Saturday, December 1, 2012

Emerging diseases like new coronavirus being monitored closely in Oman: WHO

Two Jordan cases in April shift novel coronavirus picture

Nov 30, 2012 (CIDRAP News) – The World Health Organization (WHO) reported today that two cases of novel coronavirus (CoV) infection occurred as part of a cluster of hospital respiratory infections in Jordan back in April. Besides adding one more to the list of affected countries, the announcement signaled that the virus emerged 2 months earlier than previously thought and increased the likelihood that it can spread from person to person.
Also today, the WHO said testing confirmed the virus in a fatal case that was part of a previously noted family cluster of four illnesses in Saudi Arabia. Today's developments increased the overall case count to nine, including five deaths, in three neighboring countries: Saudi Arabia, Qatar, and Jordan.
The cases include five, with three deaths, in Saudi Arabia; two in Qatar; and the two fatal illnesses in Jordan. The latest count is two more than reported yesterday. Five cases involved acute renal failure.
The Jordanian illness cluster in April involved 11 people, including eight healthcare workers, in a hospital intensive care unit in Zarqa, according to a report from the European Centre for Disease Prevention and Control (ECDC) on May 4. Health officials had mentioned the cluster previously as suspicious in light of the novel coronavirus. Until now, the first novel CoV infection was believed to be that of a Saudi man who died in his home country in June, though his case was not reported until September.
At the time of the Jordanian cluster, officials from US Naval Medical Research Unit 3 (NAMRU 3) in Cairo tested patient samples at Jordan's request and found they were all negative for known coronaviruses and other viruses, the WHO said in one of its two statements today. No specific tests for the novel virus existed at the time, since it hadn't been discovered yet.
In October, after the discovery of the novel CoV, Jordan sent stored samples to NAMRU-3 for testing, the WHO said. Recently the lab provided results that confirmed the novel virus in two of the cases. The WHO did not say how many of the patients were tested.
In response to Jordan's request, WHO experts arrived in Amman on Nov 28 to help investigate the cases and strengthen the country's sentinel surveillance for severe acute respiratory infections, the agency reported.
The WHO said the existence of the case clusters in Jordan and Saudi Arabia increases "the possibility of limited human-to-human transmission or, alternatively, exposure to a common source. Ongoing investigation may or may not be able to distinguish between these possibilities."
In the Saudi Arabian family cluster, two of the three confirmed cases were fatal. One more family member also had a similar illness and recovered but tested negative by polymerase chain reaction, the WHO noted.
Despite the two clusters, the WHO said, "Based on current information, it [the virus] does not appear to transmit easily between people, unlike the SARS [severe acute respiratory syndrome] virus." The SARS virus, also a coronavirus, sickened about 8,000 people and killed about 900 in 2003.
Saudi Arabia's deputy minister for public health, Ziad A. Memish, MD, today suggested that the virus in the Saudi Arabian family cluster may be different from the strain in the earlier cases.
"We think the virus in the last family cluster is different as it had significant spread among households while none of the previous cases behaved in a similar way," Memish said in e-mailed comments to CIDRAP News. Memish was among the authors of a description of Saudi Arabia's second novel CoV case, published this week in the Saudi Medical Journal.
The Jordanian cases seem to confirm the need to watch for the novel virus in places beyond just Saudi Arabia and Qatar, as recommended by the WHO lately. Last week the agency called for broader vigilance, and yesterday it offered more detailed surveillance recommendations.
The WHO reiterated those recommendations today. It said authorities should consider testing of patients with unexplained pneumonia, especially if they live in or visited the Arabian peninsula or neighboring countries. Any cluster of severe acute respiratory infections in healthcare workers should be carefully investigated, regardless of the location, the statement said.
Memish agreed on the need for wider surveillance, commenting, "We have been saying all along that cases of novel coronavirus are not limited to KSA [the Kingdom of Saudi Arabia] and Qatar. And today's announcement from WHO about the two cases from Jordan in early April 2012 is an evidence supportive of our suspicions.
"No country in the world screens all pneumonia patients for novel coronavirus except KSA and Qatar, and as long as this is the case no novel coronavirus cases will be recovered anywhere else," he added.
The WHO said it is not recommending special screening for the virus at points of entry, nor does it recommend any travel or trade restrictions.
In other developments, the WHO today revised a statement it issued yesterday to correct the number of deaths attributed to the virus at that point. Yesterday's statement mentioned seven cases with just one death; the revised statement changed the number of deaths to three. 

