Over the next few weeks officials at the World Health Organization (WHO) face a tough and politically charged call. The Muslim month of fasting, Ramadan, begins July 9 and could draw as many as two million people from around the globe to the holy sites of Saudi Arabia in a pilgrimage called umrah. But a new disease, called Middle Eastern respiratory syndrome, or MERS, could threaten them.
Infectious disease control at mass gatherings is always a challenge, but this year even more so. Saudi Arabia is currently waging battle with MERS, yet it has released only the barest of details that scientists or public health officials could use to try to prevent its spread within Saudi Arabia or around the globe. In early May Saudi officials startled the world by announcing 13 new cases over the course of a few days. Since the start of May there have been 38 new cases worldwide—31 of them in Saudi Arabia—and 20 of the victims have died. With virtually no clues to draw on about where the virus lives in nature and how people contract it, WHO is trying to figure out what guidance to give those pilgrims, and the countries they will return to, about how to avoid infection and the international dissemination of a devastating new illness.
MERS triggers severe pneumonia and kidney failure in some cases. It is a cousin of SARS, severe acute respiratory syndrome, which broke out in mainland China in late 2002, spread from there to Hong Kong in 2003, and was then transported in the lungs of international travelers to Singapore, Hanoi, Toronto and other cities. Health officials do not want to pull out the big hammers used during the SARS outbreak, such as WHO travel advisories that urged the world’s citizens to avoid infected hubs such as Hong Kong and Toronto. On the other hand, no one wants umrah and the even larger hajj pilgrimage that will follow in October to trigger a pandemic.
The new virus was first isolated in June 2012. But its existence came to the world’s attention only weeks before last October’s hajj, when an Egyptian infectious diseases specialist who had been working in Saudi Arabia’s second largest city, Jeddah, reported that he had treated a man who died from an infection caused by a new coronavirus. Whether MERS has or can gain the capacity for sustained person-to-person spread is unknown. Kamran Khan, an infectious diseases physician who researches global flight patterns as a means of predicting disease spread, has had a worried eye on the Muslim religious calendar for some time. “We still don't have a good idea where this (virus) is coming from, so taking measures to mitigate risks are constrained,” says Khan, who works at the Saint Michael’s Hospital Keenan Research Center in Toronto.
Coronaviruses such as MERS, SARS and numerous others are named for the hallmark halo, or crown, they appear to sport in their outer shells. Many infect bats; the few that infect people cause illnesses ranging from the common cold to the severe lung devastation seen with many MERS cases, forcing patients to undergo mechanical ventilation. MERS has not yet evolved to spread as well as SARS can. And SARS, which was no wimp, killed about 11 percent of cases before it disappeared in 2004.
Last fall and in the early part of 2013 MERS infections popped up sporadically in a variety of places. Testing of samples from an April 2012 outbreak in Jordan revealed the virus had killed two nurses there. Three men in a family in the Saudi capital, Riyadh, appeared to have passed the virus to one another. Sick people from Qatar and the United Arab Emirates were medivacked to the U.K. and Germany. And more recently tourists have taken the infection to the U.K., France, Tunisia and Italy.
The affected Arabian Peninsula countries have not been particularly forthcoming with information, and global health experts have yet to hit on the right strategy for persuading officials to get serious about finding the source of the infections or the scope of the illness in people. An outbreak of H7N9 bird flu virus in China at the beginning of April also distracted attention from MERS.