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05/20/2013

In Geneva, a sit-down chat with WHO's coronavirus expert

Margaret Chan
WHO director general Dr. Margaret Chan addresses the 66th World Health Assembly in Geneva. (Jennifer Yang/Toronto Star)

This week, I will be blogging from the 66th World Health Assembly in Geneva, which I'm attending under a UN Foundation press fellowship. One of the first main events was a speech by WHO director-general Dr. Margaret Chan, who chose to open her statement by invoking the memory of SARS.

Why bring up SARS now? Because these days, public health officials are wringing their hands over two new viruses with pandemic potential: the H7N9 bird flu in China and a SARS-related coronavirus that has emerged in the Middle East, now being called MERS (Middle East Respiratory Syndrome).

Both viruses "remind us that the threat from emerging and epidemic-prone diseases is ever-present," Chan said in the Palais de Nations

"Constant mutation and adaptation are the survival mechanisms of the microbial world," she said. "It will always deliver surprises."

But while Chan publicly thanked China for "collecting and communicating such a wealth of information" on H7N9, she made no mention of how Middle Eastern governments have responded to MERS. Thirteen months after the first known cases, the world still has very little information about this deadly virus, which has now killed 20 people and infected at least 31. A recent outbreak in the eastern part of Saudi Arabia — the country where the majority of cases have been reported — has also infected 22 people and killed nine, and very little is known about these latest cases.

There are no specific events at the World Health Assembly dedicated to discussing the coronavirus (update: according to this Saudi Gazette report, Saudi Arabia has requested that coronavirus be discussed in Geneva this week) but on Monday morning, I sat down briefly with the pleasant and soft-spoken Dr. Tony Mounts, WHO's technical lead on the coronavirus, to talk MERS — what we know about it, what we don't know, and how worried we should be. 

How concerned are you about the novel coronavirus? 

So far, the mitigating feature is we haven't seen this spread beyond health care facilities and close family, except for the two cases that were recently announced. So that’s reassuring — that it’s mostly a hospital-based outbreak among people that may have increased susceptibility.

There are a few things that have been happening recently that I think raise our level of concern. If this was just a hospital outbreak, that would not be so concerning. We’ve seen that before — we think the Jordan cluster back in April 2012 was probably a hospital outbreak that burned itself out and did not extend beyond the hospital. 

But here you also have cases that are showing up in other countries; you have a case in France and local transmission in France. Again, it seems to have limited itself to the hospital setting but to see it spread to other countries like that is a real concern. There are a lot of workers from the Indian subcontinent and the Philippines working in the Middle East — people are also going back to some of these areas where there may not be the same facilities for picking up cases.

So my concern is that there may be travelers who are taking this back to Karachi or to Delhi or to Mumbai or Manila who are not being detected and you could have local transmission in those settings and it wouldn't be discovered until it's spread quite far.

What do we know so far about the possible source of this virus?

Still, we don’t know any more than we did in the beginning. The genetics of the virus make it look like a bat virus. But today, in spite of quite a bit of work going on to try and find the sources, nobody's been able to demonstrate the virus in an animal species. We think it must be an animal virus — it just doesn’t make sense that this would be a human virus circulating for a long period of time undetected. We just haven't been able to find the animal; there's no smoking gun.

WHO experts recently went to Saudi Arabia to help investigate the recent outbreak. What did WHO learn?  

We came back with some idea of what the government is doing — the extent of the acitvities and intensity of the investigations that are going on. The (WHO) participants, when they returned, they were actually fairly reassured that everything is being done that possibly could be done to investigate the causes of this outbreak and try and find the source. The (Saudi Arabian) ministry of health and the hospital where this outbreak was based had instituted some measures that seem to be stopping the transmission that was occurring in the hospital. So that was reassuring.

Can you describe some specific measures being taken in Saudi Arabia?

