In my last post 36 hours ago, I raised questions about Saudi Arabia’s apparent delay in reporting new cases of the novel coronavirus that has been causing low-level unease since last summer. (For the full history of that, check these posts.) So it’s only fair to say that, within 24 hours, the Saudi government behaved very differently with a new report.
The bad news is, the new report is about yet more cases of the novel virus. But the good news is, the report of the new cases was quickly shared internationally, by the government’s Deputy Minister for Public Health, via the international disease-alert mailing news ProMED.
Here is the complete post:
Subject: Urgent update nCOV cluster KSA
This is a preliminary update on the status as of a few minutes ago. Three further cases have been discovered from the investigation which is still ongoing:
Case 8: 53 y.o. female with comorbidities. Date of symptoms [27 Apr 2013] she is in stable but critical condition
Case 9: 50 y.o. male with comorbidity. Date of symptoms [30 Apr 2013] with pneumonia and he is well on the inpatient ward.
Case 10: 33 y.o. male with comorbidity. Family contact of a deceased patient. Date of symptoms [28 Apr 2013]. Inpatient in the medical ward and doing well.
As stated earlier our investigation of contacts and active screening of inpatients who fit case definition is ongoing.
Ziad A Memish,MD,FRCP(Can),FRCP(Edin),FRCP(Lond),FACP
Deputy Minister for Public Health
This report is striking for several reasons. First: It appears to be a much quicker alert than the earlier one which raised eyebrows, because the patients are still in hospital (in the earlier one, five of the seven had already died). And it is an active notification, if it’s OK to use that surveillance term in this context; that is, it is a push into international public health networks,compared to the earlier posting by the Saudi Press Agency which people might or might not have read. (There is also something quite interesting going on, with a Ministry of Health using the unofficial — that is, non-governmental/non-WHO — channel of ProMED to announce this. It speaks to the ever-growing influence of ProMED in the global conversation about public health.*) The Ministry apparently informed the WHO in a timely manner also, as that agency has a quick update posted here.
Now the obvious concerns: It represents three new cases; it represents at least one possible family cluster, with one of these cases being a relation of a case announced earlier; and it represents a possible local cluster, since according to the extended ProMED post, all 10 — the seven announced Thursday, and these three — are from the same eastern region, Al-Ahsa. In a note appended to the post, ProMED editor Marjorie Pollack puts the reports into a chronology:
From the dates of onset of some of the earlier cases, it seems to suggest there may have been a common exposure(s) and possibly followed by some person-to-person spread — the 1st case had onset on 14 Apr 2017; the next 2 additional cases had onset 3 days later on 17 Apr 2013, followed by 4 additional cases with date of onset 5 days later on 22 Apr. The 3 newer cases (1st reported today 3 May 2013) had dates of onset 27 Apr 2013, 30 Apr 2013 and 28 Apr 2013, only this latter case (with date of onset 28 Apr 2013) is identified as a definite family contact of an earlier onset deceased patient.
She also raises an issue that is implied in the case descriptions but needs to be teased out: whether these cases arose in part because age and underlying ill health made the patients vulnerable:
Of these 10 newly reported cases, all 10 (100 percent) have a history of one or more comorbidities, suggesting a predisposition to more severe illness when confronted with a serious infection. The ages range from 24 years of age to 94 years of age, with the mean age of 57 years (by 10 year age cohorts: 20-29 years old – 1 case; 30-39 years old – 1 case; 40-49 years old – 0 cases; 50-59 years old – 6 cases, 60-69 years old – 0 cases; 70-79 years old – 0 cases; 80-89 years old – 1 case; 90-99 years old – 1 case).
I was traveling again yesterday, but Helen Branswell and my former CIDRAP colleague Robert Roos both got up stories examining this report yesterday evening. They both raise an issue will need further examination: whether some part of this apparent cluster of cases can be traced to hospital procedure. That is important because, if transmission happened not in the outside world but within the hospital — as happened in SARS** — then the perception of how much risk is posed by this new virus could be recalibrated.
There is some interesting chatter in the ProMED post about Al-Ahsa being a date-growing area, which could indicate that bats feeding on the dates are harboring or transmitting the virus. Early analyses of the virus last fall (in these three papers) raised the possibility of bat involvement. On Twitter this morning, though, there is also chatter that we shouldn’t leap to that assumption too quickly, and that the granular details of the date-growing economy in the area need to be examined.
There is obviously a great deal more to be learned about this ongoing slow outbreak, which might — or again, depending on the details, might not — be picking up speed. But it’s one more reminder that nature is the universe’s most expert player of three-card monte. No matter how hard you focus on where you think the problem is, the actual threat may be somewhere else.
(*Disease geeks will know this already, but for those to whom ProMED is a new thing: This volunteer-run list is the reason that the world eventually learned about SARS 10 years ago, during the time when the government of China was still attempting to keep knowledge of that outbreak within its borders — and because of that episode, was the reason the International Health Regulations were rewritten in 2007 to give equal status in disease alerts to “unofficial” communications.)
(**I told the story of the emergence of SARS, within months of it occurring, in a chapter in my book Beating Back the Devil. That chapter used to be on the publisher’s website, but I just checked and it apparently was taken down in a redesign. So I may need to put it back up myself, but that will require retyping it. Stay tuned.)
Coronavirus: Public Health Image Library, CDC