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 Saudi health sources and international virologists said poor
communication and a lack of accountability in government
departments, inadequate state oversight and a failure to learn from
past mistakes have all hindered Saudi Arabia's battle against the
SARS-like virus.
They say it is too soon to tell if reforms introduced by a new
acting health minister can overcome what they see as underlying
problems.
Some top Saudi health officials say they accept that delays in
reporting MERS cases were caused by poor communication between
hospitals, laboratories and government departments, but they stress
things have improved significantly since the appointment of the new
minister in late April.
The health ministry "has put in place measures to ensure best
practices of data gathering, reporting (and) transparency are
strictly observed", it says, and "to ensure that from now on, case
information will be accurate, reliable and timely".
Saudi Arabia has been host to the vast majority of cases of MERS - a
viral infection which can cause coughing, fever and pneumonia -
since it was first found in humans two years ago.
International concerns over Saudi Arabia's handling of the outbreak
grew last week when it said it had under-reported cases by a fifth
and revised the case numbers to 688 from 575.
People in the kingdom are still becoming infected with and dying of
MERS every day, and sporadic cases have been found outside Saudi
Arabia as infected people travel. The worldwide death toll from MERS
now stands at more than 313 people.
International scientists have complained of a lukewarm response from
Saudi authorities to offers to help with the scientific research
needed to get a handle on the outbreak, and have questioned the
quality of data collection and distribution that could help reveal
how the disease works.
UNREPORTED CASES
Tariq Madani, head of the scientific advisory board at the health
ministry, said 58 of the 113 cases added last week had been
confirmed as positive in government hospitals and laboratories, but
the results had simply not been passed by those institutions to the
ministry.
Another 22 cases tested positive at the King Faisal Specialist
Hospital in Jeddah, but duplicate samples were not sent to
government laboratories and the institution did not communicate the
results to the health ministry, he said.
A spokesman for King Faisal Specialist Hospital declined to comment
further and referred all queries back to the health ministry.
The remaining 33 cases had tested positive in private laboratories
but showed as negative in government ones, Madani said.
Madani said he did not believe the under-reporting had been
deliberate and he thought a 20 percent shortfall in reported cases
was not unusual in a disease outbreak.
"This can happen anywhere in the world, that 20 percent of patients
may not be reported. This is within the limit. It's actually less
than 20 percent," he said.
However, Ian MacKay, an associate professor of clinical virology at
Australia's University of Queensland who has been tracking the MERS
outbreak since the virus was first identified in 2012, is skeptical
about the notion that it is normal for 20 percent of cases to go
unreported.
"I know of no global scientific norms that define a threshold below
which it is normal to under-report cases of any viral cluster,
outbreak or epidemic," he said.
Madani said in some cases patients intermittently shed the virus, so
it is not caught in a test. The ministry's policy, he said, had been
to say that if there was a discrepancy between test results, only
government laboratory results should stand.
The new acting health minister Adel Fakieh has changed that policy,
Madani said, and from now on positive tests from any laboratory
accredited by the health ministry will count as confirmed cases.
The appointment of Fakieh has also led to other changes, he said.
Authorities have brought in tighter infection procedures in
hospitals and are trying to be more transparent about how they are
tackling MERS.
"After the change of minister they involved people more in
preventative methods. There were text messages on hand washing, the
public has been more involved," said a Saudi public health expert
who was critical of the ministry earlier this year. He, like some
others interviewed for this article, spoke on condition of anonymity
because he was not authorized to comment.
But some international scientists still complain that data published
online by Saudi authorities, which includes daily updates on
confirmed new infections and deaths in different cities, is not
comprehensive enough to allow them to research the disease.
[ID:nL6N0OM2VH]
The European Centre for Disease Prevention and Control (ECDC), for
example, said it was not clear whether the new cases listed by Saudi
authorities met the World Health Organisation's definition of
confirmed cases. The ECDC also noted the absence of detail such as
age, gender, residence, probable place of infection and other
information.
