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MERS WHO and KSA Transparency Concerns Increase
MERS-CoV=Middle East respiratory
* Proportion of genome obtained compared with a full genome value of 30 119 nucleotides.
† Code used in figure 2; single letter codes refer to patients from Assiri and colleagues.16
‡ Patient described by Albarrak and colleagues.24
§ Patient described by Memish and colleagues.25
¶ Same patient providing sample for van Boheemen and colleagues.26
19 September 2013 - WHO has been informed of an additional 18 new laboratory-confirmed cases including three deaths with Middle East respiratory syndrome coronavirus (MERS-CoV) infection in Saudi Arabia.
The patients are reported from Hafar Al-Batin, Medina and Riyadh. Their ages ranging from three to 75 years old. These cases were announced by the Ministry of Health in Saudi Arabia on 1, 5, 8, 10 and 11 September 2013.
The above table and legend (in red) and the WHO September 19 MERS-CoV update (in blue), demonstrate serious concerns about Kingdom of Saudi Arabia Ministry of Health (KSA-MoH) and WHO transparency on MERS cases.
The KSA-MoH updates rarely give dates associated with patients, and age/gender information is uneven. In the past, WHO updates provided key pieces of information such as dates for disease onset, hospital admission, and discharge / death, in addition to age and gender. As seen in the September 19 update above, this information has been withheld for the 18 KSA cases cited (it is not in the WHO or KSA-MoH updates).
However, as seen in the above table, the withholding of key information has been extended to peer reviewed papers, including the recent Lancet paper on sequences or the New England Journal of Medicine (NEJM) paper on the Al Hasa outbreak. The above table does not list the age and gender of the patients, which are critical for confident linking the cases to WHO updates. The initial cases in the table have been described in publications so age and gender is known for the confirmed cases in Al Hasa, as well as the first confirmed case in KSA (60M in Bisha – BS1), the first confirmed case in Riyadh (45M gym teacher – RY1), and a case from the first confirmed cluster in Riyadh (39M son of index case – RY2).
However, the more recent cases are not described in publications, and identification requires matching of the sample collection date with the dates of hospitalization. This analysis indicates RY3 was from a fatal case (61M) who developed symptoms while traveling in Egypt. Although this case died in early 2013, details on travel and disease onset are lacking. However, the sequence includes clustered polymorphisms shared by sequences from Bisha (EMC) and Jordan (JOR), supporting an origin outside of Riyadh. Although this case was used to suggest that MERS was radiating out from Riyadh, the match of RY1 with BS1 and the likely origin of RY3 from Egypt impact one of the main points of the paper (which requires some background on RY3, which was not given in the paper).
Similarly, the NEJM paper on the Al Hasa outbreak failed to give information on the probable cases, other than the two key cases (index and super spreader) and the admission dates and location (which indicated the vast majority of the probable cases were dialysis patients). The outcomes for the probable cases (other than the fatal outcomes for the index and super spreader), and their positions in the transmission graph, also affected interpretation of the data regarding fatality rates in these probable cases, as well as the length and number of transmission chains.
The September 19 WHO report, as well as earlier reports on the Al Hasa cases which withheld age, gender, disease onset, hospital admission, and date of death or discharge, further limits the analysis of the cases and clusters, and raises serious KSA-MoH and WHO transparency concerns, which will likely increase as more pilgrims fly in and out of KSA before and after the Hajj.