Background and summary of novel coronavirus infection – as of 30 November 2012

Editing is mine:

Over the past two months, WHO has received reports of nine cases of human infection with a novel coronavirus. Coronaviruses are a large family of viruses; different members of this family cause illness in humans and animals. In humans, these illnesses range from the common cold to infection with Severe Acute Respiratory Syndrome (SARS) coronavirus (SARS CoV). 

Thus far, the cases reported have come from Qatar, Saudi Arabia and Jordan. All patients were severely ill, and five have died.
The two Qatari patients are not linked. Both had severe pneumonia and acute renal failure. Both are now recovering.
A total of five confirmed cases have been reported from Saudi Arabia. The first two are not linked to each other; one of these has died. Three other confirmed cases are epidemiologically linked and occurred in one family living within the same household; two of these have died. One additional family member in this household also became ill, with symptoms similar to those of the confirmed cases. This person has recovered and tested negative, by polymerase chain reaction (PCR) tests, for the virus.

Two confirmed cases have been reported in Jordan. Both of these patients have died. These cases were discovered through testing of stored samples from a cluster of pneumonia cases that occurred in April 2012. 

The two clusters (Saudi Arabia, Jordan) raise the possibility of limited human-to-human transmission or, alternatively, exposure to a common source. Ongoing investigation may or may not be able to distinguish between these possibilities.

The current understanding of this novel virus is that it can cause a severe, acute respiratory infection presenting as pneumonia. Acute renal failure has also occurred in five cases.
WHO recognizes that the emergence of a new coronavirus capable of causing severe disease raises concerns because of experience with SARS. Although this novel coronavirus is distantly related to the SARS CoV, they are different. Based on current information, it does not appear to transmit easily between people, unlike the SARS virus. 

WHO has closely monitored the situation since detection of the first case and has been working with partners to ensure a high degree of preparedness should the new virus be found to be sufficiently transmissible to cause community outbreaks. Some viruses are able to cause limited human-to-human transmission under condition of close contact, as occurs in families, but are not transmissible enough to cause larger community outbreaks. Actions taken by WHO in coordination with national authorities and technical partners include the following:
  • Investigations are ongoing to determine the likely source of infection and the route of exposure. Close contacts of confirmed cases are being identified and followed up.
  • An interim surveillance recommendation has been updated to assist clinicians to determine which patients should undergo laboratory testing for the presence of novel coronavirus.
  • Laboratory assays for the virus have been developed. Reagents and other materials for testing are available, as are protocols, algorithms and reference laboratory services. WHO has activated its laboratory network to assist in testing and other services. WHO has also issued preliminary guidance for laboratory biorisk management.
  • Guidance is available for infection control.
Based on the current situation and available information:
  • WHO encourages all Member States to continue their surveillance for severe acute respiratory infections (SARI) and to carefully review any unusual patterns.
  • Further, testing for the new coronavirus of patients with unexplained pneumonias should be considered, especially in persons residing in or returning from the Arabian peninsula and neighboring countries. Any new cases should be promptly reported both to national health authorities and to WHO.
  • In addition, any clusters of SARI or SARI in health care workers should be thoroughly investigated, regardless of where in the world they occur. These investigations will help determine whether the virus is distributed more widely in the human population beyond the three countries that have identified cases.
  • WHO does not advise special screening at points of entry with regard to this event nor does it recommend that any travel or trade restrictions be applied.
WHO continues to work with Member States and international health partners to gain a better understanding of the novel coronavirus and the disease in humans and will continue to provide updated information. As the situation evolves, WHO will reassess its guidance and revise it accordingly. 

