The Middle East Plague Goes Global

When the Black Death exploded in Arabia in the 14th century, killing an estimated third of the population, it spread across the Islamic world via infected religious pilgrims. Today, the Middle East is threatened with a new plague, one eponymously if not ominously named the Middle East respiratory syndrome (MERS-CoV, or MERS for short). This novel coronavirus was discovered in Jordan in March 2012, and as of June 26, there have been 77 laboratory-confirmed infections, 62 of which have been in Saudi Arabia; 34 of these Saudi patients have died.

Although the numbers — so far — are small, the disease is raising anxiety throughout the region. But officials in Saudi Arabia are particularly concerned.

This fall, millions of devout Muslims will descend upon Mecca, Medina, and Saudi Arabia’s holy sites in one of the largest annual migrations in human history. In 2012, approximately 6 million pilgrims came through Saudi Arabia to perform the rituals associated with umrah, and this number is predicted to rise in 2013. Umrah literally means "to visit a populated place," and it’s the very proximity that has health officials so worried. In Mecca alone, millions of pilgrims will fulfill the religious obligation of circling the Kaaba. And having a large group of people together in a single, fairly confined space threatens to turn the holiest site in Islam into a massive petri dish.

The disease is still mysterious. Little is understood about how it is transmitted and even less regarding its origins. But we do know that MERS is deadly, with a mortality rate of about 55 percent — a remarkably higher lethality than that posed by its close cousin, the severe acute respiratory syndrome (SARS) virus, which in 2003 terrified travelers across the globe but posed a fatality rate of only 9.6 percent. The MERS coronavirus is new to our species, so mild and asymptomatic infections seem to be rare, but the human immune response to infection is itself so extreme that it can prove deadly in some cases.

Like SARS, the MERS virus spreads between people via close contact, shared medical instruments, and coughing. Once inside the human lung, the MERS virus sparks a series of reactions that all but destroy normal lung function. Patients can descend into pneumonia so severe that they require machine-assisted breathing to stay alive, in as little as 12 days. Unlike SARS, the MERS virus is also capable of attacking the kidneys and can be passed on to others via exposure to contaminated urine. And for some of those who survive acute MERS, years of rehabilitation may be necessary, just like for some of the 2003 SARS victims.

And like back in 2003, when health officials worried about airplane travelers in confined spaces transmitting the virus across the globe, the hajj poses a unique risk of transmission, one that could catapult this still-small outbreak into a full-fledged pandemic. Containment will become nearly impossible as millions of pilgrims flock from virtually every country on the globe to the kingdom during the holy month. Indeed, MERS has already crossed continents; two suspected cases were reported in France as recently as June 12, and confirmed cases have been reported in Germany and Britain. The first patient in each of these cases had traveled in the Middle East before reaching his/her home destination, only then to be diagnosed with MERS.

Traditionally, the onus to protect the pilgrimage and prevent disease rests on the shoulders of the Saudi royal family. Today, that responsibility lies with the kingdom’s Ministry of Health, which has deployed all its disease-fighting resources to tracking down MERS.

The ministry also must deal with the distinct possibility that pilgrims from abroad could bring other diseases to the kingdom, especially polio. (Saudi Arabia has been polio-free since 1995, but there was an importation as recently as 2004.) Polio is still endemic in several Muslim countries, including Nigeria and Pakistan, and outbreaks this year have surfaced in Somalia and Kenya. It has been eliminated in Saudi Arabia, but pilgrims from outside could carry the disease back into the region. Worryingly, live polio viruses identical to those circulating in Pakistan were discovered in the sewers of Cairo in January and in Israel in June.

Despite these risks of disease transmission, neither the World Health Organization (WHO) nor the Saudi government has placed explicit travel guidelines in advance of this influx. In spite of having previously predicted that the number of pilgrims would increase from 2012, Saudi Arabia’s Ministry of Hajj has issued a directive to umrah visa operators to "cut down the number of foreign and domestic pilgrims by 20 and 50 percent, respectively," reported a local newspaper that was quoting an informed source. In an unprecedented move, Saudi authorities are urging pilgrims to postpone their hajj plans due to "ongoing expansion work" at the Grand Mosque. Saudi clerics have also approved of this decision. It is unclear whether the timing of these announcements is mere coincidence or a discrete Saudi effort to limit the number of pilgrims without causing panic. Either way, cutting down on the number of pilgrims would be a fairly effective way to prevent the spread of MERS or any other virus.

But even if pilgrims postpone their plans for pilgrimage, they are not the only mobile population in the region who could serve as global vectors. As of April 2013, there were an estimated 7.5 million migrant workers living and legally working in Saudi Arabia; this number does not include the many more thousands of laborers in the country illegally. Migrant workers come from across the world, including India, Indonesia, Pakistan, and the Philippines. According to a recent New York Times report, approximately 124,000 undocumented workers have left Saudi Arabia since April 1 under an amnesty program that lets them sort out their status without penalties for visa violations. The MERS outbreak also comes at a time when Saudi officials are looking to deport as many foreign workers as possible in order to free up the job market for Saudi nationals. This has caused tension — and in some cases violence — which increases distrust between the two groups and makes it less likely for an infected migrant worker to seek out medical care from, or to cooperate with, Saudi officials.

Fear of a MERS outbreak from migrant workers returning home has prompted other countries to take special precautions. In early June, the Philippine government began conducting thermal scans of incoming migrant workers from Saudi Arabia at the airport in Manila, and the Nepalese government wrote a letter to hospitals and laboratories, directing them to adopt precautionary measures when treating patients with respiratory illness. During the SARS epidemic, the WHO did release a travel advisory, and passengers going through Chinese airports were subjected to a temperature scan; thankfully, neither the Philippines nor Nepal has yet reported a case of MERS.

