WHO provides additional data on Corona cases from Saudi Arabia in October

Earlier this month, I noted that the World Health Organization (WHO) did not report information on five Corona cases from Saudi Arabia from October  (see Has WHO overlooked 5 Corona cases in Saudi Arabia?), although theses cases were counted in the world-wide total in the Disease Outbreak News posted on November 7, 2014 (link).

Two days ago, the WHO provided additional details about these five cases (link)  that are not available on the statistics page of the Saudi Arabia Ministry of Health website. The reporting of these additional case details is important to understanding the nature of human Corona infections.

Since, the last WHO update on Corona from Saudi Arabia (through October 30, 2014), the Saudi Arabia Ministry of Health website has reported almost 20 new Corona cases (link),. Hopefully, WHO will publish details about these cases soon as well.

Has WHO overlooked 5 Corona cases in Saudi Arabia?

Previously, I discussed discrepancies between the Corona case counts for the World Health Organization (WHO) and the European Centre for Disease Prevention and Control (ECDC) (link). The WHO case count differed from the number posted on the Saudi Arabia Ministry of Health website by 15 cases. At least 12 cases previously announced by the Saudi Arabia Ministry of Health had not yet been posted in Disease Outbreak News by the WHO through October 21, 2014.

Yesterday the WHO reported in aggregate 12 new Corona cases from Saudi Arabia from the period October 18 to October 26, 2014 (link). These 12 cases do not equate to the 12-case differential noted in my previous post. The most recent WHO report regarding cases from Saudi Arabia (October 16 link) only enumerates cases through October 11, 2014. However, between October 12 and October 16, the Saudi Arabia Ministry of Health website announced five additional Corona cases, Taif (3), Riyadh (1), and Al Karj (1).

Hopefully, the WHO will report these cases in the future or discuss why they are not included in the total count for Corona cases from around the world.

Links to five Saudi Arabia Corona Cases (October 12-16)

http://www.moh.gov.sa/en/CCC/PressReleases/Pages/Statistics-2019-10-12-001.aspx

http://www.moh.gov.sa/en/CCC/PressReleases/Pages/Statistics-2019-10-13-001.aspx

http://www.moh.gov.sa/en/CCC/PressReleases/Pages/Statistics-2019-10-14-001.aspx

http://www.moh.gov.sa/en/CCC/PressReleases/Pages/Statistics-2019-10-16-001.aspx(2 cases)

Corona-CoV Clusters in Saudi Arabia

As previously noted, at least seven clusters of Middle East respiratory syndrome coronavirus (Corona-CoV) cases have occurred in the Kingdom of Saudi Arabia (KSA) [1]. An additional eighth cluster can be inferred from official reports for the city of Medina [2]. Besides Medina, 3 clusters have been reported from Riyadh, and one each from Al Hofuf, Mecca, Asir Province (Bisha?), and Hafar Al-Batin. 

Besides these clusters, in July, the World Health Organization (WHO) reported laboratory confirmation of a female healthcare worker from Hafar Al-Batin  who had contact with a previously confirmed case [3]. The only prior confirmed case from Hafar Al-Batin  was a 16-year-old male who was reported to have died in June [4]. This would constitute another cluster from Hafar Al-Batin.

Since August 1, the KSA  Ministry of Health has reported at least seven individuals from Riyadh who were in contact with previously confirmed cases. Because of the lack of case details it is not possible to ascertain how many clusters of Corona-CoV cases may have occurred since then in Riyadh or are occurring there at this time.

The table below presents information on the location and potential number of cases associated with Corona-CoV clusters in the KSA using cluster numbers assigned by the CDC [5]. The maps shows the general areas where these clusters occurred.

Location of Corona-CoV Clusters in Saudi Arabia

[1] Corona-CoV is a Threat to Healthcare Workers and Hospital Patients

[2] A Corona-CoV Cluster Outbreak in Medina, Saudi Arabia 

[3] Middle East respiratory syndrome coronavirus (Corona-CoV) - update 

[4] MOH: Two New Confirmed Cases of Coronavirus Recorded in Al-Ahsa and the Eastern Region and One Case Passed Away in Hafr Al-Batin 

[5] Middle East Respiratory Syndrome (Corona): Clusters under Investigation

Corona-CoV is a Threat to Healthcare Workers and Hospital Patients

Recently, the European Centre for Disease Prevention and Control (ECDC) produced a summary report on the status of the Middle East respiratory syndrome coronavirus (Corona-CoV) outbreak for the 130+ cases that have been reported since March 2012 [1].

While epidemiological data about these cases are presented in this report, several aspects of the report need further elaboration and discussion. As discussed on a USA Center for Disease Control web page [2] and noted in the ECDC report,  human clusters are prevalent for this novel disease. At least 14 Corona-CoV clusters have been reported. Single clusters have been reported from several countries, France, Italy, Jordan, Tunisia, and the United Kingdom. And the Kingdom of Saudi Arabia, which has reported more than 100 Corona-CoV cases, has experienced at least seven cluster outbreaks in seven separate geographic areas.

The ECDC authors state

We identified 14 clusters of 2-34 cases, where the primary cases were identified or suspected. However, data quality on the clusters is weak. All of the known 14 primary cases in clusters were adult men (24-83 years old) who were most likely exposed on the Arabian Peninsula. Of 129 cases with available information on transmission, 33 (26 percent) were possible nosocomial transmissions, 15 of these cases were healthcare workers (HCW). 17 of the 23 cases reported as HCW were female.

