Last Thursday, April 24, a man who works in the health care industry stepped onto a British Airways plane in Riyadh, the capital and largest city of Saudi Arabia, with a small, unintended, and very unwelcome gift for all Americans. Here's how the Middle East Respiratory Virus came to the United States.
Nobody ever heard of MERS until two years ago. It's a virus that doesn't bother the Middle Eastern camels it starts out with--it has also been found in Egyptian tomb bats--but they seem to pass it along to humans, and then the wickedness sets in. The MERS coronavirus is related to both the common cold and Severe Acute Respiratory Syndrome (SARS), the disease that started in China and killed almost a thousand people in 37 nations between November 2002 and July 2003.
Fortunately, MERS is much less virulent than SARS so far. It has only reached 13 countries since its discovery. MERS settles in the lower lungs. Like flu and pneumonia, it attacks the respiratory system from there.
BASIC PUBLIC HEALTH RECOMMENDATIONS
- Wash your hands often, preferably with soap and water for 20 seconds,
- Use alcohol-based sanitizers when sink facilities are unavailable,
- Avoid close contact with people who are sick,
- Don't spread germs by touching your eyes, nose, and/or mouth, and
- Disinfect frequently touched surfaces.
It may also pay to get vaccinated against influenza and pneumonia, especially if you're traveling, as these vaccines provide some respiratory protection. Get this done at least 4–6 weeks before travel. Warnings about birth defects and autism from vaccines have attracted undeserved hysteria. Vaccines may be your best protection from disease and illness.
MERS has no vaccine, and no cure. It demands immediate hospitalization, often for months, isolation, steroids and aggressive respiratory therapies, usually more than a week of intensive care, and emergency life support for critical organ failure. It ends only with slow, painful recovery and severe long-time effects, or with death. One in every three victims passes on.
Being a health care worker, our traveler probably knew at least some of those details, but he had no idea he was carrying the disease. It was just settling in, and he hadn't felt the symptoms yet when he took off. Local TV reported that he came to the US to attend a conference. After flying to London, the traveler changed planes at Heathrow Airport and connected on a flight to Chicago's sprawling O'Hare International Airport, the fifth busiest in the world (after Atlanta, Beijing, London Heathrow, and Tokyo Haneda) and the closest to his final destination.
The man would have been pretty fatigued by then, and maybe starting to feel his illness slowly coming on. Most of us would probably have just brushed it off as simple tiredness or jet lag after a day and night spent on planes and in airports, and perhaps he did so too. After landing and going through Customs, he took a bus from Chicago to Munster, Indiana, an industrial Lake Michigan suburb less than an hour from the airport and just over the Illinois state line.
He probably arrived exhausted and had a rest, but he would have woken up feeling worse than he expected. The next day (the 27th, last Sunday), the traveler began to have trouble breathing. Respiratory symptoms came on quickly, much faster than with an ordinary cold or flu.
Experiencing shortness of breath, coughing, and also fever on Monday morning, April 28, he went to the emergency department of Munster's Community Hospital. Being a health worker himself and having just left a region experiencing a recent uptick in severe respiratory disease, maybe he suspected he had caught something nasty in the Middle East. At any rate, ER medics did not like what they saw and admitted him to the hospital that day.
Alert to both the patient's symptoms and his travel history, Indiana public health officials tested the patient for the new coronavirus. The state laboratory and the federal Centers for Disease Control and Prevention confirmed MERS-CoV in the patient on Friday afternoon, May 2.
At this point, automatic US public health protocols started kicking in. Following CDC’s established procedures for MERS and other potentially lethal respiratory viruses, the state and CDC alerted US hospitals and physicians, linked in with the scientists and global database of the World Health Organization, and released the news to the media at 3:30 EDT.
By about 7:00 p.m., major news agencies, television, and the Chicago Tribune had reported the story. Dr. Anne Schuchat, assistant surgeon general and director of CDC’s National Center for Immunizations and Respiratory Diseases, explained that the man's name, age, and exact occupation have not been released because federal law protects patients from intrusion at a difficult time through the Health Care Access, Portability, and Renewability (HIPAA) privacy rule. She also advised Americans:
"It is understandable that some may be concerned about this situation, but this first U.S. case of MERS-CoV infection represents a very low risk to the general public.”
Panic was obviously a consideration in the announcement, but Schuchat had a good point, echoed by Marc Sprenger, director of the European Centre for Disease Control in an interview cited by Lawrence LeBlond of redOrbit.com (Your Universe Online) yesterday. We have had progress understanding this disease. The first outbreak caused the World Health Organization to set up a surveillance network as well as intense scientific investigations, and the US and other nations did the same. They discovered the zoonotic (animal) sources and the fact that MERS is usually seasonal. At least one lab even began working on a vaccine.
