The Middle East Plague Goes Global
foreignpolicy.com
foreignpolicy.com
Part 1:
When the Black Death exploded in Arabia in the 14th century, killing an estimated third of the population, it spread across the Islamic world via infected religious pilgrims. Today, the Middle East is threatened with a new plague, one eponymously if not ominously named the Middle East respiratory syndrome (MERS-CoV, or MERS for short). This novel coronavirus was discovered in Jordan in March 2012, and as of June 26, there have been 77 laboratory-confirmed infections, 62 of which have been in Saudi Arabia; 34 of these Saudi patients have died.
Although the numbers -- so far -- are small, the disease is raising anxiety throughout the region. But officials in Saudi Arabia are particularly concerned.
This fall, millions of devout Muslims will descend upon Mecca, Medina, and Saudi Arabia's holy sites in one of the largest annual migrations in human history. In 2012, approximately 6 million pilgrims came through Saudi Arabia to perform the rituals associated with umrah, and this number is predicted to rise in 2013. Umrah literally means "to visit a populated place," and it's the very proximity that has health officials so worried. In Mecca alone, millions of pilgrims will fulfill the religious obligation of circling the Kaaba. And having a large group of people together in a single, fairly confined space threatens to turn the holiest site in Islam into a massive petri dish.
The disease is still mysterious. Little is understood about how it is transmitted and even less regarding its origins. But we do know that MERS is deadly, with a mortality rate of about 55 percent -- a remarkably higher lethality than that posed by its close cousin, the severe acute respiratory syndrome (SARS) virus, which in 2003 terrified travelers across the globe but posed a fatality rate of only 9.6 percent. The MERS coronavirus is new to our species, so mild and asymptomatic infections seem to be rare, but the human immune response to infection is itself so extreme that it can prove deadly in some cases.
Like SARS, the MERS virus spreads between people via close contact, shared medical instruments, and coughing. Once inside the human lung, the MERS virus sparks a series of reactions that all but destroy normal lung function. Patients can descend into pneumonia so severe that they require machine-assisted breathing to stay alive, in as little as 12 days. Unlike SARS, the MERS virus is also capable of attacking the kidneys and can be passed on to others via exposure to contaminated urine. And for some of those who survive acute MERS, years of rehabilitation may be necessary, just like for some of the 2003 SARS victims.
And like back in 2003, when health officials worried about airplane travelers in confined spaces transmitting the virus across the globe, the hajj poses a unique risk of transmission, one that could catapult this still-small outbreak into a full-fledged pandemic. Containment will become nearly impossible as millions of pilgrims flock from virtually every country on the globe to the kingdom during the holy month. Indeed, MERS has already crossed continents; two suspected cases were reported in France as recently as June 12, and confirmed cases have been reported in Germany and Britain. The first patient in each of these cases had traveled in the Middle East before reaching his/her home destination, only then to be diagnosed with MERS.
When the Black Death exploded in Arabia in the 14th century, killing an estimated third of the population, it spread across the Islamic world via infected religious pilgrims. Today, the Middle East is threatened with a new plague, one eponymously if not ominously named the Middle East respiratory syndrome (MERS-CoV, or MERS for short). This novel coronavirus was discovered in Jordan in March 2012, and as of June 26, there have been 77 laboratory-confirmed infections, 62 of which have been in Saudi Arabia; 34 of these Saudi patients have died.
Although the numbers -- so far -- are small, the disease is raising anxiety throughout the region. But officials in Saudi Arabia are particularly concerned.
This fall, millions of devout Muslims will descend upon Mecca, Medina, and Saudi Arabia's holy sites in one of the largest annual migrations in human history. In 2012, approximately 6 million pilgrims came through Saudi Arabia to perform the rituals associated with umrah, and this number is predicted to rise in 2013. Umrah literally means "to visit a populated place," and it's the very proximity that has health officials so worried. In Mecca alone, millions of pilgrims will fulfill the religious obligation of circling the Kaaba. And having a large group of people together in a single, fairly confined space threatens to turn the holiest site in Islam into a massive petri dish.
The disease is still mysterious. Little is understood about how it is transmitted and even less regarding its origins. But we do know that MERS is deadly, with a mortality rate of about 55 percent -- a remarkably higher lethality than that posed by its close cousin, the severe acute respiratory syndrome (SARS) virus, which in 2003 terrified travelers across the globe but posed a fatality rate of only 9.6 percent. The MERS coronavirus is new to our species, so mild and asymptomatic infections seem to be rare, but the human immune response to infection is itself so extreme that it can prove deadly in some cases.
Like SARS, the MERS virus spreads between people via close contact, shared medical instruments, and coughing. Once inside the human lung, the MERS virus sparks a series of reactions that all but destroy normal lung function. Patients can descend into pneumonia so severe that they require machine-assisted breathing to stay alive, in as little as 12 days. Unlike SARS, the MERS virus is also capable of attacking the kidneys and can be passed on to others via exposure to contaminated urine. And for some of those who survive acute MERS, years of rehabilitation may be necessary, just like for some of the 2003 SARS victims.
And like back in 2003, when health officials worried about airplane travelers in confined spaces transmitting the virus across the globe, the hajj poses a unique risk of transmission, one that could catapult this still-small outbreak into a full-fledged pandemic. Containment will become nearly impossible as millions of pilgrims flock from virtually every country on the globe to the kingdom during the holy month. Indeed, MERS has already crossed continents; two suspected cases were reported in France as recently as June 12, and confirmed cases have been reported in Germany and Britain. The first patient in each of these cases had traveled in the Middle East before reaching his/her home destination, only then to be diagnosed with MERS.