Friday, November 30, 2012

The deaths of two people in Jordan-like virus "SARS"

December 01, 2012
World Health Organization said Friday it was concluded that the deaths of two people in Jordan in April / April resulted from injuries new virus from the same family virus severe acute respiratory syndrome, SARS, which raised a warning globally in September / September. organization added the United Nations that confirmed so far infected at least nine people in three countries in the Middle East with the virus, which was not known in humans, including a Saudi, was wounded acute respiratory last month.

but Georgi Hartl, spokesman for the organization said that the two deaths in Jordan, which Takdta in Samples were tested recently in a lab collaborates with the World Health Organization in Egypt does not alter the assessment of the organization that the virus does not spread easily apparently among humans. he told Reuters: "cases in Jordan does not alter the risk assessment at the moment. have not seen a new pattern. they are two Kadimtan . " the organization said that the Geneva-based said in a statement: "I was informed the organization today the cases and deaths Erdnitan bringing the total number of cases that were confirmed laboratory to nine."
The results of the initial checks of the samples had tested negative for HIV and other viruses associated with respiratory in April / April . and share new virus with, SARS, in some of the symptoms, the organization said that "the new virus can seem sore pneumonia, as acute renal failure in five cases.  

Overall, confirmed so far five cases of HIV infection new in Saudi Arabia, including three cases of one family died, including three, also confirmed wounded two in Qatar, both recovering. " Hartl said that the two deaths Alerdnitan were among 12 cases of acute respiratory appeared in April / April and were related to hospital in Zarqa, about 40 kilometers from Amman, He added that most cases were health workers.

Predicting the next zoonotic pandemic

Excerpt: LONDON, 30 November 2012 (IRIN) - Chances are high the world’s next pandemic will be a disease originating in animals, like 60 percent of current documented human infectious diseases. Even after hundreds of thousands of human deaths from zoonoses (diseases transmitted from animals to humans), experts say there is still limited information about how zoonoses are spread or just how to predict the next outbreak. “There is no question of whether we will have another zoonotic pandemic,” wrote Stephen Morse, a public health professor at Columbia University in New York, in a November 2012 series on zoonoses in the UK medical journal, The Lancet. “The question is merely when, and where, the next pandemic will emerge.” -snip- The Nairobi-headquartered International Livestock Research Institute (ILRI) has pointed out how urban livestock and agriculture can breed disease in some of the world’s most crowded places. In a recent survey in Dagoretti, one of eight districts of Kenya’s capital, Nairobi, the institute found up to 11 percent of households were affected by cryptosporidiosis, a diarrhoeal disease caused by a pathogen found in cattle, raw milk, soil, vegetables and contaminated water. Changing harvests may be another contributor to the spread of zoonoses. In the southwestern USA where El Niño (rising sea surface temperatures across the central and eastern Pacific Ocean) dumped more rain, vegetation growth increased, which then attracted more rats. Hantavirus is not fatal in rats - which carry the disease - but is in humans who became infected through the rats. The interplay of biology, ecology and sociology make forecasting the next pandemic difficult, say experts in the Lancet series who call for boosting cooperation between experts (often working in silos) to meet the “huge, and rising” threat of zoonoses.

Novel coronavirus infection - update

In addition to the fatal case of novel coronavirus in Saudi Arabia reported to WHO on 28 November, two fatal cases in Jordan have been reported to WHO today, bringing the total of laboratory-confirmed cases to nine.
The latest confirmed case from Saudi Arabia occurred in October 2012 and is from the family cluster of the two cases confirmed earlier.
The two cases from Jordan occurred in April 2012. At that time, a number of severe pneumonia cases occurred in the country and the Ministry of Health (MOH) Jordan promptly requested a WHO Collaborating Centre for Emerging and Re-emerging Infectious Diseases (NAMRU – 3) team to immediately assist in the laboratory investigation. The NAMRU-3 team went to Jordan and tested samples from this cluster of cases.
On 24 April 2012 the NAMRU-3 team informed the MOH that all samples had tested negative for known coronaviruses and other respiratory viruses. As the novel coronavirus had not yet been discovered, no specific tests for it were available.
In October 2012, after the discovery of the novel coronavirus, stored samples were sent by MOH Jordan to NAMRU-3. In November 2012 NAMRU-3 provided laboratory results that confirmed two cases of infection with the novel coronavirus.
The MOH Jordan has requested WHO assistance in investigating these infections. A mission from WHO Eastern Mediterranean Regional Office (EMRO) and headquarters arrived in Amman on 28 November 2012 to assist in further epidemiological surveillance and to strengthen the sentinel surveillance systems for severe acute respiratory infections (SARIs).
In summary, to date a total of nine laboratory-confirmed cases of infection with the novel coronavirus have been reported to WHO – five cases (including 3 deaths) from Saudi Arabia, two cases from Qatar and two cases (both fatal) from Jordan. 

