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Saudi Arabia Dramatically Increases Confirmed MERS Deaths
Recombinomics Commentary 07:00
June 04, 2014

The results of the audit showed that the total number of cases registered in the Kingdom since 2012 until the morning of June 3, 2014 is 688, including 282 deaths, 53 were still receiving treatment, and 353 had had recovered

Sources in the hospital for medical "home" has been receiving two cases riddled with the virus after their transfer from a hospital in Al-Ahsa. The sources pointed out that the baby died after his health deteriorated, result satisfactory complications due to the virus, while the other injured were transported to a hospital isolation room

The above comments (in red) are from the Kingdom of Saudi Arabia Ministry of Health (KSA-MoH) website announcing the result of an audit on MERS-CoV cases, which produced a dramatic jump in the number of lab confirmed deaths.  The totals posted on the website prior to the announcement were 575 cases, including 190 deaths.  Thus, the new totals increased the number of cases by 113 and the number of deaths by 92 raising the case fatality rate (CFR) from 33.0% to 41.0% using the total number of confirmed cases.  However, the CFR based on outcomes (death or discharge) is 44.4% (282/635).  The confirmed cases include contacts of “sporadic cases”, which frequently included younger and healthier patients who were asymptomatic or had mild cases that resolved without progression to pneumonia, and these cases had a CFR of zero, so the CFR of “spontaneous” cases, which are the focus of MERS surveillance, is greater than 50%.

The MoH did not provide detail on why the newly discovered cases were not included in the original totals, but the announcement included a graph of all confirmed cases which highlighted the newly added cases, which began in May of 2013.  The above comments (in blue) from one of many media reports on MERS-CoV in May of 2013 describe children who died or were hospitalized with MERS symptoms.  These media reports were very detailed and included comments made by agency officials at news conferences which cited MERS in children, but none of these cases were included in the official totals, and are likely acknowledged in the updated figures.  In 2013 the MoH claimed that MERS in children were only media and internet rumors and the true status of MERS confirmed cases was limited to the totals at the government site.

These statements were from a long list of claims that lacked credibility, which are likely associated with the dismissal of the former head of the KSA-MoH, as well as the more recent announcement of the dismissal of the Undersecretary.  The acting head has pledged more transparency and the website has provided more detail on cases, which included disease onset dates and obvious nosocomial cases.  Initial reports also contained the names of hospitals with new cases, but those reports were replaced with a more general designation for these hospitals and clinics.

The detail on the hospitals cast doubt on claims that the explosion of MERS cases in Jeddah and Riyadh were largely due to poor infection control which created the close relationship between the sequences from cases in Jeddah and Mecca.  The more detailed reports indicated local cases were in many different hospitals and included cases who developed symptoms prior to admission, which strongly supporting the emergence of a novel sub-clade in Jeddah with likely spread to Mecca.  Sequences from exported cases from Riyadh and Medina suggested a second novel sub-clade had emerged in those two cities

All four locations have reported a record spike in cases, but sequences from all 2014 cases in Medina and Riyadh have been withheld.  Only one sequence has been released from Mecca and the most recent collection date for the Jeddah sequences is April 14.

In the past, all 2013 and 2014 sequences from MERS cases in KSA have been generated by one lab, which has withheld the important recent sequences, which are likely closely related to the two sub-clades which were in 2 of 2 cases exported from Jeddah (which matched the Jeddah/Mecca sub-clade) and in 3 of 3 sequences from Riyadh or Medina (which matched the Riyadh/Medina sub-clade).

The announcement of the audit results by the KSA-MoH has been useful. 

The next step should include the release of full and partial MERS sequences from the explosion of cases in April and May, as well as involvement of additional labs in the confirmation and extension of the sequencing data.

The classification of 11 out of 11 recent sequences into these two sub-clades raises serious concerns about implications for spread linked to upcoming pilgrimages associated with Ramadan, which begins at the end of this month.

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