Controlling the spread of the virus is only half the battle. There is no MERS vaccine, drug, or simple diagnostic test available. And once MERS patients are identified, caring for them presents its own set of complications. Not only is the treatment for MERS intensive and complicated, but health-care workers must carefully protect themselves so as to minimize the risk of contracting or unwittingly spreading infection.
If in-hospital spread is occurring within state-of-the-art, high-tech hospitals, the potential for MERS transmission inside squalid Syrian hospitals and makeshift refugee clinics is significant. It would seem nearly impossible to mitigate in-hospital spread of MERS in Syria, where over a third of public hospitals are no longer in service and supplies of even the most rudimentary medicines and equipment are scarce. Should the MERS virus get a foothold in such settings, further international spread of MERS seems inevitable, especially amid highly mobile populations fleeing political instability.
Although the WHO has publicly praised Saudi Arabia for "urgently taking crucial actions" in this crisis, it is becoming clear that in spite of officials' cooperation, there are some real practical problems facing Saudi authorities.
First and foremost, the Saudi Ministry of Health is understaffed and in need of assistance. At least one foreign laboratory collaborating with the Saudis received samples of MERS that had deteriorated because they were packaged and shipped incorrectly, rendering them unusable. International collaborators who have been eager to aid the Saudis face staffing bottlenecks, causing delays that are agonizing in an outbreak context.
But that one foreign laboratory was fortunate to get the samples sent to it at all, since the Saudi Ministry of Health has also been embroiled in a "patent" dispute surrounding MERS that has reportedly stymied research efforts by foreign scientists. Last summer, a Dutch team from Erasmus Medical Center in Rotterdam received two patient samples from an Egyptian scientist working then in Jeddah, Saudi Arabia. The Dutch sequenced the MERS DNA and claimed ownership of the samples. All scientists hoping to work on the MERS problem must either obtain samples directly from the Saudi Ministry of Health or sign legal agreements with Erasmus. For example, the U.S. Centers for Disease Control and Prevention (CDC) is still waiting to receive samples of MERS for testing that were collected in October 2012 because the legal teams from the CDC and Erasmus cannot negotiate agreeable terms for a material transfer agreement. These legal delays are unusual, especially during a disease outbreak such as this, and Margaret Chan, director-general of the World Health Organization, publicly criticized Erasmus for putting patent laws ahead of protecting "your people."
Meanwhile, the WHO has its own institutional problems. The organization's emergency-response system is bankrupt (though it only needs $10 million to function for the rest of 2013). Despite these budgetary constraints, surveillance must be ramped up, particularly in the region itself. The WHO has also been trying to improve dialogue and information sharing about MERS, but the organization's efforts have fallen short. Its most recent attempt -- a three-day meeting in Cairo attended by 100 experts -- came up short; the result amounted to little more than language that in essence just reiterated pre-existing agreements about global standards for disease surveillance and reporting that took effect after the International Health Regulations (2005).
Participants at the meeting did recognize the urgency of the situation, however, and acknowledged that the world is at a critical point in the trajectory of the MERS outbreak. As Keiji Fukuda, WHO assistant director-general for health security and the environment, said: "We need to exploit this chance to agree and implement the best public health measures possible across the board, for in so doing, we stand the best chance of controlling this virus before it spreads further."
It wouldn't be possible -- or even desirable -- to stop the flow of people in and out of Saudi Arabia and the Middle East, be they migrant workers, refugees, humanitarian volunteers, or religious pilgrims. The immediate challenges are to identify the animal sources of MERS and stop its animal-to-human spread. In lieu of knowing the virus's origin, human-to-human transmission must be halted -- and the best first step to accomplishing this is through radical improvements in hospitals' hygiene practices and through swiftly identifying infected friends, family members, and co-workers of those who develop the MERS disease.
But that's only a stopgap solution. Unless the many barriers to a transparent international research and information-sharing system disappear, it will be exceedingly difficult to reduce the risk of infection. Otherwise, the world could be dragged into another Black Death, and MERS could easily spread far beyond the bounds of the region for which it is named.
Laurie Garrett is senior fellow for global health at the Council on Foreign Relations.
Maxine Builder is a research associate at the Council on Foreign Relations.
This situation will hopefully influence patent debates about DNA everywhere: (yeah, ok, maybe it might)
But that one foreign laboratory was fortunate to get the samples
sent to it at all, since the Saudi Ministry of Health has also been
embroiled in a "patent" dispute surrounding MERS that has
reportedly stymied research efforts by foreign scientists. Last
summer, a Dutch team from Erasmus Medical Center in Rotterdam
received two patient samples from an Egyptian scientist working
then in Jeddah, Saudi Arabia. The Dutch sequenced the MERS DNA and
claimed ownership of the samples. All scientists hoping to work on
the MERS problem must either obtain samples directly from the Saudi
Ministry of Health or sign legal agreements with Erasmus. For
example, the U.S. Centers for Disease Control and Prevention (CDC)
is still waiting to receive samples of MERS for testing that were
collected in October 2012 because the legal teams from the CDC and
Erasmus cannot negotiate agreeable terms for a material transfer
agreement. These legal delays are unusual, especially during a
disease outbreak such as this, and Margaret Chan, director-general
of the World Health Organization, publicly criticized Erasmus for
putting patent laws ahead of protecting "your people."Evernote Clearly for Chrome solves the need for a login quite nicely.