Fifth coronavirus death reported

Hat-tip Caregiver

A fifth person has died from a new respiratory illness similar to the Sars virus, according to the World Health Organization.
The WHO said the two latest deaths were in Jordan. The disease had previously been detected only in Saudi Arabia and Qatar, although one patient was transferred to the UK for treatment.
It brings the total number of cases of the infection to nine.
There may also be evidence of human to human spread of the virus.
It causes pneumonia and sometimes kidney failure.
There was a series of severe cases of pneumonia in Jordan earlier in the year. However, the novel coronavirus had not been discovered at the time so did not appear in routine tests.
Two of the deaths in April have now been confirmed as being part of the outbreak.
Coronaviruses are a group of viruses ranging from the common cold to the Sars (severe acute respiratory syndrome) virus. They infect a wide range of animals.
In 2002 an outbreak of Sars killed about 800 people after the virus spread to more than 30 countries around the world.
The WHO is still trying to work out where the infection came from. Studies show that the virus is closely related to one found in some species of bats.
How readily the virus spreads will be important for assessing how great a threat it poses.
The WHO said that, unlike Sars, the new coronavirus, "does not appear to transmit easily between people".
However, it warns that two clusters in Saudi Arabia and Jordan, "raise the possibility of limited human-to-human transmission" or they could have been exposed to the same source of the infection.

WHO Corrects Coronavirus Statement

From Avian Flu Diary
The `buzz’ in flublogia yesterday centered around the low-profile release of a new statement on the novel Coronavirus by the World Health Organization.  Not unexpectedly, it increased the number of confirmed cases to 7 (with 1 probable).

Somewhat confusingly, however, it cited only one death, contradicting earlier reports of two deaths(see WHO Confirms 7th Coronavirus Case for the original statement).
Sometime over the past 12 hours or so, a corrected version of the statement has been uploaded to the WHO site, and now they cite three deaths.


Indonesia: Poultry Die-off Bekasi & Sanden

Map of outbreaks
Blue: Bekasi, Red: Sanden

Esophageal Suspected Bird Flu, Poultry in Sanden Dozens of Sudden Death
November 29, 2012
BANTUL - Dozens of birds ducks in the District of Sanden and Jetis known died suddenly since last two months. Allegedly, the mass death of birds due to virus attack Avian Influenza (AI). According to the Head of Animal Health Department of Agriculture and Forestry (Dispertahut) Bantul, Agus Riyadmadi, so far it only received reports from a number of farmers in the village of Srigading, Sanden, and Village Trimulyo, Jetis. "Data while, there were about 50 ducks that died suddenly. Symptoms are almost the same, lame duck walk, giddy, and finally seizures. It is similar to the symptoms of H5N1 (bird flu). However, this is not the bird flu, " said Agus, Thursday (29/11). Agus explained, the virus that causes the death of dozens of ducks this time more virulent than H5N1. Therefore, the H5N1 virus is not known to cause death in ducks. To ascertain the cause of death, Center for Veterinary Wates Yogyakarta has taken samples about two months ago. It takes about two to three months for the Center for Veterinary publish the results of the study. Kasi Animal Health Services Dispertahut Bantul, Subeno added, duck deaths with symptoms of paralysis and seizures can also be due to environmental factors.

Sukakarya - Hundreds of chickens owned by Andi (35), in Kampung Pulo Panjang, Sekamakmur Village, District Sukakarya, Bekasi, died suddenly. Poultry was confirmed positive for bird flu.

According to Andi, already one week chicken flocks continue to die suddenly, before dying, the chicken was issued a number of symptoms or signs. Such discoloration comb, from red to blue, otherwise it looks like the head to swell. Meanwhile, officers of livestock, fisheries and marine (EPF) Bekasi, Marullah which today conducted a space to explain, based on examination repit test known that, hundreds of chickens tested positive for bird flu or H5N1 virus. Department immediately undertake countermeasures by providing disinfectant disekitaran chicken coop and ordered the owner to be gutted chickens to death by burning. "When there are people who have a fever then advised to immediately health check to the nearest health center for fear of contracting the H5N1 virus hit-borne sick chickens, "said Marullah.

Thursday, November 29, 2012

Russia: #H5N1 in Temryuk District

Samples from the place of death of birds in Temryuk district tested in Moscow

Bird flu - the main cause of mass death of birds in Temryuk district and Anapa. This was officially announced today in the Regional Office of Rosselkhoznadzor.

