WHO Announces Family Cluster of Cases of New Coronavirus

Lung tissue containing the original SARS coronavirus (CDC, 2003)

(This post has been updated; read to the end.)

Holidays. It never fails.

Today, while the United States has been largely off-line following our Thanksgiving holiday (and while Northern Europe was on its way to the pub for Friday evening revelry), the World Health Organization announced four new cases of the novel coronavirus that caused a great deal of worry immediately before the October hajj season. (Earlier posts here and here.)

In its bulletin, released by the WHO’s Global Alert and Response team (GOAR), the agency said:

  • Four additional laboratory-confirmed cases have been identified; one of the four has died.
  • One case is in Qatar, the location of one of the original two cases earlier this year.
  • Three of the new cases, including the dead person, are in Saudi Arabia, site of the other original case (who also died).
  • Two of the three Saudi cases, including the dead person, are members of the same family.
  • In that family, two other people have also fallen ill, and one has died. The man who recovered showed no laboratory evidence of infection with the novel coronavirus. Analysis of the case of the person who died is continuing.

A quick recap: This new virus concerns public health officials because it is related to the viral cause of SARS, which swept the globe in 2003, sickening more than 8,000 people and killing almost 800. News of it first emerged in September, when a post to the mailing list ProMED described the illness and death in June of a man who lived in Saudi Arabia. That bulletin caused physicians in London who were treating a man from Qatar to realize that their patient was suffering from the same illness. The timing and location of the cases caused international concern, because Saudi Arabia was about to host the annual hajj, which brings millions of observant Muslims to the country in closely crowded conditions, and thus could have been a transmission risk.

Since then, very little new has been released.

On Sept. 27, the journal EuroSurveillance published two reports, a case definition and recommendation for public health measures by the European Centre for Disease Prevention and Control (the EU’s equivalent of the United States’ CDC) and the UK’s Health Protection Agency, and a first attempt at PCR-based identifying tests, by scientists at the HPA, in Berlin, and at the Erasmus Medical Center in Rotterdam, who collaborated on that first ProMED post.

On Oct. 17, the New England Journal of Medicine carried a description of the first Saudi case written by the authors of that first ProMED post, Dr. Ali Moh Zaki of the Soliman Fareek Hospital in Jiddah and Dr. Ron Fouchier and other staff from Erasmus.

On Nov. 4 and Nov. 20, ProMED carried reports of two additional cases beyond the first two, both in Saudi. The Nov. 4 report, of a man who fell ill in Riyadh and recovered, was submitted to ProMED by Dr. Ziad Memish, the Kingdom’s deputy minister for public health. The Nov. 20 report relayed an announcement from the Kingdom’s Ministry of Health reporting an additional case in Riyadh. (There has been no indication whether these cases are included in the four new ones announced by the WHO, or are separate. Prior to today’s brief announcement, the WHO had not issued any bulletins on the new virus since Oct. 10.)

Meanwhile, on Nov. 13, the UK’s Health Protection Agency announced that its laboratories had achieved a complete genome of the virus isolated from the case treated in London, finding it to be most closely related to a coronavirus isolated from bats in the Netherlands several years ago. (This is important because the SARS virus, originally thought to be harbored by civet cats, was identified in 2005 as actually originating in bats.)

And in addition, there have been some indications that the flow of information on this new virus may not be complete as health authorities might wish. Among them: On Oct. 22, Dr. Memish complained on ProMED of “incomplete, even hysterical reporting” and said that the initial report of the first Saudi case “intentionally or inadvertently circumvented” “internal reporting mechanisms.” Two days later, Debora Mackenzie of New Scientist reported that the physician who sent that first report, Dr. Zaki, lost his job in the Kingdom after official actions that he described to her as “threatening,” and fled to Egypt, where he is from.

So where does that leave us today?

The WHO statement is notable for what it does not say: It does not give ages, genders or places of residence for the new cases, and it has nothing to say about how they may have become infected — including whether person-to-person transmission of the virus has occurred, which would be one reasonable hypothesis given the family relationships.

But it does say that the agency assumes the virus to be more widely distributed than these cases suggest, and urges countries to be on the look-out for additional cases. Notably, it suggests testing patients with severe pneumonia even if they have no travel history to Saudi Arabia or Qatar, which is a lowering of the screening threshold from what the agency recommended earlier:

WHO encourages all Member States to continue their surveillance for severe acute respiratory infections (SARI) and is currently reviewing the case definition and other guidance related to the novel coronavirus. Until more information is available, it is prudent to consider that the virus is likely more widely distributed than just the two countries which have identified cases. Member States should consider testing of patients with unexplained pneumonias for the new coronavirus even in the absence of travel or other associations with the two affected countries. In addition, any clusters of SARI or SARI in health care workers should be thoroughly investigated regardless of where in the world they occur.

Much more to come on this, I am sure. Over the weekend, consider following Helen Branswell of Canadian Press and Declan Butler of Nature, who got stories about this posted this afternoon; and also indefatigable emerging-diseases blogger Crawford Killian, who has picked up indications that the new Qatar case may actually be in Germany.

Update: I failed to notice that Mike Coston of Avian Flu Diary has confirmed the reports of the new Qatar case actually being in Germany. Mike found a statement from Germany’s Robert Koch Institute about the man’s illness. So (and I should have said this earlier), for more about this evolving story, you should follow Mike too.

Update 2, Nov. 24: Helen Branswell has written a very thoughtful second-day story that highlights the behind-the-scenes frustration felt by international health authorities over the apparent paucity of information coming out of Saudi Arabia. It’s important to remember that, other than moral suasion, the WHO has no real power to compel governments’ behavior. The free flow of information was supposed to be guaranteed by the revision of the International Health Regulations in 2007, which holds countries responsible for notifying the rest of the world of any major epidemic within their borders. That revision was prompted by China’s attempt to keep news of the start of SARS from passing beyond its borders — an attempt that was unsuccessful, as the news got out through the same email list ProMED which has hosted the first alert of this new coronavirus. But it is widely agreed that SARS would not have been so bad if the epidemic had been acknowledged earlier, so that the world could be prepared once the virus started to move. As Helen highlights, no one wants to see secrecy or the fear of stigma create another SARS again.

Update 3, Nov. 25: I’ve received back-channel confirmation that the two cases announced by the Ministry of Health on ProMED earlier in November are contained within the family cluster announced on Friday. So, first, there are still six cases, not eight (as there would have been if those two were additional); and also, this appears to pin the location of the family cluster to Riyadh, which is the location given by the Ministry in those ProMED posts.



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