MERS alert

Middle East Respiratory Syndrome (MERS), a viral respiratory illness caused by Coronavirus (CoV), collectively known as MERS-CoV, is spreading rapidly in South Korea, in what is its first known large outbreak outside the Middle East. According to a World Health Organization (WHO) report, 150 Koreans are infected with MERS virus and 18 of them have died.

The MERS-CoV continues to spread quickly. A 68-year old Korean man, who traveled to the Middle East, had been exposed to the virus, resulting in the current outbreak in South Korea. Presently, hundreds of thousands of Nepali migrant workers are working in Middle East countries, especially in Saudi Arabia, from where the majority of MERS-CoV cases (around 85 percent) are being reported.Despite this, our government is delaying precautionary measures. Information about this virus is scant and scientists are desperately trying to understand the nature/behavior of MERS-CoV, its transmission routes, difference in death and transmission rates between Middle East and South Korea and its management.

MERS-CoV was first reported in September 2012 in Saudi Arabia. Since then, approximately 1,227 have been infected, and 449 have died. More than 16 countries outside the Middle East (including the US, and some European and Asian countries) have reported MERS-CoV in patients who had travelled to Middle East or had close contact with confirmed MERS-CoV cases. However, no major outbreak of MERS-CoV has been reported from these countries.

Contrary to this, South Korea is facing a rapid spread of MERS-CoV from person to person. Hospitals generally follow strict infection control guidelines including wearing of personnel protective equipment such as eyeglasses, gowns, and gloves to avoid/reduce risk of possible spread of an infectious disease. During Korean MERS outbreak, however, patients were believed to have contracted the virus in hospital or health care center. Therefore, Korean outbreak has prompted speculation on its mode of transmission other than droplet transmission.

Fever, cough and shortness of breath are key symptoms of MERS-CoV infection. Some people may have gastrointestinal problems including diarrhea and vomiting. The symptoms may appear five days after infection, but this period ranges from two to 14 days. A person with laboratory confirmation of MERS-CoV infection, irrespective of clinical signs and symptoms, is regarded as a confirmed case.

It is so far not clear whether laboratory testing is available for confirmation of MERS-CoV in Nepal. Perhaps not surprisingly no confirmed case has been reported in the country. However, there could be many probable latent cases. Indeed, most patients with infectious diseases go undiagnosed or unnoticed in Nepal owing to lack of high tech equipment. Serological testing can also confirm the virus.

Variation in death and transmission rates between South Korea and the Middle East has drawn attention of scientists worldwide. Currently, death rate in Korea is estimated to be 12 percent, while it is up to 40 percent in the Middle East. Many scientists attribute differences in death and transmission rates to viral mutations.

Recently two research groups from South Korea and China shared genetic study of this virus. However, they were unable to draw definite conclusions.

At this moment, WHO does not advise to precautionary measures at points of entry or travel restriction in MERS-CoV reported areas. Nepal, one of the WHO member countries, is following the advice, and therefore is reluctant to put preventive measures in place. But who would take the responsibility if MERS-CoV spreads in Nepal? The country had recently faced a major outbreak of swine flu and was unable to contain the virus effectively due to lack of diagnostic equipment and antiviral drugs.

The length of MERS virus outbreak depends on adequacy of financial and human resources. Therefore travel restriction or preventive measures or advices should be based on individual basis, from one country to the next, and sometimes even on regional basis. For example, developed countries have well-equipped infectious disease hospitals, enough skilled specialists, well-organized rapid respond teams and pre-planned responses that are lacking in least developed countries.

South Korea may soon bring this outbreak under control, but an LDC like Nepal, without a single well-equipped infectious disease hospital, might face unexpected challenges in containing the virus. Early detection, quick response to an outbreak, active surveillance and political commitment will be needed to deal with it.

Again, MERS-CoV now has up to 40 percent death rate in developed countries. It could be much worse here. Nepal, therefore, should take this disease as a serious threat to public health and take adequate preventive measures at the earliest—as thousands of Nepali migrants are traveling to and from the Middle East and South Korea every single day. There is no doubt that Nepal is at a risk of MERS-CoV outbreak. A single infected traveler can trigger a devastating outbreak here.

The author is with Sukraraj Tropical and Infectious Disease Hospital

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