Among the dead birds - swans, cormorants, ducks, coots. According to local environmentalists, have been found and curly pelicans, which are listed as endangered. To date, about a thousand dead birds of different species.

The prosecutor's office launched a probe region. In the so-called endangered area now check all poultry and poultry will hold vaccination.

"There will be a compulsory monitoring of blood tests to exclude the circulation of the virus in poultry in private yards and at poultry farms, respectively, will be vaccinated against bird flu," - said Alexander Malakhov, Deputy Head of Rosselkhoznadzor in Krasnodar Krai and Adygea.

Now all samples from the scene PE sent to Moscow, to the central laboratory Rosselkhoznadzor. There or confirm strain H5N1, or call another cause of bird death. Internet forums have already started discussing the possible poisoning of birds. And the administration Temryuk district deputy head today held an emergency meeting to denote the potential solutions to the problem.

The last outbreak of bird flu was detected in the region in 2007. Then killed more than three thousand wild birds. This happened in Anapa. H5N1 strain infects the respiratory system of birds and the digestive organs. Almost always causes death. Route of infection - airborne.

Specialists suggest that this time the flu was in our region due to the seasonal migration of wild birds from other countries. 

New Vaccine May Offer Better Protection in the Event of a Flu Pandemic

By , GuideNovember 28, 2012
A new flu vaccine being developed by Medicago Inc., and not yet on the market, may offer better cross protection against the flu as well as have a shorter manufacturing time than current flu vaccines. Researchers gave mice a dose of the vaccine, developed to prevent avian influenza H5N1, but were surprised to find that the vaccine not only protected against that virus but a second strain of H5N1 and another flu virus dubbed H2N2.

The rapid mutation of the flu virus has been a major hindrance in the effectiveness of current flu vaccines. While more research is needed, if subsequent studies show similar results, the vaccine developed by Medicago could offer better protection against the flu than we've ever had before. Another advantage of this vaccine is that it is manufactured a different and faster way than current vaccines. Hypothetically, if there was an outbreak of a flu virus that we did not have a current vaccination against, the Medicago vaccine could be quickly developed and produced. This vaccine has passed Phase I and II FDA trials but has not finished the approval process. You can read more about this vaccination at Newswise.

Philippine Gov't bans Australian poultry

November 29, 2012

THE PHILIPPINE government has banned poultry and poultry products from Australia due to an outbreak of Highly Pathogenic Avian Influenza (HPAI) in New South Wales. Agriculture Secretary Proceso J. Alcala issued Memorandum Order No. 33 dated Nov. 28 that bans the "importation of domestic and wild birds and their products including poultry meat, day old chicks, eggs and semen originating from New South Wales, Australia."

The order also covers the suspension of the processing and issuance of the Veterinary Quarantine Clearance needed by importers of these products.

Except for heat-treated products, imports of poultry and poultry products from New South Wales will be confiscated by quarantine officers and inspectors at all major ports.

An outbreak of HPAI of the serotype H7 was detected in free range laying hens in New South Wales, Australia last Nov. 9.

"There is a need to prevent the entry of HPAI virus to protect the health of the local poultry population as well as human health," the memorandum read.

Avian influenza or bird flu is a disease capable of causing extremely high mortality in domestic or wild birds, which can be transferred to humans, causing diseases or even death.

Antibiotic-Resistant Superbug Spreading Quickly

hat-tip Caregiver!
 Nov 29, 2012

CHARLOTTESVILLE, Va. - The doctors tried one antibiotic after another, racing to stop the infection as it tore through the man's body, but nothing worked. In a matter of days after the middle-aged patient arrived at University of Virginia Medical Center, the stubborn bacteria in his blood had fought off even what doctors consider "drugs of last resort." "It was very alarming; it was the first time we'd seen that kind of resistance," says Amy Mathers, one of the hospital's infectious disease specialists. "We didn't know what to offer the patient."
"From the perspective of drug-resistant organisms, (CRE) is the most serious threat, the most serious challenge we face to patient safety," says Arjun Srinivasan, associate director for prevention of health care-associated infections at the Centers for Disease Control and Prevention.
Since the first known case, at a North Carolina hospital, was reported in 2001, CREs have spread to at least 41 other states, according to the CDC. And many cases still go unrecognized, because it can be tough to do the proper laboratory analysis, particularly at smaller hospitals or nursing homes.


