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05/29/2013

New details and updates on the novel coronavirus

It has been a busy day for coronavirus news. Today, the World Health Organization confirmed five new cases of the virus, which the scientific community has now agreed to call MERS, or the Middle East Respiratory Syndrome. The Saudi Arabian ministry of health also announced one more case and three deaths.

So, WHO's new global tally for MERS: 49 cases, 27 deaths (this does not include the cases from today's Saudi announcement). This gives a mortality rate of 55 per cent (although the true death rate could be lower if there are undetected mild cases out there).

Meanwhile, two separate papers were published today, shedding a bit more light on this mysterious new virus and providing more evidence that MERS can spread between people in a limited way. Both papers examined clusters of MERS infections, a recent one in France and one in Saudi Arabia from last fall.

The first paper, published in the Lancet, analyzes France's first cases of MERS, involving a 64-year-old Frenchman who visited Dubai for eight days in early April and fell sick. He died on Tuesday. The second French patient – a 51-year-old man with no recent travel history – shared a hospital room with the first patient for three days and also caught the virus. He is still alive.

The second paper was published in the New England Journal of Medicine and looks at a cluster of cases in a family living in urban Riyadh, Saudi Arabia. In this case, a 70-year-old retired soldier – again with underlying health conditions, such as diabetes, heart disease and hypertension – fell sick on October 5th with a host of ailments. He and two of his sons (both of whom also later became sick) had travelled to Bahrain six months earlier so that the father could seek treatment for chronic knee pain.

The father died on October 23. Days later, his eldest son – a Saudi factory worker who was a smoker but mostly healthy – was admitted to an emergency room shivering, feverish and coughing up blood. He was discharged from the hospital but returned hours later with dangerously low blood oxygen levels. He died November 2nd – but one day later, his 16-year-old son, began coughing, wheezing and growing feverish. On November 3rd, the man's 31-year-old brother also started showing symptoms. Both the teenager and his uncle eventually recovered, however.

The duo of papers detail epidemiological information, clinical details and specific tests performed to diagnose the MERS cases all hugely valuable to public health officials and researchers working with what has so far been a paucity of good data.

To me, as a non-scientific observer of this new virus, here are some of the key takeways from these two new studies:

The incubation of this virus may be longer than we previously thought. The authors of the Lancet paper say their findings suggest that the virus's incubation period could reach nine to 12 days (previous reports suggested a shorter incubation period of a week or ten days). This provides crucial information for public health officials on the alert for new cases of the virus; it could also mean that infected patients should be quarantined for longer periods.

The possibility that feces could play a role in spreading the virus. The Saudi study adds more weight to a suggestion raised in the Lancet paper, that fecal contamination could be playing a role in spreading MERS. "Shedding of virus in stool peaked on day 13," according to the study, and three of the four men had gastrointestinal symptoms.

Fecal contamination of a sewage system has been suspected in one the most devastating SARS outbreaks in 2003 -- one that erupted at a Hong Kong residence and infected 320 people in just three weeks. (See page 52 of this report).

We still don't know how people are getting infected, even in these two clusters. With the French cases, the two men shared a room (with their beds 1.5 metres apart) and a bathroom for three days but it's unclear how or when the first man passed the virus to the second. It’s possible that the second man was infected by respiratory droplets coughed up by the first (although no medical procedures were performed on Patient One that would generate aerosolized droplets, the paper reports) or through fecal contamination, since Patient One had diarrhea.

The Saudi cluster is also puzzling. MERS is genetically similar to a coronavirus found in bats and it is thought that people are probably catching this bug from some animal source. But this Saudi family has no pets and there are no domestic animals near their home; the only relative who had any animal contact was the 31-year-old (the last one in the family to get sick) – he had "attended the slaughtering of a camel on October 24" but that was still more than two weeks after his father, the first patient, began showing symptoms. Furthermore, these four men share a large home occupied by 24 other people, including nine children – and no one else got sick.

Strangely, the majority of MERS cases so far have been men – and insights into this family’s interior life illustrate how Saudi men could have different environmental exposures than women. In this household, the men – both the adults and adolescents – ate together, and separately, from the women and children. The men also socialized and visited a local mosque together. And while the women cared for the sick men in their homes, they scarcely visited them once they were admitted to hospital (this detail leads the study’s authors to suggest that maybe there is a reduced risk of catching MERS in its earlier stages).

The need for "more coordinated international collaboration and sharing of clinical research." These exact words appear in the concluding paragraphs of the New England Journal of Medicine study, which was co-authored by officials with the Saudi Arabian ministry of health. Over the past few weeks, the WHO has been diplomatically signalling to Saudi Arabia that it wants MERS information to be shared more rapidly and transparently. One hopes this sentence is a signal back that the message has been received.

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. Follow her on Twitter: @jyangstar

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