The results of their early investigation indicates this is a nosocomial outbreak, meaning it's spread within the hospital environment. So they're doing the kinds of things you’d normally do with a hospital outbreak: spacing the patients a little more, doing isolation when somebody has respiratory symptoms, trying to be more rigorous about all of the infection control practices ... they've instituted all of these things and as you know, they've invited people from the outside — a hospital infection control specialist from Canada — who's helping to advise them on the specifics of the interventions. It does seem to have stopped the transmission in the hospital.

Why is there still so little known about this novel coronavirus?

I think the investigation is still going on and they’re still trying to collect and collate all of the information. The story we got from the (WHO) mission that returned is that the Saudis feel a little bit like they’re drinking from a fire hose — it’s just a huge amount of information that they’ve been collecting in a very short period of time and they just haven't had the time to completely analyze and put it all together in summaries.

We have every expectation that they’re going to put this (information) together and share it with the world.

Some have raised concerns about a lack of transparency around the sharing of information about the coronavirus. Do you share these concerns?

(Saudi Arabia) has shared information about the cases when asked and they've notified us of new cases when they occur. So they are fulfilling all of the obligations under the International Health Regulations but we do need this additional information to really understand the threat that this virus poses. The biggest question we need to know is what kind of exposures are happening that cause people to get infected; what are people doing, what are they coming into contact with, what are they eating or doing that results in infection. 

The Saudis are giving us information. We would like more of it. Hopefully we’re working a bit more closely with them during the World Health Assembly and helping them understand what we need. I think that they’re starting to wrap up some of their early investigations; I’m hoping some of that information will become available very soon.

There have been some reports following the recent outbreak in Saudi Arabia that the coronavirus has mutated — can you confirm that?

We haven’t seen the virus from this outbreak. There’s no genetic sequencing from this outbreak. I presume it’s being sequenced but it takes some time. 

How similar is the current novel coronavirus situation to the early days of SARS?

There’s a limited amount of information about the very beginning of SARS so we don’t really know what happened leading up to when it became very public and very evident. There are some similiarities — the type of illness it causes is similar, although of course the virus is in the same family. But we’re not seeing the kind of easy transmissions with this virus that we saw in SARS.

Are there serological studies currently underway?

The Jordanians have just completed an investigation using serology of their cases that happened a year ago. We’re expecting the results from that study in the next couple of weeks. 

In that initial cluster, we only had two confirmed cases — there were about a dozen people that had a similar illness but there were only clinical materials remaining to be tested from two or three people. So what they have to do now is go back and draw blood from all of those people to see if the illness that they had was actually this infection. 

The coronavirus is not on the official agenda this week at the World Health Assembly. Do you expect it to come up?

A lot of what happens at formal meetings like this is a lot of the work actually gets done at informal sites — at coffee time and at lunch time. I know there are lots and lots of those kinds of meetings going on and lots of discussions. So even if it isn't raised formally on the floor of the plenary session, there are lots of discussions with the Saudis and other countries in the region. There’s already been some discussions around the need to ramp up and increase the level of surveillance in other countries in the Middle East and try to get lab capacity up to speed in other countries so they can detect the virus. There’s no reason to expect that this virus is limited to Saudi Arabia.

What would it take for you to start really getting worried about the coronavirus situation?

The biggest warning sign would be onward transmission. Right now the only places that we’ve seen human-to-human transmission is two settings; one is the hospital, and one is close family members. We've had several clusters like that ... local transmission where contact is very close, where there are factors that facilitate transmission of viruses between people — but we’ve not ever seen that extend beyond that, to transmit onward into the community. So the minute we see transmission occurring in a setting that doesn’t normally facilitate transmission, that would be a concern.

This interview has been edited and condensed.

Jennifer Yang is the Star’s global health reporter. She previously worked as a general assignment reporter and won a NNA in 2011 for her explanatory piece on the Chilean mining disaster. This week she is blogging from Geneva, where she is attending the World Health Assembly under a UN Foundation press fellowship. Follow her on Twitter: @jyangstar

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