Public health officials in the Gulf states are playing down fears about an outbreak of the deadly MERS coronavirus among pilgrims travelling to the Hajj in Saudi Arabia this month, though doctors are advising the elderly, people with existing health conditions, pregnant women and young children to stay away.
As of 4 October, according to the World Health Organization (WHO), laboratories in the region had confirmed 136 cases of the Middle East Respiratory Syndrome Coronavirus (MERS-CoV), including 58 deaths since April 2012.
Most cases and deaths have been in Saudi Arabia, where two million Muslims are expected to converge in mid-October for the annual Hajj pilgrimage to the holy cities of Mecca and Madinah.
The virus is seen as a cousin of Severe Acute Respiratory Syndrome (SARS), which swept through Asia in 2002-3, killing over 700 people.
MERS-CoV can cause breathing difficulties, diarrhoea, kidney failure, and in extreme cases, death.
Saudi Arabia’s Health Minister Abdullah Al Rabia says his country is ready for an outbreak, but stressed that he was confident there would be no problem, given there were no recorded cases during either July's Umrah pilgrimage or last year's Hajj.
The country, which has had 120 cases and 49 deaths since September 2012, has assigned two laboratories for MERS-CoV-specific testing. It will also use existing health surveillance points at borders (set up to ensure pilgrims are vaccinated against Meningococcal Meningitis and Yellow Fever) to be on the look-out for cases.
Health authorities around the Middle East, many of whom already send large health support teams to the Hajj, will also be raising awareness of the virus among pilgrims, with a focus on reminding people what they should do if they return from Saudi Arabia and feel unwell.
Dubai Health Authority in the United Arab Emirates is to launch an awareness campaign for pilgrims travelling to the Hajj although details are yet to be released.
The risks of MERS-CoV transmission were discussed at length during a week-long meeting of the International Mass Gathering Medicine Conference held last month in Saudi Arabia, home to the Global Center for Mass Gathering Medicine run by the Saudi government.
Over 1,000 health officials from WHO, the US government's Centers for Disease Control and Prevention (CDC) and various governments from around the world attended the event, which focused on MERS-CoV.
One of the difficulties with the virus is that the early symptoms can be easily confused with the common cold. Unless doctors are specifically screening for the virus, it can be hard to pick up.
Another challenge is that despite more than one year of research, scientists remain unsure about the source of the virus and how it is transmitted.
"Until we have a definitive source of infection, it is hard to give targeted advice," explained Richard Brown, a medical doctor and regional adviser for communicable disease surveillance and epidemiology for WHO's South East Asia Regional Office.
Brown, who is also focal point for WHO's International Health Regulations, told IRIN: "There is an assumption that the source is animals, and we have seen some very interesting studies about bats and camels, but if they are a possible source of infection, we don't really know how it's getting from those animals to humans, or whether perhaps even these animals are being infected from yet another, undiscovered source.”
He added: "People need to be careful in a very generic way, such as ensuring good hand hygiene. We would normally tell people to avoid very crowded situations, but obviously in this case, with the Hajj, that is unrealistic."
Anthony Mounts, a medical doctor and technical lead for the MERS-CoV response with WHO in Geneva, stressed the importance of global awareness about MERS-CoV, not just among countries in the Middle East, or those sending pilgrims to the Hajj.
"The Hajj could possibly be an issue, but actually there are pilgrims that go to sites in Saudi Arabia all through the year. When you look back at our data, we have not seen cases emanating from these people," he explained.
“However”, he added, "the concern extends beyond the countries in the immediate region. If you look at the way people travel in the region, in particular the workforce, they come from a lot of poor countries, from places like Pakistan, India and the Philippines, all of which are places which don't perhaps have the best infrastructure to respond to a virus or even to detect it."
Mounts said WHO is working globally to ensure all countries are able to test for MERS-CoV and know what to look for.
Brown agrees that while mass gatherings pose a particular risk for MERS-CoV, health actors must always be vigilant.
"The thing that almost makes it easier about Hajj is that you know when people are going and when they are coming back. But if you have migrant workers coming and going the whole time, then it requires constant vigilance," he explained.
"When people are exiting the country, you should be giving them some basic health advice. And, if they are returning to their home countries, it's about encouraging them to proactively mention to people where they have been to sensitize the clinician to the possibility of infection."
