On 13 June, WHO and the Republic of Korea’s Ministry of Public Health and Welfare presented the results of their joint assessment of the MERS outbreak. The assessment led to a series of recommendations. These include further strengthening of measures to control the current outbreak, such as continuing to strengthen contact tracing, and enhanced precautions in hospitals to prevent transmission, as well as increased communication with the public and better preparation for future outbreaks.
As of 16 June 2015, the Republic of Korea has reported 155 laboratory-confirmed cases and 19 deaths. The outbreak, which started with the introduction of MERS-CoV infection into the country by a single infected traveler, was amplified by infection in hospitals and movement of cases within and among hospitals.
The number of new cases occurring each day, which is the most accurate picture of whether the outbreak is slowing down, appears to be declining. This suggests that the containment measures in place are having an effect in reducing new infections. As these containment measures have been recently intensified, it is too early to measure their full impact on the transmission.
An early concern was whether the MERS-CoV virus changed and whether the transmission patterns in Korea were different compared with past outbreaks occurring in the Middle East. Scientists in the Republic of Korea and China have completed full genome sequencing of coronaviruses from the current outbreak. Findings were analyzed by a group of virologists convened by WHO. Preliminary analysis of these findings suggest that the MERS CoV viruses isolated in Korea are similar to those isolated in the Middle East. Furthermore, the joint mission found that the transmission patterns are similar to that seen previously in the Middle East.
Challenges in early diagnosis
MERS CoV is difficult to diagnose, particularly in the early part of an outbreak when awareness is relatively low. The initial, or “index” case, did not report his recent travel history to the Middle East when he first sought treatment. MERS was not suspected, and the initial case exposed others for more than a week before he was isolated. Additionally early symptoms of MERS resemble other influenza-like illnesses making it difficult to recognize or suspect MERS.
In the early stage of the disease when upper respiratory track is infected, the virus may be more difficult to detect. The laboratory diagnosis is more robust with samples taken in the lower respiratory track usually in the later stage of the disease when the patient is hopitalised. Furthermore, samples taken from the upper respiratory system (e.g., nasal swabs) can sometimes provide negative test results when lower respiratory samples, which are difficult to collect, may be positive.
As noted by the joint mission, Korea follows a policy of retesting symptomatic contacts following initial negative results.
As has been seen in this and other outbreaks, lapses in early detection and isolation, and the tendency to refer patients to other facilities for testing or management, can facilitate rapid spread from a single infected person.
MERS CoV spread in Korea
Conditions and cultural traditions specific to Korea have likely also played a role in the outbreak’s rapid spread. The accessibility and affordability of health care in Korea encourage “doctor shopping”; patients frequently consult specialists in several facilities before deciding on a first-choice facility.
Moreover, it is customary in Korea for many family members and friends to visit loved ones when they are in the emergency room or admitted to hospital. It is also customary for family members to provide almost constant bedside care often staying in the hospital room overnight, increasing the risk of close exposures in the health care setting.
Actions to control the MERS CoV outbreak
WHO and the Republic of Korea carried out a joint mission to assess the epidemiological patterns of MERS CoV in the Republic of Korea as well as the characteristics of the virus and clinical features. It also reviewed the public health measures implemented since the start identification of the first case on 20 May 2015.
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