This post was written by Daniel R. Lucey, Adjunct Professor of Microbiology and Immunology at the Georgetown University Medical Center (GUMC) and a Senior Scholar at the O’Neill Institute for National and Global Health Law. Any questions or comments about the post can be directed to firstname.lastname@example.org. The original post appeared on the CSIS Korea Chair Platform and can be found here.
The Middle East Respiratory Syndrome (MERS) is caused by a mildly contagious virus that can cause a life-threatening pneumonia typically in persons with any of four pre-existing medical conditions: lung disease, kidney disease, immunodeficiency, or diabetes. Given the ongoing first MERS outbreak in Korea, beginning when a traveler returned home from the Middle East and then became ill one month ago, there are several key points to know about this virus and why it can be stopped in Korea soon.
First, the virus that causes MERS is only a distant relative of the virus that caused the Severe Acute Respiratory Syndrome (SARS) in 2003 and it is much less contagious than SARS or influenza. Second, MERS outbreaks are mostly linked to hospitals, and these outbreaks have been stopped in at least six other countries, preventing MERS epidemics from spreading in the general population of any country. Third, in most persons without the above four pre-existing conditions the MERS virus causes less severe or mild illness, or even no symptoms at all. Fourth, genetic sequencing in several laboratories of the virus from at least two Korean patients (one hospitalized in China) does not show any evidence of a mutation that would make this virus more contagious than any other MERS virus in the Middle East.
The current hospital(s)-associated MERS outbreak can be stopped in Korea with sustained cooperation across all of society. This cooperation includes a comprehensive rapid public health response, effective outbreak communication with the public, and transparency from both organizational leaders and individuals in quarantine.
The earliest known outbreak of MERS was retrospectively recognized in a hospital in Zarqa, Jordan in April 2012. At least nine health care workers, patients, and family members were infected. The outbreak was stopped by a rapid public health response lead by the Ministry of Health focusing on strict infection control and prevention measures. The virus was only discovered later, however, from a patient who died in June 2012 of a pneumonia in Jeddah, Saudi Arabia.
Research in 2013 in Qatar, Saudi Arabia, and UAE suggested camels could transmit the MERS virus to people. Afterwards person-to-person spread could occur, especially in the hospital setting. The World Health Organization (WHO) states that the exact transmission routes of the MERS virus have not been proven; however, for health care workers they recommend both contact and respiratory precautions with use of masks, gloves, gowns, eye protection, and rigorous hand hygiene. Infection prevention precautions for the general public against MERS have not been rigorously studied, including the use of face masks. Given that spread of the virus in the general population is not known to have occurred, such studies were not possible. On the other hand, fear of MERS will hopefully increase good hand hygiene practices by the public in Korea, as occurred elsewhere during SARS and Ebola. Hand hygiene is effective to prevent many infections transmitted by contact.
In 2013 and 2014, multiple hospital outbreaks of MERS were reported across Saudi Arabia. At least some were initiated by camels infecting people who then came to hospital and triggered outbreaks due to inadequate infection control and prevention measures for MERS. As of June 4, 2015 the Saudi Ministry of Health reported on their MERS website 1,019 confirmed cases and 450 deaths due to MERS since June 2012. The United Arab Emirates (UAE), which has had a small number of hospital-associated outbreaks, has the next highest total of MERS cases at 76 of whom 10 have died. Hospital outbreaks in other nations have been smaller, e.g., < 5 cases in Iran, UK, and France. Multiple other nations have had zero transmissions in hospitalized patients, including Malaysia, the Philippines, USA, Germany, Austria and others.
As of June 7th, Korea has reported 64 confirmed patients and five deaths due to MERS, with infections linked to health care facilities. While the number of cases in Korea could surpass that of UAE in the week ahead, the outbreak should be able to be stopped soon before the virus can spread to other health care facilities, or into the general community. Fortunately, unlike the Middle East, reintroduction of the MERS virus from camels will not occur in Korea.
How can the outbreak be stopped? There is no proven effective antiviral drug or immune-based treatment (such as an antibody or convalescent plasma from persons who survive MERS). Thus, the traditional effective measures of isolating people who are ill, and quarantining people after exposure to the virus are essential to control MERS, as they are for SARS and Ebola. Providing health care workers with the appropriate training, protocols, and personal protective equipment (PPE) for MERS are also essential, as they were for SARS and Ebola.
In addition, close cooperation must occur between hospitals, and between public health officials, hospitals, and outpatient facilities to prevent patients with MERS from going to different medical facilities and triggering additional outbreaks. This key principle was learned and implemented in Asia, as well as in Toronto where I witnessed it while working during the SARS outbreak.
At the same time, effective communication with the public is also essential, as it was with SARS, Ebola, and anthrax in the USA in 2001. Based on lessons from SARS and many other outbreaks, the WHO convened a meeting in Singapore, soon after the SARS epidemic ended, to create “best practices for communicating with the public during an outbreak”. Posted on the WHO website this guide highlights and give examples from multiple outbreaks of the importance of five principles for effective communication with the public during outbreaks. These are: (1) build, restore, and maintain trust (2) announce findings early (3) be transparent (4) listen to the public’s perception of risks and concerns and (5) plan ahead in order to adhere to the above principles.
I would add that transparency during outbreaks must be a two-way street. While health and government leaders must be transparent with the public, individual persons who are in quarantine must also be transparently honest with public health officials if they do not adhere completely to the requirements. The length of quarantine is usually the maximum number of days of the incubation period i.e., the time between the last exposure and the possible onset of illness i.e., 14 days for MERS (versus 10 days for SARS and 21 days for Ebola). Quarantine can be challenging, even in a home environment, but adherence is necessary to break the chain of transmission of these viruses.
Looking to the near future, cooperation across all-of-society against the common enemy of the MERS virus will be crucial to stop this outbreak. Indeed, Korea can make valuable lessons to the world in terms of how they responded to stop this MERS outbreak. Perhaps a better understanding of how this virus spreads from person-to-person will be gained by rigorous epidemiological studies. Perhaps the first effective antiviral, or antibody-based, therapies for MERS will come from Korea. Perhaps a stronger international effort to develop MERS vaccines for people, and not only camels, will follow this outbreak, perhaps spearheaded by Korea or China.
In addition, Korea is one of the 10 members of the steering committee of the Global Health Security Agenda (GHSA) that was founded in February 2014 by the US and several dozen other nations, along with organizations that include WHO, FAO, and OIE. The vision for the GHSA is to attain a world secure from global health threats posed by infectious diseases. During the current second year of the GHSA, the annual high-level meeting is scheduled to be held in Seoul this September. The MERS outbreak and response in Korea will surely be on the meeting agenda three months from now.
The views reflected in this expert column are those of the individual authors and do not necessarily represent those of the O’Neill Institute for National and Global Health Law or Georgetown University. This blog is solely informational in nature, and not intended as a substitute for competent legal advice from a licensed and retained attorney in your state or country.