The New Coronavirus: Uncertainty, and How to Talk About It

Have we dodged a bullet? Or is the other shoe yet to drop?

The uncertainty over the novel coronavirus that was recognized last month is captured in a research report and editorial just released this evening by the New England Journal of Medicine. (I believe these are the first peer-reviewed papers on the new organism, though it has several times been written up in the European CDC’s bulletin, EuroSurveillance.) The papers are a treatment report and analysis of the first known case, the 60-year-old Saudi man who died in June, and an examination of the larger issues raised by this case and the second known one, which occurred in Qatar and London in September.

Short summary of the situation from the second paper, co-authored by the former chief of the division of viral diseases at the US CDC:

Since there has been no evidence of human-to-human transmission or virus transmission to healthcare workers, [the novel virus] is not currently a public health risk. (NEJM Anderson 2012)

So recapping a bit:

The story of this new organism appeared to start Sept. 14 with the discovery that a 49-year-old man who was from Qatar but had traveled to Saudi Arabia was severely ill in a London hospital, where his family had paid for him to be medevac’d for treatment. Six days later, a report on the international disease-alert mailing list ProMED described the illness of the Saudi man three months earlier. The report by the treating physician, Dr. Ali Mohamed Zaki, included a note that he had shared a viral isolate from the patient with Dr. Ron Fouchier in Rotterdam, who had provisionally identified it as a betacoronavirus, related to the viral cause of SARS. (For why this ignited such concern, take a look at my last post.)

Shortly afterward, an isolate from the London patient was partially sequenced and found to be almost identical to the virus found in the Saudi patient; and both viruses were identified as being most closely related to bat viruses. (The novel virus was dubbed hCoV-EMC, with “hCoV” standing for human coronavirus and “EMC” in tribute to Fouchier’s lab at Erasmus Medical Center.) And quite quickly after that  came a report that the London patient had stayed, while in Qatar, on a property where he owned sheep and camels, raising the possibility that the virus might have come to him through, and been changed by replication in, an intermediate animal host.

The first paper published tonight is a detailed report on the Saudi patient by Zaki, Fouchier, and Fouchier’s Erasmus colleagues. It details the man’s rapid decline from severe pneumonia and renal failure (he was admitted after 7 days of symptoms and died 11 days later), the careful lab and genetic analyses that followed, and the search for any commonalities between him and the Qatar/London patient, as well as any illnesses in any close contacts or health care workers. No links, and no person-to-person transmission of the novel virus, have  been found.

The editorial puts those findings into context. It recounts four recent viral public health emergencies — Nipah virus in 1998, West Nile virus in 1999, SARS in 2003 and the pandemic H1N1 flu in 2009 — to demonstrate that the time from identification, to analysis with increasingly sophisticated tools, and then to public health response, is shortening. Without underestimating the importance of those outbreaks, it raises the possibility that novel organisms may now be identified before they become a widespread threat. That’s provided, of course, that alert health care personnel recognize what is going on, and sound the alarm:

The detection of HCoV-EMC… probably forecasts an increasingly common theme in which new pathogens are identified before they may develop the potential for efficient human-to-human transmission. From past experience, an astute clinician, public health official, or laboratory worker will recognize an unusual event and contact the appropriate health officials, who will investigate the event. Good communication between the clinic, laboratory and public heath community is important. (NEJM Anderson 2012)

This is somewhat reassuring — but it also raises so many questions. What happens, on the one hand, if recognition doesn’t take place, or communication is not swift? (Recall that, though the Saudi hospital contacted the Erasmus lab quickly, most of public health did not learn of the case until 3 months had gone by.) And what happens if, on the other hand, all those communications work well enough to raise public alarm — and then nothing further happens? (Recall that, in 2009, public reaction to the generally mild presentation of pandemic H1N1 was generally that authorities were crying wolf.)

It is of course — of course — far better to have early warning of novel threats, than not. Yet as much as that brings some reassurance, it also poses new challenges in communicating the risks of novel organisms to the public. With luck, this novel coronavirus will remain a blip, and not an outbreak, and public health will be granted some time to think these issues through.

Cites:

• Zaki, AM et al. Isolation of a Novel Coronavirus from a Man with Pneumonia in Saudi Arabia. New England Journal of Medicine. Online First, Oct 17, 2012. DOI: 10.1056/NEJMoa1211721
• Anderson, LJ and Baric, RS. Emerging Human Coronaviruses — Disease Potential and Preparedness. New England Journal of Medicine. Online First, October 17, 2012. DOI: 10.1056/NEJMe1212300

SARS image, PHIL, CDC