Health officials also know how difficult it is to pass the virus between people. WHO, CDC, and Indiana health officials are not yet sure how this particular patient contracted MERS, but it has appeared in other health care workers and relatives of patients. After 400 confirmed cases, there's no evidence that MERS spreads from person to person in larger community settings. With mutation, it might start doing so, but mutation has not occurred and may never do so.
Neither WHO nor CDC has issued any travel warnings, only this level 2 alert. Neighboring Egypt has cautioned the very young, old, and immunocompromised to avoid Saudi Arabian travel for now. Saudi Arabia has warned its residents to limit contact with animals and avoid consuming camel milk and camel meat.
CAUTION TO US HEALTH CARE WORKERS VISITING THE ARABIAN PENINSULA
"If you are traveling to provide health care services in the Arabian Peninsula, please review CDC’s recommendations for infection control of confirmed or suspected MERS cases. CDC recommends that you practice these precautions and monitor your health closely."
Officials do not know exactly how many people have had close contact with the patient. They do know that he had little interaction with others after reaching Indiana. Health officials in Britain have begun contacting air passengers who sat near him. Presumably Riyadh has taken similar precautions.
A bit trickier than contacting fellow air passengers is finding the other passengers on the bus from O'Hare to Munster. Bus companies often don't know who bought tickets, who actually used them, and who sat where on any given trip. The general notice gives fellow passengers traveling from O'Hare through Munster at that time an opportunity to check on their travel and health. Public health experts will pursue any other information.
As Schuchat stated, the US government has already taken steps to protect the general public. National disease prevention and control measures include alerts to all health providers (both individual providers and hospitals) about increasing surveillance for severe acute respiratory infections and carefully reviewing any unusual patterns. CDC advises providers to "immediately report patients with unexplained respiratory illness and who meet CDC’s criteria for 'patient under investigation' to CDC through the state or local health department" and to collect specimens from all PUIs.
Also, we have had the general news notification, and searches are ongoing for anyone who may have had close contact with the patient to advise them to alert their health care providers and monitor themselves for the two weeks it would take for the virus to show up. According to Donald G. Mcneil, Jr., of The New York Times, the World Health Organization has advised hospitals to routinely test all patients who have returned from the Middle East within 14 days.
MERS SIGNS AND SYMPTOMS
From the Centers for Disease Control: "Most people who have been confirmed to have MERS-CoV infection developed severe acute respiratory illness. They had fever, cough, and shortness of breath. About 30% of these people died. Also, in other countries, the virus has spread from person to person through close contact, such as caring for or living with an infected person. CDC recognizes the potential for the virus to spread further and cause more cases globally, including in the United States."
Family, close friends, and health care workers have the greatest risk of contracting MERS from this patient. That's why he has to stay in isolation and everyone who visits and cares for him must wear masks and gowns until at least 10 days past the end of his symptoms. There's also a slight risk to his flight crews, bus driver, and fellow travelers, because this disease appears to thrive in closed settings.
To cope with situations like this, Federal officials and each individual commercial airline have pre-established procedures to report onboard illnesses and manage sick air travelers. (This writer has experienced emergency landing and triage of a critically ill heart patient and can testify to its amazing speed, privacy, and effectiveness.) However, since the man did not show symptoms until after reaching his destination, the guidelines were never applied.
Munster Community Hospital has issued a statement regarding the admission of the patient and noted that it is "maintaining appropriate isolation protocols for the protection of health care staff." The patient was reported Saturday afternoon in stable condition and receiving close care and supplementary oxygen.
The hospital has been working cooperatively with the Centers for Disease Control and Prevent and the Indiana State Department of Health on tracking patient family members and monitoring all exposed health care workers. Karl Plume of Reuters reports that at Community Hospital Friday night, the news created no panic in the busy emergency room, where every one of about 20 seats was occupied.
PUBLIC HEALTH CAUTION:
Everyone who develops fever and cough or shortness of breath within 14 days after traveling from countries in or near the Arabian Peninsula should see their health care providers and let them know where they traveled.
Nations of immediate concern:
- Saudi Arabia
- United Arab Emirates (UAE)
Additionally, the following other countries have had MERS cases that are considered travel-associated:
- United Kingdom (UK)
- United States of America (USA)
Two new infections were detected in Jordan, Egypt reported its first case, and two more deaths have been registered in Saudi Arabia since last Thursday. To date, over 130 fatalities have occurred worldwide. See the World Health Organization website for more information about cases and deaths by country.
Doctors and scientists agree that health officials have so far handled the introduction of this dangerous disease to the United States with caution and apparent thoroughness. The CDC has advised that the situation is still fluid and will continue to update the public on its progress.