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Paradigm Shift Intervention Monitoring
Beta Coronavirus Risk Assessment
Onset Age (yrs) Sex Probable place of infection Date reported Source Outcome
1 April 2012 45 F Jordan** 30/11/2012 WHO/IHR Dead
2 April 2012 25 M Jordan** 30/11/2012 WHO/IHR Dead
3 13/06/2012 60 M KSA* 20/09/2012 KSA/Promed Dead
4 03/09/2012 49 M Qatar/KSA*** 22/09/2012 HPA/WHO Alive
5 NK NK NK KSA 04/11/2012 KSA/Promed/SMJ Alive
6 12/10/2012 45 M Qatar**** 23/11/2012 RKI/WHO Alive
7 NK NK M KSA* 19/11/2012-23/11/2012 KSA/Promed/WHO Alive
8 28/10/2012 NK M KSA* 23/11/2012 WHO Dead
9 Oct 2012 NK M KSA* 28/11/2012 WHO Dead
10 26/1/2013 60 M Pakistan/KSA 8/11/2013 EWRS Alive/Hospitalised
11 6/2/2013 NK M United Kingdom* 12/02/13 HPA Alive/Hospitalised
* Part of family cluster
** Healthcare worker and part of outbreak linked to hospital
*** Patient transferred to UK
**** Patient transferred to Germany
NK: not known
The above comment and list of novel beta coronavirus confirmed cases are from the latest ECDC update. The prior report claimed that human transmission was unlikely because of an absence of confirmed mild cases, which somehow indicated that the source of infection was animal or environmental. However, as seen in the above list, 7 of the 11 confirmed cases were from the three cited clusters (linkage to an ICU in Jordan, a familial cluster in Saudi Arabia, or a familial cluster in the UK. Even prior to the latest case, the two earlier clusters included 5 of the 10 confirmed cases as well as a number of milder cases which WHO classified as “probable” because of failures to confirm the presence of the novel coronavirus.
However, above list has glaring omissions with regard to disease onset dates, as well as the linkage between the above confirmed cases and symptomatic milder cases, which were not confirmed. These symptomatic contacts were cited as probable cases by WHO indicating that the epidemiological data suggested that there were milder cases which were not confirmed due to testing limitations.
The largest group of probable cases was in the Jordan ICU cluster, which included the first two cases on the above list. WHO has not been transparent on the age, gender, or disease onset dates for these cases.. Since the ECDC has published “risk assessments” they should have access to the IHR reports, which should include disease onset dates.
The Jordan Ministry of Health initially denied that the death of the second health care work (25M intern) was unrelated to the first death (40F nurse), the second cases, but after these cases were confirmed he acknowledged that the deaths were 7 days apart (April 19 and 26, respectively). The week gap in the dates of death suggests the disease onset dates were similarly gapped, which is more consistent with human to human transmission than a common environmental source. Moreover, one of the symptomatic cases was the son of the nurse and most of the symptomatic co-workers were hospitalized. The failure to confirm any of the surviving cluster members suggests that the assay’s ability to identify mild cases is suspect.
Similarly, WHO has withheld disease onset dates for the familial cluster in Riyadh (cases 7-9). However media reports indicated the two fatal cases were father and son, with the father being 70 years of age. Moreover, the dates of death were four days apart, which also supports human to human transmission. Similarly, WHO failed to confirm the presence of one of the symptomatic family members, who was also classified as a probable case, raising additional concerns for the lab testing.
Thus, the ECDC earlier position had little support, and mild cases are likely widespread but undetected due to a limited testing protocol, as well as heavily biased testing which targets severe cases.
The latest cluster has a large disease onset time gap in two well separate locations, providing the most compelling data on human to human transmission.
An update of the ECDC risk assessment is long overdue.