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Coronavirus Comments By Saudi Arabia MoH
The above comments are from an October 22, 2012 ProMED letter from Ziad Memish, who is Deputy Minister of Public Health for the Kingdom of Saudi Arabia (KSA) as well as Director WHO Collaborating Center for Mass Gatherings.
His letter was in response to the ProMED September 20 publication of a September 15 letter from Ali Zaki, Professor of Microbiology at the Dr Kakeeh Hospital in Jeddah, Saudi Arabi. His letter described a Jeddah patient who was fatally infected with a novel coronavirus which was identified with a pancornavirus PCR test and subsequently sequenced in collaboration with Ron Fouchier at the Emarasus Medical Center in The Netherlands. The patient had died in June and the novel coronavirus was reportable under International Health Regulations (IHR).
In the letter Dr Memesh complained that the reporting of the case had not gone through proper channels, which may have caused unnecessary collateral economic damage due to an over-reaction to the news. However, the complaint was made well after the case and virus were described in multiple independent sources, along with additional case(s).
The time line of the events surrounding the curious complaint are instructive and raise transparency and credibility concerns for the KSA Ministry of Health as well as WHO.
The Zaki letter was written almost four months after the patient died from an IHR reportable agent (a novel cornavirus). The ProMED report was on September 20, and two days later the full sequence of the coronavirus (EMC/12) was submitted to Genbank, a public sequence database. The letter was also linked to testing of the Health Protection Agency (HPA) of a severe case who like the above fatal case had been placed on life support after renal failure. A sample was tested with the pancornavirus PCR test described in the Zaki letter, and the case, who was a Qatari National (49M) who had traveled to Saudi Arabia.
The following day the Saudi Arabia Ministry of Health acknowledged the two confirmed cases as well as another fatal case who was a Saudi who died in England after seeking advanced medical care. The case had similar symptoms but was not tested for the novel coronavirus. On September 23 the WHO also acknowledged the two confirmed cases.
The following day the HPA released the sequence of the 206 BP insert from the PCR test of the Qatari case. That sequences had 35 mismatches with the most closely related sequences at Genbank, bat sequences (HKU4 series and HKU5 series) from Guangdong Province in China, but there was only 1 mismatch (99.5% identity), with they EMC sequence from the fatal Saudi case from June (June 22 collection date). The phylogenetic analysis placed the sequences in group 2c adjacet to SARS CoV sequences in group 2a.
On September 27 the full sequence from the fatal case was made public, and a revised sequence was made public on October 16, which was followed the next day by the publication of a New England Journal of Medicine report on the fatal Saudi case.
Thus, the Memesh complaint on October 22 was written after the Qatari case was confirmed in England and the two confirmed cases were described by the KSA MoH (in addition to the suspect fatal case who was not tested) as well as WHO.
The letter noted that the full story had not been told and subsequent reports by the KSA MoH and WHO raised serious concerns.
On November 4 the KSA MoH announced a third confirmed case. The report noted that the case was treated at a Riyadh hospital and was recovering, but the age of the case ,as well as associated dates (disease onset and hospitalization) were withheld.
On November 19 the KSA MoH announced a fourth confirmed case. Like the earlier report the case was treated at a Riyadh hospital and was recovering, but the age/gender as well as key dates were withheld. The KSA did not describe relatives with the same symptoms, including two who had been PCR confirmed or the fact that two of the relatives had died. Instead the KSA MoH noted an absence of serious outcomes.
On November 23 a fifth confirmed case was described on the Robert Koch Institute (RKI) website. This case was another Qatari who had also gone to Europe (Germany) for treatment and was recovering from an October infection.
On November 23 WHO also issued an update, with 4 confirmed cases including two who were epidemiologically linked, increasing the total number of confirmed cases to six. The description of three of the cases matches those disclosed by the KSA MoH or RKI, while the sixth case was the confirmed fatal case. The two epidemiologically linked cases were from the same family and lived in the same house. However, there were two additional family members who were symptomatic, including one who had died. The surviving symptomatic family member tested negative for the novel coronavirus. Like the KSA MoH reports, the WHO update gave no age or gender for the six confirmed or suspect cases and also failed to give any dates.
Subsequent media reports contained additional information, which raised serious concerns. All six cases were male, and the unconfirmed fatal case (who died from renal failure complications) was 70 years of age and the father of the other fatal case (who died from complications linked to multi-organ failure) in the cluster, which developed in October, but reported on November 23. Moreover, the fatally infected son was hospitalized four days after his father died, suggesting a significant time gap in disease onset dates for the father and son, which would strongly support human to human transmission. Another media report quoted a WHO spokesperson, who also alluded to the time gap in disease onset dates for the cluster, which supported H2H transmission.
Thus, the recent WHO update raised concerns about the absence of reports on the cluster by the KSA-MoH as well as the withholding of age and onset dates by the KSA-MoH and WHO. Media reports suggested that all 6 of the recently described confirmed and suspect cases were from October, but reported in November, including the November 23rd report which announced the cluster, which including a failure to detect the novel coronavirus in one of the surviving symptomatic family members.
These recent reports raise serious questions regarding the delays in reporting these cases as well as the withholding key information including age and disease onset dates supporting human to human transmission. The cases were active in October during peak Hajj activity, and now the WHO is suggesting more widespread testing.