Will we be able to respond adequately when an unknown virus with pandemic potential emerges? The recent outbreak of MERS in the Middle East was an interesting testcase. Martine van Roode (Erasmus MC) and Carolina dos Santos Ribeiro (RIVM) analysed the factors that hampered, or enabled, the flow of information, in Qatar and the wider Arabian peninsula.
C: The MERS-virus first emerged in April 2012 in Jordan, but no alert was given then. Doctors noticed severe pneumonia but did not identify a known etiology for these infections. Months later an Egyptian doctor in Saudi Arabia came across a patient who had symptoms that looked like a severe flu but a test turned out negative for the main suspicion of swine flu (H1N1). The doctor remained suspicious and sent samples to Erasmus Medical Center in Rotterdam. There they sequenced the virus and discovered it was a new type of coronavirus. Later on, the Saudi authorities accused the doctor of sending the samples without authorization. He was fired and had to leave the country.
M: Coronavirus infection in humans could have a zoonotic origin, and soon there was evidence that camels were a host reservoir species for this virus. But how the disease is transmitted from camel to human is still a matter of debate.
C: When you have a human case infected with an unknown virus with pandemic potential, the rules are that you have to notify WHO, in the case of MERS the first Alert came from a Promed mail. The WHO alerts the national authorities from the countries involved and starts its own investigation in order to update and inform the international community of the risks. The International Health Regulations and its implemented networks is the global channel for performing such communications.
M: In the case of MERS there was a gap in time between the sequencing and the WHO alert. What happened in that time? Might barriers have existed that hampered the flow of data and information between relevant stakeholders?
C: It is a very sensitive issue. When you see an emergent infectious disease you want to act as fast as you can but you also want to act correctly. You must find the right balance between timeliness and robustness. For instance, after a new virus is sequenced you can immediately publish the raw sequence in a publicly available database as GeneBank. So every doctor, researcher and lab can use it. But you must be sure you have the correct sequence. The data can contain mistakes. And getting confirmation from other labs is difficult because them you must share biological samples, and the regulations for that can be very strict making the process time-consuming.
M: We focused our case study on events that related to Qatar, reflecting on the wider region of the Arabian Peninsula. One barrier at least is the priority to publish data in the scientific literature, before making it publicly available. That’s important for scientists’ careers but scientific journals are reluctant to accept publications containing pre-published data. We also found important enablers. If cases start to pop up everywhere, and the data became of high public health importance, stakeholders (researchers, organizations, magazines) are more willing to share data because this is important for a public health response.
C: Politics is an important barrier. The WHO is a political organization since it relies on support and funding from member States. It doesn’t need the authorization of a country to send a global alert, but at the same time it doesn’t want to get involved in all kinds of conflicts and loose the trust of its stakeholders. The collaboration between WHO and de Saudi government during the MERS epidemic showed many ups and downs, especially in the first years after the epidemic started. But after a while, all affected countries were collaborating well with WHO.
M: We managed to interview a lot of people from several organizations in different countries but nobody from Saudi Arabia. Still, I think our research is a unique collaboration, between the RIVM, Erasmus MC, the Ministry of Public Health in Qatar, the Vrije Universiteit in Amsterdam and many scientific and governmental organizations. Especially the government of Qatar was really willing to collaborate. That really helped us to see the collaboration between stakeholders and corresponding flow of data shared between stakeholders during the MERS outbreak response, on the national level.’
C: An important barrier from the NCOH point of view was the collaboration between human and animal health organizations.
M: MERS was an emergency for public health and camels were suspected to play an important part – but the animals don’t get sick from the virus.
C: And camels are very economically important in the region giving them a very high social status. Camel owners simply didn’t want to believe their animals were in any way involved, since they were not even sick. And what would happen? Would they kill the animals? Because of these fears it took the authorities a lot of time to gain nthe trust of the sector and implement measures to prevent the viral transmission from camels to humans.
M: Here in the Netherlands we had similar problems in One Health collaboration with the outbreak of Q-fever. It shows how difficult it is to take effective measures when it involves different sectors.
C: I think what is really needed is more coordination at the top level. When an emergency arises the top organizations (WHO, FAO, OIEOIE) are still working according to their own rules and mandates. What we must have is an integrated and coordinated response from these organizations as soon as the suspicion arises that a new zoonotic disease is emerging, for MERS this was clearly not the case.
M: And countries must have an integrated infrastructure in place before the outbreak occurs. Take Qatar, that was also faced with the outbreak of MERS. It formed a joint One Health investigation team that was effective and helpful towards a coordinated outbreak response. The Qatari government asked the WHO “what data do we need to collect for good reporting of cases?” That was a good example for other countries to work together with organizations such as WHO for guidance to set up a coordinated national outbreak response. But that was activated only when the epidemic started. These systems should be established before an outbreak occurs and be continuously tested and improved.
Carolina dos S. Ribeiro is a senior advisor at the RIVM (Netherlands Institute for Public Health and the Environment) Center for Infectious Disease Control, and an external PhD student connected to the Vrije Universiteit Amsterdam (Athena Institute)
Martine van Roode is project manager grants at the department of Viroscience, Erasmus MC
This is the long version of the interview, which appeared in One Health Magazine #2 2019. Want to read more interviews about One Health: go to the complete One Health Magazine #2, 2019 (PDF).