In order to track the virus' spread, WHO has set up the International Health Regulations Emergency Committee on MERS-CoV.
However, at its third meeting last month, the Committee voted unanimously that the conditions for a Public Health Emergency of International Concern (PHEIC) have not at present been met.
This means there will not be a global high alert, as was seen over the last decade when there were outbreaks of SARS, Avian Flu H5NI and Swine Flu.
Experts find some comfort in two things: the pace of the disease has not accelerated, nor has the disease mutated.
"Although we have seen human to human transmissions occur in healthcare facilities, between patients, from patients to doctors, among healthcare staff and close family members, we haven't yet seen that third or fourth level of community transmission," Mounts said, meaning when the disease is spread more randomly among strangers.
"There have been quite a lot of investigations looking for this [community transmission], they just haven't found it yet. What's more, the clusters that we have seen seem to extinguish themselves with relatively modest interventions, which was not the case with SARS."
|What is MERS-CoV?
MERS-CoV is short for Middle East Respiratory Syndrome Coronavirus. It is a particular strain of the “coronavirus” family that causes illnesses ranging from the common cold to more serious respiratory conditions. It is regarded as a cousin of Severe Acute Respiratory Syndrome (SARS), which claimed more than 700 lives when it hit Asia in 2002-2003. It was initially labelled Novel Coronavirus (nCov).
|How widespread is MERS-CoV?
No one is really sure. It is possibly being under-reported because doctors are mistaking it for the common cold and people who are otherwise healthy are able to fight it off. While the World Health Organization (WHO) is taking MERS-CoV seriously, setting up an Emergency Committee to track its progress and organize the response, experts there do not believe it has met the criteria to be named an in international public health emergency. Nor does WHO advise against travel to any countries or special screening at points of entry.
|How fatal is the virus?
So far 58 people have died. At over 40 percent so far, the death rate of MERS-Cov is high compared to SARS. But it is possible people contracting the virus have been able to fight off the symptoms and therefore have not reported it. As such, only the most serious cases are being identified. The elderly or those who have underlying health conditions, like diabetes and hypertension, are most vulnerable to MERS-CoV. This is one explanation for the high death rate among those who get infected.
|How would you know if you had MERS-CoV?
It is hard to tell because the symptoms are very similar to the common cold, though in the case of infection, they will rapidly escalate from a fever and cough to breathing difficulties. Many patients have also had gastrointestinal symptoms, including diarrhoea, and some have had kidney failure.
|What is the treatment for MERS-CoV?
No vaccine is currently available. Treatment depends on the patient’s clinical condition and would involve general supportive medical attention. In advanced cases, patients have been submitted to intensive care units to support their breathing and other organ functions.
|Does MERS-CoV come from camels?
A study published in The Lancet Infectious Diseases journal found a high level of MERS-CoV antibodies among camels in the Middle East. This suggests that the virus, or something very similar, has recently been circulating among camels and this may be the source of the infections seen over the last year. However, researchers still do not know how the virus is being transferred from camels to humans. Given that none of the confirmed MERS-CoV patients had a history of direct interaction with camels, an intermediary carrier could be taking the virus from camels to humans. Scientists say it is also possible that the antibodies found in camels could be a very closely related virus, rather than the actual virus itself.
|What about bats?
A team of US and Saudi scientists have looked at bat populations in the Middle East to see if the nocturnal animals may be a source of MERS-CoV. They found that a faecal sample from one bat in Saudi Arabia yielded a fragment that was a 100 percent match for the MERS-CoV, though some have questioned whether the fragment was too small to give an accurate or useful reading. Again, there is still no information about how the virus has been or could be transmitted to humans.
|How can you protect yourself from MERS-CoV?
Until more is known about where MERS-CoV comes from and how it is spread, it is hard to give specific advice. The US Centers for Disease Control and Prevention (CDC) recommends general common sense hygiene precautions. These include: washing your hands often with soap and water for 20 seconds, and if water is not available to use an alcohol-based hand sanitizer; covering your nose and mouth with a tissue when you cough or sneeze; avoiding touching your eyes, nose, and mouth with unwashed hands; avoiding close contact, such as kissing, sharing cups, or sharing eating utensils, with sick people; and cleaning and disinfecting frequently touched surfaces, such as toys and doorknobs.
|Sources: World Health Organization; Centers for Disease Control and Prevention; The Lancet journal.|