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Paradigm Shift Intervention Monitoring
& WHO Reports Confuse MERS Blogosphere
We previously reported two cases of MERS-CoV infection in health care workers,2 one of which was fatal.
The above comment from the introduction in the New England Journal of Medicine (NEJM) paper describing mild MERS in health care workers (HCWs) in the Kingdom of Saudi Arabia (KSA) confirms the death of the HCW in critical condition in the NEJM paper on the outbreak in Al Hasa. Although this case (45M) is the first reported death of a HCW in the KSA, and was well covered in the literature (see figure above) and media reports, the failure of the KSA Ministry of Health (MoH) or WHO to re-cite his HCW status when his death was reported has caused considerable confusion in the MERS blogosphere.
The two first confirmed HCWs in KSA were reported on May 14 by the KSA-MoH, which noted that both cases were in the eastern province. The following day WHO provided additional information by noting that one case (45M) had developed symptoms on May 2 and was in critical condition, while the second HCW (43F) developed symptoms on May 8 and was in stable condition.
The confirmation of MERS in two HCW was well covered by local media, and one publication included the patient’s name (Ismail mystic), nationality (Jordanian), and location (Aramco Hospital in Dhahran).
More detail was provided by the NEJM paper on the MERS outbreak in the eastern region. The detailed report included a figure (above) on the transmission between two probable cases (index case and super spreader) as well as 23 confirmed cases (which included the two HCWs represented above by hexagons). The milder case (R infected by index case A) was listed as a 42F who developed symptoms on May 8, was hospitalized on May 12, and was discharged on May 23. The more severe case (V infected by K who was infected by F who was infected by the super spreader, C) was designated as a 45M who developed symptoms on May 2, was hospitalized on May 3, and was transferred to the ICU on May 9, where he was ventilated. When the paper went to press on May 23 he was still ventilated in the ICU. The paper also noted that he was in hospital D, which was Aramco. Also noted (in supplement) was his interaction with a probable case, which was described as “face to face contact with the symptomatic but untested relative of another case patient.”
The untested relative was described in media reports as the unconfirmed son (26M) of the index case, who was hospitalized in Aramco (with media photo). Another son (33M) of the index case was patient O, who was infected by the index case. The index case (56M, Mohammed al-Sheikh) and his two sons were well covered in local media (print, photo, and videos) as well as Reuters, which was described in ProMED.
Thus, the critical HCW was well covered by the KSA-MoH, WHO, local media, and high profile (NEJM) peer reviewed publications.
However, when the patient died, the reports by KSA-MoH and WHO did not re-cite the fact that one of the prior cases was the previously confirmed HCW. The KSA-MoH report on June 16 cited the deaths of four prior cases (and did note that two were from Taif and two were from the eastern region). The WHO report on the next day simply said that “four previously laboratory-confirmed cases have died.”
This lack of detail in the KSA-MoH and WHO reports on his death created confusion in the MERS blogosphere, but the deaths were covered in the local media, and the paper that gave details in May when the confirmed case was announced gave the same details on his death, noting his name, nationality, and hospital, as well as the fact that he was a cardiologist.
Moreover, the more recent NEJM paper (quoted above) notes that there were two confirmed HCWs in the Al Hasa outbreak and one had died. Since the earlier paper had reported the discharge of the milder case, it was clear that the more severe case (45M represented as patient V) had died.
However, more detail in KSA-MoH and WHO reports on MERS clusters, including HCWs, would be useful.