Wednesday, November 28, 2012

HK alert to coronavirus threat

November 27, 2012
Hong Kong has an effective mechanism to detect novel coronavirus cases, Secretary for Food & Welfare Dr Ko Wing-man says, adding the Government has successfully isolated two travellers from the Middle East who had suspicious symptoms when they entered the city.

Speaking to the media today, Dr Ko said the Government is very concerned about the six coronavirus cases reported by the World Health Organisation. With the approach of winter, the Government has already taken numerous measures against influenza and avian flu, he said.

They include the launch of the flu vaccination scheme, and the stepping up of surveillance against influenza, avian flu and novel coronavirus infection among medical staff.

The Government has also boosted surveillance at immigration checkpoints in the detection of novel coronavirus cases, both for local residents returning to Hong Kong, and for visitors.

He urged the public to consult a doctor when they fall ill, and to reveal their recent travel history. He advised the public not to touch wild animals and birds, and not to eat them, or bring them to Hong Kong.

Hong Kong: 22 ill with flu-like infection, 9 Hospitalized

November 28, 2012
The Centre for Health Protection is investigating an upper respiratory tract illness outbreak at a Kowloon City kindergarten, affecting 22 children.

The children are 11 boys and 11 girls, aged three to five. They have developed symptoms since October 28.

Nine required hospitalisation and all are stable. Eight tested positive for adenovirus.

The centre has provided health advice to the kindergarten.

Monday, November 26, 2012

New vaccine may give lifelong protection from flu

25 November 2012
by Debora Mackenzie

Flu season has come early this year in parts of the northern hemisphere, and many people are scrambling to get their annual vaccination. That ritual may someday be history. In a first for any infectious disease, a vaccine against flu has been made out of messenger RNA (mRNA) – the genetic material that controls the production of proteins. Unlike its predecessors, the new vaccine may work for life, and it may be possible to manufacture it quickly enough to stop a pandemic. We become immune to a flu strain when our immune system learns to recognise key proteins, called HA and NA, on the surface of the flu virus. This can happen either because we have caught and fought off that strain of flu, or because we received one of the standard vaccines, most of which contain killed flu virus. Continued:

Few more excerpts from article below

A few more excerpts from the Helen Branswell piece below:

Dr. Fouchier was front and centre in the laboratory effort during the 2003 SARS outbreak. It was his lab, at the Erasmus Medical Centre in Rotterdam, that proved what’s called Koch’s postulates — the test that confirmed that the newly identified coronavirus was actually causing the disease SARS.

During the early days of the SARS outbreak, the WHO rapidly put together a virtual network of laboratories, tapping into expertise around the world to combat the alarming new disease.

But this time? In the summer, Dr. Fouchier’s lab identified and sequenced the new coronavirus and developed a test for it. But since then, it’s been “radio silence,” Dr. Fouchier said in an interview Friday.

“Everything I’ve heard since then has just come from the lay press, which is completely in contrast to how we acted back in the SARS era,” he said.

“That was completely different during the SARS outbreak. We were all talking together, exchanging results and giving each other ideas about what to test, how to test, where to test. And none of that is happening now. We just have to rely that they’re doing the right thing.”
Officials in the know should be sharing more information, Dr. Osterholm agreed.
“At this point in any outbreak investigation, there clearly is more information that is known by health officials than likely has been shared,” he said.

“But if there were ever a time for complete transparency, now is the time. We’ve learned that in the past and I’d hate to see us have to relearn the lesson again.”

Lack of transparency concerns experts following new WHO advice for coronavirus

Helen Branswell
Last updated

The World Health Organization has warned countries to heighten their surveillance for possible cases of infection with the new coronavirus, suggesting patients with unexplained pneumonias should be tested even if they don’t have links to Saudi Arabia and Qatar.

The agency also suggested investigating clusters of severe respiratory infections, and clusters of such illnesses in health-care workers, regardless of where they happen in the world.

Up until now the WHO has said that testing for the new coronavirus should be restricted to patients with severe respiratory infections who had recently travelled to or who were residents of a country that had recorded cases. To date the only confirmed infections have been in Qatari and Saudi nationals.

That change in advice, the basis for which the WHO did not explain, raised eyebrows among some infectious diseases experts, who were quick to try to read between the lines.