Information on geographic clusters of cases can provide important insight for public health officials into the mode of transmission, the transmissibility of the novel pathogen, and the potential identification of the non-human reservoir of a pathogen. What is not mentioned by the ECDC authors is that about 50% of all reported Corona-CoV cases have occurred in a cluster as defined by the World Health Organization (WHO) [3]. What is also not mentioned by the ECDC authors is how the index cases in these clusters became infected. The non-human source of this coronavirus has yet to be identified.

Of greater concern is the fact that at least 33 cases may have resulted from nosocomial transmissions. Nosocomial infection is a result of pathogen transmission within a hospital or healthcare facility.  This means that these 30+ individuals, including healthcare workers, contracted Corona-CoV in a healthcare facility such as a hospital. They did not contract the disease from an intermediate animal source. Infections within a healthcare facility are associated with human-to-human transmission. 

Several reports indicate that at least nine of these nosocomial infections were hospital patients most likely with comorbidities.  However, more alarming is that a number of healthcare workers were also infected in the hospital or healthcare treatment facility. This means that the coronavirus is transmissible not just among elderly individuals with chronic diseases but also among healthy younger healthcare workers who should be aware of, and prepared for, the dangers of human-to-human transmission.

Discussion

 

The nature of the transmissibility of the Corona-CoV is not clear, but the fact that numerous clusters have been reported and that human-to-human transmission is occurring among both patients and healthcare workers in healthcare facilities is cause for serious concern and demonstrates a need for increased monitoring and surveillance for this novel disease.

 

 [1] Taking stock of the first 133 Corona coronavirus cases globally – Is the epidemic changing?

[2] Middle East Respiratory Syndrome (Corona): Clusters under Investigation

[3] Interim surveillance recommendations for human infection with Middle East respiratory syndrome coronavirus

 

It Is Not Too Soon to Develop a Corona Vaccine

Middle East Respiratory Syndrome Coronavirus (Corona-CoV) is spreading throughout Saudi Arabia. The first known human infections of Corona-CoV occurred in 2012 in Jordan in a hospital setting.[1] Since then, more than 130+ suspected and confirmed cases have been recorded from eight countries in Europe, Africa, and the Middle East. More than 100 cases (about 80% of all cases) have occurred in Saudi Arabia.  More concerning is that the number of cases is increasing rapidly in Saudi Arabia. In the last two weeks the Saudi Arabia Ministry of Health has reported about 25 new cases.[2]

Most of these new cases in Saudi Arabia appear to have been infected by human-to-human contact. It is time for public health officials to be proactive and support plans for developing a Corona-CoV vaccine. Spanish researchers have taken the first step and report that they are working towards developing a Corona-CoV candidate vaccine.[3] More Corona-CoV vaccine research is needed immediately, just in case.

[1] Novel coronavirus infections in Jordan, April 2012: epidemiological findings from a retrospective investigation

[2] Kingdom of Saudi Arabia Ministry of Health Media Statements

[3] Engineering a Replication-Competent, Propagation-Defective Middle East Respiratory Syndrome Coronavirus as a Vaccine Candidate

h/t Giuseppe Michieli

Case Details from the Current Corona Outbreak in Riyadh Saudi Arabia, August 2015

The current outbreak in Riyadh started mid-July when a 56-year-old man became infected with Middle East Respiratory Syndrome coronavirus (Corona). This individual had frequent contacts with camels and consumed raw camel milk. This man infected his 52-year-old wife, his 53-year-old brother, and 30-year old son. The index case and his wife are reported to have died.

Almost 120 cases have been confirmed during this Corona outbreak in Riyadh through August 28, 2015.  As in other Corona outbreaks, more males then females are infected, about 61%. The males range in age from 2-109 years old with a median age of 61. The females range in age from 25 to 98 with a median age of 58.

The fatality rate for this outbreak is about 25%, with similar death percentages for both males and females. However the fatality statistics could change because the Saudi Arabia Ministry of Health is reporting that there are at least 50 cases still under treatment.

In this outbreak, most of the infections had been contracted by either visiting or being treated in a hospital with current Corona patients. A few cases are reported to have contact with confirmed Corona patients possibly outside of a healthcare setting. Information on family clusters is not available. It is difficult to assess the extent of family clusters, since that information is not generally available. 

Besides the initial family cluster in this outbreak, one other possible family cluster can be proposed from the data. A 56-year-old female experienced symptom onset on August 7, with her death reported on August 17. The World Health Organization reports that a 28-year-old female had contact with this woman and became symptomatic on August 12. A third individual, a two-year-old boy, also had contact with this woman and became symptomatic on August 12 as well. The boy is reported by the Saudi Arabia Ministry of Health to have recovered. Speculating, this cluster would seem to be a result of a daughter and a grandson interacting with the 56-year-old grandparent.

Healthcare workers represent about 11% of all infected individuals in this current outbreak.  This is similar to the overall percentage of healthcare workers infected with Corona in Riyadh since 2012. About 10% of all of Corona cases reported from Riyadh since 2012 were healthcare workers.

The epidemiological similarities among various Corona outbreaks should begin to provide a framework for understanding and controlling this disease in the future.