You probably have not been following this viral infection that has been quietly simmering in the Middle East since 2012. It is not your fault, why should you care about a pathogen that has caused infections in only about 1,300 patients, most of whom were tucked away in hospitals in Saudi Arabia? It probably does not give rise to concern for many in the US since it appears that transmission from camels appears to be an important component to its spread—why should you be concerned about getting sick from animals we in the US only rarely see in zoos? The world has also been a little distracted since 2014 with Ebola; it seems that we can only focus on one big, scary killer bug at time, thank you very much.
However, as if we did not already suspect the Ebola scare for the US was overblown, we received confirmation from a study led by researchers at Arizona State University that found the media did in fact fan the flames of hysteria last October, perhaps recklessly. All in, only nine people were infected with laboratory-confirmed Ebola in the United States; only two contracted it within our borders and just two of the rest brought Ebola here unintentionally; two persons died–an unfortunate man from Liberia and an American medical hero. However, for several weeks at parties and at the office, Ebola was the principal topic of discussion, and at worst you were perhaps wondering if we were going to see gruesome Ebola zombies vomiting and hemorrhaging in our streets.
It’s not that we should have ignored Ebola. Over 20,000 people contracted Ebola in West Africa, and almost half died as a result. It was a major health disaster. It has been suggested the world came to the realization that something big was brewing in West Africa too late; the epidemic began in December 2013 and increasingly larger numbers of cases began to present as early as the March of 2014, but a massive response from the developed world was not really mounted until summer 2014. We should have cared sooner, and overdid it when we started to take notice because we finally had to deal with it. And deal with it our governmental health officials did well domestically behind the scenes—contact tracing of every person entering the US from Ebola affected countries for at least 21 days covering the incubation period required extensive man-hours and resources.
From the beginning, Ebola in the western world did not have the potential to be the killer that it was in Western Africa simply based on our advanced healthcare infrastructure. Denuded of hospital facilities after years of civil war, the populations in Liberia and Sierra Leone never had much more than a chance at anything short of self-resolution of symptoms once infected. Remember, Ebola came on top of endemic malaria and other viral and bacterial infections that mimic the initial symptoms of Ebola and are big killers in themselves already in those tropical countries. And we certainly don’t have the burden of malnutrition that greatly downgraded survival potential in West African patients.
However, our public panic was damaging to us in a number of ways. Health officials have utilized social media sites such as Google and Twitter since 2006 to detect incipient outbreaks of disease; based on the concept that patients suffering from symptoms will do searches on Google or chat with others on Twitter can be tracked to show where people are becoming ill. This ‘digital epidemiology’ has yielded some useful information regarding other diseases such as tuberculosis. But as demonstrated in the case of Ebola in the US in October 2014, the traffic on these sites was virtually all pollution from the intense interest generated by mainstream national and local news media. Thus, this valuable epidemiological tool had been compromised. Our government was not immune; unfocused mania over Ebola led to some rash decisions by our highest ranking health officials on how to respond. Do you remember the hundreds of millions of dollars wasted on building 11 Ebola Treatment Units in Liberia that only served a couple of dozen patients? The worst way the mania bubble hurt us is in the way it burst some weeks after it peaked. Americans went from obsessed about Ebola to completely uninterested. However, we certainly were not yet out of the woods; our hospitals and health infrastructure took a long time to get up to speed to deal with a disease that could have flared into large outbreaks had it possessed greater virulence.
That brings us back to MERS-CoV, which has all the makings for a terrifying news story. It is caused by a virus, from the same family of viruses, coronaviruses (they appear in the form of a crown under an electron microscope) as the virus that caused SARS epidemic back in 2003. Remember that one? SARS spread across China, into Hong Kong, Singapore, Vietnam, Canada and ultimately 26 countries in which it infected over 8,000 cases with 774 deaths—a death rate of 10 percent. MERS apparently can be transmitted like SARS via respiratory secretions such as from coughing, and as of this writing has infected over 1,300 cases with 455 deaths—a death rate of 35%! Got your attention?
After years of essentially remaining contained in the Middle East, it was brought to South Korea by a Korean businessman whose infection rapidly spread to secondary and tertiary cases. Fortunately, this outbreak has not made the rounds in the community so far as almost all of the subsequent cases contracted it while being treated or working at hospital facilities. Health officials find some solace in that fact, but consider that the Korean government has received admonishment to do a better job of containing the outbreak, in particular because of inadequate hospital procedures. A number of cases have been found to be likely exposed during protracted emergency room waiting times. Think about how your last visit to the emergency room went for you? Imagine going in for stitches on your foot at the ER and bringing home a deadly disease that you can spread through the air.
So, get ready for the tumult. We have already seen a few cases arrive in the US, but they did not spread the disease to any secondary cases. However, as the number of cases grows overall, it is likely this thing is going to spread, regardless of where. The annual Hajj, in early autumn when Muslim pilgrims from all over the world travel to the city of Mecca and live in close quarters for several days of prayer, provides an ideal opportunity for worldwide spread of MERS each year it persists there. Saudi officials are taking precautions, but like all governments when an outbreak is present, transparency gives way to the attitude of “nothing to see here, and keep those tourists coming, it’s business as usual”. But don’t be condescending Americans, the notorious Spanish influenza pandemic of 1918-1919 that extinguished 50-100 million lives worldwide may likely have emerged in Kansas. The last really scary outbreak, one where I felt that maybe this was the BIG one, was the H1N1 epidemic in 2009: the two patient zeroes detected with the human-to-human transmissible version of swine flu were children living 130 miles apart in California!
We dodged the bullet in 2009 because in the end that influenza strain was not sufficiently virulent, and the world’s health authorities took effective action to contain it. We will dodge the bullet with MERS-CoV, as well. As noted above, it has demonstrated so far an inability to spread freely in the community despite its airborne mode of transmission. In the several years of this outbreak, it has not evolved into a more virulent form. States such as California already have elaborate contact tracing and isolation protocols in place should any locally-acquired cases emerge. That finally is my point: MERS-CoV is not going to be the gateway to Armageddon, but do not expect our media to handle its story responsibly. Get ready for MERS to dominate your cocktail party conversation sometime in 2015.
Steven Smith, M.Sc. is an Infectious diseases epidemiologist