But another reason for concern over disease outbreak in this region is the huge — and continually growing — population of Syrian refugees, currently estimated at 1.6 million individuals by the United Nations’ refugee agency, UNHCR. Add to that the almost 4.25 million internally displaced Syrians, living in overcrowded and unsanitary conditions within the country, and the scale of the problem grows. During humanitarian crises, the WHO works with member states primarily in an advocacy and planning role, helping to minimize suffering and death, as well as protect the country’s health system. In this capacity, the WHO has already articulated its concerns about the potential for disease outbreaks in Syria and neighboring countries, particularly within the crowded refugee camps that have sprung up in Lebanon, Jordan, and Turkey, noting that the warm summer months bring a heightened risk.

MERS has proved difficult to control even in the most advanced, well-funded hospitals, with clusters of infections being reported in health-care facilities in not only Saudi Arabia, but also Jordan and France. This was highlighted in an epidemiological study of 23 cases in Saudi Arabia, published in the New England Journal of Medicine on June 19 by officials from the WHO and the Saudi Ministry of Health. Before this paper was published, officials from both organizations went to great lengths to limit concern over in-hospital spread, reassuring the public that MERS was not as in-hospital contagious as SARS. But this new study demonstrates the contrary: "A total of 21 of the 23 cases were acquired by person-to-person transmission in hemodialysis units, intensive care units, or in-patient units in three different health care facilities."

Controlling the spread of the virus is only half the battle. There is no MERS vaccine, drug, or simple diagnostic test available. And once MERS patients are identified, caring for them presents its own set of complications. Not only is the treatment for MERS intensive and complicated, but health-care workers must carefully protect themselves so as to minimize the risk of contracting or unwittingly spreading infection.

If in-hospital spread is occurring within state-of-the-art, high-tech hospitals, the potential for MERS transmission inside squalid Syrian hospitals and makeshift refugee clinics is significant. It would seem nearly impossible to mitigate in-hospital spread of MERS in Syria, where over a third of public hospitals are no longer in service and supplies of even the most rudimentary medicines and equipment are scarce. Should the MERS virus get a foothold in such settings, further international spread of MERS seems inevitable, especially amid highly mobile populations fleeing political instability.

Although the WHO has publicly praised Saudi Arabia for "urgently taking crucial actions" in this crisis, it is becoming clear that in spite of officials’ cooperation, there are some real practical problems facing Saudi authorities.

First and foremost, the Saudi Ministry of Health is understaffed and in need of assistance. At least one foreign laboratory collaborating with the Saudis received samples of MERS that had deteriorated because they were packaged and shipped incorrectly, rendering them unusable. International collaborators who have been eager to aid the Saudis face staffing bottlenecks, causing delays that are agonizing in an outbreak context.

But that one foreign laboratory was fortunate to get the samples sent to it at all, since the Saudi Ministry of Health has also been embroiled in a "patent" dispute surrounding MERS that has reportedly stymied research efforts by foreign scientists. Last summer, a Dutch team from Erasmus Medical Center in Rotterdam received two patient samples from an Egyptian scientist working then in Jeddah, Saudi Arabia. The Dutch sequenced the MERS DNA and claimed ownership of the samples. All scientists hoping to work on the MERS problem must either obtain samples directly from the Saudi Ministry of Health or sign legal agreements with Erasmus. For example, the U.S. Centers for Disease Control and Prevention (CDC) is still waiting to receive samples of MERS for testing that were collected in October 2012 because the legal teams from the CDC and Erasmus cannot negotiate agreeable terms for a material transfer agreement. These legal delays are unusual, especially during a disease outbreak such as this, and Margaret Chan, director-general of the World Health Organization, publicly criticized Erasmus for putting patent laws ahead of protecting "your people."

Meanwhile, the WHO has its own institutional problems. The organization’s emergency-response system is bankrupt (though it only needs $10 million to function for the rest of 2013). Despite these budgetary constraints, surveillance must be ramped up, particularly in the region itself. The WHO has also been trying to improve dialogue and information sharing about MERS, but the organization’s efforts have fallen short. Its most recent attempt — a three-day meeting in Cairo attended by 100 experts — came up short; the result amounted to little more than language that in essence just reiterated pre-existing agreements about global standards for disease surveillance and reporting that took effect after the International Health Regulations (2005).

Participants at the meeting did recognize the urgency of the situation, however, and acknowledged that the world is at a critical point in the trajectory of the MERS outbreak. As Keiji Fukuda, WHO assistant director-general for health security and the environment, said: "We need to exploit this chance to agree and implement the best public health measures possible across the board, for in so doing, we stand the best chance of controlling this virus before it spreads further."

It wouldn’t be possible — or even desirable — to stop the flow of people in and out of Saudi Arabia and the Middle East, be they migrant workers, refugees, humanitarian volunteers, or religious pilgrims. The immediate challenges are to identify the animal sources of MERS and stop its animal-to-human spread. In lieu of knowing the virus’s origin, human-to-human transmission must be halted — and the best first step to accomplishing this is through radical improvements in hospitals’ hygiene practices and through swiftly identifying infected friends, family members, and co-workers of those who develop the MERS disease.

But that’s only a stopgap solution. Unless the many barriers to a transparent international research and information-sharing system disappear, it will be exceedingly difficult to reduce the risk of infection. Otherwise, the world could be dragged into another Black Death, and MERS could easily spread far beyond the bounds of the region for which it is named.