Map: Geographic Distribution of Ebola Cases in West Africa, August 2014

The current Ebola outbreak in Africa has now grown to more than 2200 cases from four countries, Guinea, Liberia, Nigeria, and Sierra Leone. (link) The map below shows the geographic distribution of Ebola cases within Guinea, Liberia, and Sierra Leone in West Africa based on recent reports. See map notes.

Another reported MERS infection in Saudi Arabia

Yesterday, Saudi Arabia reported a new case of Middle East Respiratory Syndrome (MERS) infection, a 72-year-old male from Riyadh. (link) This is the first MERS infection reported from Saudi Arabia since July 10 (link) and the first MERS cases reported for Riyadh since July 7. (link)

Because the incubation period of MERS is reported to be between 5 and 14 days, and assuming the Saudi Arabia Ministry of Health is reporting all MERS infections in the country, this newly reported case does not seem to be a result of human-to-human transmission but rather an independent infection most likely from a non-human animal source. It is unlikely, but possible, that this individual contracted the coronavirus from an asymptomatic human carrier. There is no reason to believe that this case resulted from a deliberate release of the coronavirus. See The discrepant epidemiology of Middle East respiratory syndrome coronavirus (MERS-CoV) for a hypothesis that MERS infections are a result of a bio-terrorist plot.

Updated Map Showing the General Locations of MERS-CoV Cases on the Arabian Peninsula (June 25, 2014)

Current map of the general geolocations of more than 700 local MERS-CoV infections on the Arabian Peninsula as of June 25, 2014. Location names are labeled in red. The area of the circle depicts the relative number of reported cases at that location. 

 

Map note: On June 3, the Saudi Arabia Ministry of Health announced more than 100 additional MERS cases that occurred between May 2013 and April 2014 (link).  No geographic information about these cases was provided by the Ministry of Health and they are not included on this map. Previous map, April 21, 2014 here.

Discrepancies in the World Health Organization’s Count of MERS Cases in Saudi Arabia

With Saudi Arabia reporting more than 80% of all Middle East Respiratory Syndrome (MERS) cases to date, detailed information about the individual cases from Saudi Arabia is critical to understanding the nature and spread of this novel disease. There are some discrepancies among the MERS cases reported by World Health Organization (WHO) from Saudi Arabia. Of course, WHO is constrained by the quality of data provided by its various member states.

Generally, WHO provides detailed information on the initial cases of a novel disease outbreak in its online publication, Disease Outbreak News (DON). The first WHO report of a MERS [novel coronavirus] infection was published on September 23, 2012. Between September 2012 and April 16, 2014, WHO reported details on 228 MERS cases with varying levels of details provided by the reporting member states. Of the 228 cases reported by WHO though that date, 181 were individually reported cases from Saudi Arabia. The DON of April 14, 2014 (15 reported cases from Jeddah and Riyadh) was the last Saudi Arabian case-by-case report from WHO. After that date, WHO only provided aggregate case totals from Saudi Arabia. These aggregate totals were embedded in 6 DON reports between May 7, 2014 and June 13, 2014 as noted in the table below.

On June 13, 2014, WHO provided a summary of these aggregated cases. According to WHO, 402 cases were summarized. However, a tally of the WHO totals from the previous DONs indicates that only 401 cases were actually aggregated. A comparison of the WHO total with media reports from the Saudi Arabia Ministry of Health indicates that 404 MERS cases were publicly reported by the Ministry of Health.

For the period between April 11, 2014 and May 4, 2014, WHO reports 229 cases from Saudi Arabia, although the Saudi Arabia Ministry of Health only publicly reported 228 cases during that period. One possible explanation is that the 51 one-year-old individual from Riyadh reported on April 9, 2014 by  the Saudi Arabia Ministry of Health (link FluTrackers case # 227), not previously enumerated by WHO, was added to the aggregate total (see: link). Also,  between May 5, 2014 and May 9, 2014 Saudi Arabia Ministry of Health reported 62 MERS cases. During this same period WHO only reported 58 cases in aggregate (see: link). It is possible that WHO failed to incorporate four cases into its cumulative tally for this 5-day period in Saudi Arabia.

With the reporting of specific case details of two individuals from Saudi Arabia in DON on June 16, 2014,  WHO has now apparently returned to reporting individual case details from Saudi Arabia. Better individual case details may again be flowing from Saudi Arabia to WHO.

Depending on the quality and accuracy of the data provided by Saudi Arabia, a discrepancy of 3 or 4 cases among more than 500 reported cases falls within a reasonable error factor. Such differences will not appreciably affect interpretations or speculations drawn from such a large sample of cases.

Of more serious concern is a report on June 3, 2014  by the Saudi Arabia Ministry of Health indicating retrospective reporting of more than 100 additional MERS cases in Saudi Arabia (and acknowledged by WHO - link) going back to May 2013 (See: The Saudi Arabia Ministry of Health Quietly Announces an Additional 113 Cases of MERS). This means that from May 2013 through April 2014, about 15% of all MERS cases in Saudi Arabia were unreported. A 15% error factor is unacceptable when public health officials and the rest of the world are trying to understand the nature of a novel infectious disease with a high fatality rate.

 

The Saudi Arabia Ministry of Health Quietly Announces an Additional 113 Cases of MERS

Today, the Ministry of Health (MOH) officials in the Kingdom of Saudi Arabia (KSA) revised upward the number of Middle East Respiratory Syndrome (MERS) case and MERS-related deaths that have occurred in the KSA (link). As noted by Michael Coston (link), the KSA MOH added a total of 113 cases and 92 deaths to the official cumulative count from that county. The lack of any details for these additional cases or the individuals who died, precludes determining whether all of the unreported deaths are only from the previously unreported cases. In several instances in recent MOH media reports, there have been reported deaths that could not be correlated with previously reported cases because the combination of age/gender of the reported deaths from a specific location could not be associated with previously reported cases (link, link).

Through yesterday, publicly reported cases from the KSA represented about 82% of all MERS cases reported from around the world. Today, with these additional reported cases, the KSA lays claim to about 85% of all cases, not including the 20 infected cases that have been exported to at least 12 different countries. Without doubt, the nexus of worldwide MERS infections is the KSA.

This revelation of previously unreported cases by the KSA MOH ought to be disconcerting. A review of the graph associated with the report indicates that a few of these unreported cases go back as far as May of 2013. There are two possible conclusions about the delay in reporting these case by KSA MOH.  The fact that these cases are only now being publicly and officially reported could suggest that the MOH has been purposefully withholding information about these MERS cases since May of 2013.

Or, maybe the KSA MOH has been so overwhelmed by this outbreak, that they have only now been able to go back and sift through their data to find these additional cases. Either way, the announcement today, with no details or explanations, reflects negatively on the KSA MOH and their ability to track the MERS outbreak within their country.