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Lack of Jeddah MERS Transparency Raises Concerns
The above comments from the WHO April 14 MERS update identify the three cases (70M, 34M, 29M) in the April 10 update by the Kingdom of Saudi Arabia Ministry of Health (KSA-MoH), which is the most recent WHO update on Jeddah cases (other than the 6 which were exported to 5 countries – Jordan, Malaysia, Greece, United Arab Emirates, and Egypt). Since these three cases were announced by KSA-MoH on April 10, the same agency has reported 120 more cases in Jeddah, which are included in 237 recent PCR confirmed cases in KSA. WHO has not issued any updates on these recent cases.
Prior to the replacement of Adullah bin Abdulaziz Al Ribiah by Adel Fakeih, the Minister of Health, KSA updates had little information on MERS positive cases. Dates were withheld, as well as hospitals. WHO updates provided disease onset and/or hospitalization dates, which helped understand the spread of the virus. The mild and asymptomatic cases are contacts of confirmed cases because KSA does not test mild or asymptomatic cases unless they are contacts of confirmed cases. It is likely that many of the cases reported the KSA-MoH were delayed and released in a control manner, which created problems for WHO because the dates would have revealed these delays.
The lack of any information by WHO on the earlier cases has been extended to all of the cases, leading to no information from WHO on the 237 most recent MERS confirmed cases.
This lack of transparency by WHO, has extended to the release of sequences from these cases. All of the MERS samples are given to a lab in Germany, which published a letter at ProMED on April 26 explaining delays in the release of sequences (the German lab was closed for Easter and passage through customs created additional delays). However, the lab noted that they had almost thirty samples and had nearly complete sequences from three of the earlier Jeddah cases from early April (Jeddah_C7569, Jeddah_C7149, Jeddah_C7770).
These sequences were available at the lab website and were almost identical, even though the patients were in two different Jeddah hospitals. The identity was said to be due to poor infection control, leading to spread between the two hospitals. However, sequence data on the spike gene from 25 additional cases were said to be identical to each other, as well as the three released sequences.
This large number of identities raised concern that a novel sub-clade had emerged in Jeddah, leading to the explosion of cases and deaths (similar to the emergence of a novel SARS sub-clade with a 29 BP deletion at the Metropole Hotel in Hong Kong in 2003). This concerns was increased by the failure to release any of the spike sequences or any subsequent sequences from the 150 confirmed cases in Jeddah.
Today an interview with the head of the German lab, Christian Drosten was published, which noted that sequences from two more recent Jeddah cases and a Mecca cases were generated, and like the first three sequences from Jeddah, "all looked completely normal”. These comments raised concerns that the three recent sequence matched the three earlier sequencing, confirming the emergence of a novel sub-clade which had now spread to Mecca. However, the failure to release these sequences or any of the 25 spike sequences left some doubt in the relationships between these Jeddah and Mecca sequences. Requests for information from the Drosten and Rambaut labs (which had also been cited in the ProMED letter as a source for information on the Jeddah sequences) have not been answered, and the reasons for the failure to posts these sequences at the Dorsten website are unclear.
However, the lack of information of the Jeddah cases is not new. Over a year ago, in March of 2013 the now former Minister of Health noted that MERS is much like the flu and the vast majority of mild cases recover. He also noted that most of these milder cases were in Jeddah. However, in March of 2013 the only reported MERS case in Jeddah was the first confirmed case, who had died in the summer of 2012. Since mild MERS could not be identified without lab confirmation, the comments by the Ministry of Health suggested a lack of reporting of the lab confirmed mild MERS cases, in violation of IHR regulations.
The recent export of MERS by six patients to five countries indicates it is widespread in Jeddah (and Mecca). In spite of this explosion of cases and exports, WHO has not provided information on any of the recent MERS cases in KSA unless the case was exported and confirmed by the importing country.
The failure to release the Jeddah and Mecca sequences, as well as information of the recent confirmed cases, continues to be hazardous to the world’s health.