Madani said the ministry only published information it considered
immediately relevant to the public. He said more detailed data,
collected on all patients since the first confirmed case in June
2012, could be made available to scientists who wanted it and had
already been given to the World Health Organization.
A spokesman for the WHO confirmed the organization had received
detailed information which it was now verifying with Saudi
authorities to ensure there was no double counting of cases in the
WHO's global tally.
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"We collect extensive data on demographics, location of the patient,
their nationality. Then we collect...data in terms of clinical
manifestations, complications that happened to the patients while
they are in hospital, and the outcome," Madani said. Officials also
follow up contacts of known MERS cases daily for 14 days, he added,
asking them to stay home in isolation and admitting them to hospital
if they show symptoms.
Michael Osterholm, director of the Center for Infectious Diseases
Research and Policy at the University of Minnesota, said Saudi
authorities should be congratulated on their pledge to be more open.
"From talking to people inside the Kingdom right now, I'd say there
is a very new sense of transparency in the last few weeks," he said.
DOCTORS NOT INFORMED
However, challenges remain. The problems are evident in the case of
one kidney patient who fell ill in Jeddah in April, a main location
of the outbreak.
The man was transferred from another hospital to the King Faisal
Specialist Hospital (KFSH), but doctors there were not officially
informed by medical staff who had previously cared for him that they
suspected he might have contracted MERS, said a city health source.
As a result, King Faisal Specialist Hospital staff took no extra
precautions and within a week the head of the intensive care unit
and other staff, including a pregnant nurse, fell ill. Both the
nurse and ICU head have now recovered.
The problem was that suspicions of MERS were only communicated
verbally, rather than being put on paper in a patient's file, said
Sabah Abuzinadah, a former head of nursing for a government
commission on healthcare workers.
The King Faisal spokesman declined to comment.
Such problems were familiar to people inside Saudi Arabia who had
been involved in cases of MERS over the previous two years.
"At first the government would only accept that those patients
already in intensive care had MERS. Even when cases were coming to
the emergency room with severe respiratory symptoms they were told
to go home and not investigated," said the head of a private
hospital where some MERS cases occurred last year.
He denied that there was any deliberate attempt to hide MERS cases,
but said officials - and sometimes emergency room doctors - found it
hard to accept that a new disease had raised its head in their
hospital. The hospital declined to comment.
He said the extent of the outbreak in Jeddah in April and May showed
that complacency had set in after the rate of infection slowed
throughout last summer, autumn and winter, and when there were no
confirmed cases during last year's pilgrimage season. "We did not
learn from the outbreak last year. The Health Ministry did not get
the severity of the issue. But it was not just them who
underestimated it. Even in the best private hospitals there were
cases," he said.
COMPLEX SYSTEMS
Abuzinadah said nursing groups in the kingdom had warned the health
ministry about systemic problems in hospitals and poor government
oversight.
She said they had called for better enforcement of infection control
procedures - something Madani says is now being implemented - and
independent regulators for hospitals and healthcare professionals.
The only official body now overseeing healthcare workers is the
Saudi Commission for Health Specialities, whose board is chaired by
the minister. According to its website, it is responsible only for
training and setting standards, not for regulating or evaluating
performance.
Hospital regulation is run by the health ministry, which also
manages many of the country's hospitals.
Other hospitals are run by private healthcare companies and by other
state bodies, adding to the complexity of the system.
"It's a complicated country. Even people like Memish (the deputy
minister sacked last week) don't really have access to everything
(in terms of patient data and information)," said Christian Drosten,
a University of Bonn virologist who has worked on MERS with Saudi
scientists.
Many of the people who spoke to Reuters for this story said the
creation of a new control and command center should help coordinate
the response to MERS.
The new center, announced by Fakieh on June 1, aims to bring
together public health, research, infection control, clinical
operations and data analysis into a new unit.
"Before, our issue was with communication - other ministries only
knew what was going on by reading the newspapers," said the private
hospital head who had dealt with MERS last year. "Now, everyone is
involved."
(Editing by Janet McBride)
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