has not been as bad in Saudi Arabia as some may have feared. The government has placed some restrictions on travel during the Haj in recent years, which reduces the number of the most vulnerable coming to the country. The Command and Control Centre of the Ministry of Health advises that people over 65, pregnant women, children under 12, and those suffering immunodeficiency or chronic ailments should postpone their trip this year.
Even so, the amount of international visitors to the kingdom has continued to climb most years, from 16 million in 2012 and 2013 to 18 million in 2014 and 19 million in 2015, according to data from the country’s central bank, the Saudi Arabian Monetary Agency (Sama).
The Saudi economy has taken a hit in recent years, but mainly because of the fall in oil prices since 2014, and it is hard to separate out any impact that MERS might have had on the economy overall. However, while Saudi Arabia appears to have escaped any major economic impact so far, the same could not be said of South Korea, which saw its growth rate sharply dip in 2015 when it suffered a large outbreak of the disease. The problem was traced back to a businessman who had been infected on a visit to Saudi Arabia and then returned home.
The way Saudi Arabia and South Korea struggled to deal with the initial incidences points to a wider issue about the preparedness of the world for such outbreaks. MERS was not the first big disease to hit the headlines in recent years, nor the last. Others have included the severe acute respiratory syndrome (SARS) in Asia in 2003, Ebola in West Africa in 2014 and, most recently, the Zika virus in Brazil in 2015. On each occasion, medical authorities have struggled to cope and there has been a global scramble to deal with the problem.
That has prompted some to advocate a new approach. Speaking about the outbreak of the Zika virus, Marion Koopmans, head of the department of virology at the Erasmus Medical Center, told Dutch current affairs programme NOS Nieuwsuur in May that “We are surprised every time. There are again no vaccines or diagnostic tests and we are again one step behind.”
Koopmans suggested that a global fund should be set up to ensure there are sufficient financial resources to fund vaccines and diagnostic tests for viruses in the future, whether they are completely new or simply new strains of existing viruses. While the world waits for that to happen and for a vaccine to be discovered, visitors to Saudi Arabia would do well to follow the suggested precautions.