Monday, June 17, 2013

Eight More MERS-CoV Confirmed Cases In Jordan ICU

Recombinomics Commentary 23:15
June 17, 2013
  1 25 M 3/21 4/04  4/25 Student Deceased Confirmed 
  2 30 M 3/30 4/08  4/23 Apr Nurse Alive Probable 
  3 40 F  4/02 4/09 4/19 Nurse Deceased Confirmed 
  4 60 M 4/02 Refused admission – Physician,internist Alive Probable 
  5 29 M  4/11 4/15 4/21 Nurse Alive Probable 
  6 33 M  4/12 4/14 4/21 Nurse Alive Probable
  7 28 M  4/13 4/17 4/21 Nurse Alive Probable 
  8 45 M  4/14 4/17 4/24 Road tech (brother of case 3) Alive Probable 
  9 46 M  4/15 4/16 4/21 Nurse Alive Probable
10 25 M  4/15 4/18 4/21 Nurse Alive Probable 
11 53 M  4/18 4/21 4/23 Physician, internist Alive Probable 
12 28 F  4/19  Refused admission – Nurse Alive Probable 
13 60 F  4/26  5/01 5/05 Housewife (mother of case 2) Alive Probable
The above list from EMRO supplement provides age, gender, and disease onset dates for the 13 confirmed or probable MERS-CoV cases linked to an ICU outbreak in Jordan over a year ago. The recent release of this data raises serious transparency issues, and confirms the clear human to human (H2H) over a year ago.  The gaps in disease onset dates among the health care workers (HCWs), as well as their contacts, was expected from contemporary media reports, which described a large ICU outbreak of a SARS-like illness.  

HCWs complained of a lack of protective masks, which were denied due to concerns that patients would be alarmed.  The HCW concerns and complaints increased markedly when the second death was announced.  The HCWs referred to the fatal cases as a student, as well as a colleague, suggesting he had a relationship with the ICU HCWs.  The report describing the above case was from an epidemiological investigation that happened long after the fact, and interviews were not made with relatives of either of the confirmed / fatal cases, although the lack of use of gloves was noted (which was also due to concerns that patients would be alarmed).  Similarly, the linkage of the second death to the earlier cases was denied because of cardiac involvement, which was not present in the other cases.  However, they all had pneumonia, and the cases who recovered had a wide spread in hospitalization days.

The outbreak was reported by ECDC in May of 2012, which cited the death of the nurse as well as involvement of 1 doctor and 7 nurses.  However, attempts to identify the etiological agents failed, and new cases were not reported after the early May case cited above, so interest waned until a novel coronavirus was identified in the fall.  Retesting by NAMRU-3 confirmed MERS-CoV in the two fatal cases, but due to limited samples, the surviving cases were not confirmed.  WHO issued anupdate and classified the cases linked to the confirmed cases as probable and noted that the infections of the two family members was likely due to human to human (H2H) transmission.

However, the number of probable cases was not released and the data displayed above was withheld.  The disease onset dates clearly supported extensive H2H transmission beginning in March with the student, leading to infection of a subset of HCWs followed by a gap and a second extended wave of infections in the ICU.  The length of the second wave supported infection of the later cases by the earlier cases, and the family member at the end of the transmission change represent further onward transmission.  The multiple transmission events in an ICU were similar to SARS-CoV HCW outbreaks in 2003.  However, this type of transmission was not described in the WHO reports, which was hidden by the withholding of the disease onset dates.  Release of the above data in 2012 would have muted the various story lines claiming no H2H transmission and sporadic cases due to animal exposures.

The Jordan cluster had no linkage to animals and was clearly due to H2H transmission, although WHO has repeatedly claimed that a common source could not be excluded.  However, none of the disease onset dates supported a common source other than the index case or other HCWs.  Similarly, ECDC produced a risk analysis that claimed there were no mild MERS-CoV cases because all cases were sporadic and due to animal exposure.  When the Jordan fatal cases were confirmed, ECDC largely ignored the probable cases, which thoroughly refuted the basic foundation of their risk analysis.  They started a list of confirmed cases, which represented the Jordan outbreak with 2 fatal cases.

However recently Jordan sent to the US CDC serum samples from 124 people linked to the ICU outbreak.  Media reports note that there were 8 additional positives (in addition to the 2 previously confirmed cases).  The 8 newly confirmed cases include 6 who were symptomatic as well as a health care worker and a contact.  Since all of the probable cases were symptomatic, it seems that the 6 cases were from the above list and the 2 asymptomatic cases would represent new cases which were neither confirmed nor probable.  Alternatively, the 6 symptomatic cases may have been other patients who were not identified by the epidemiological study and the 2 cases which were HCWs or contacts were included in the above list.

Clarification of the relationship of the 8 newly confirmed cases with the probable cases listed above would be useful.

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