Saudi Mers response hobbled by institutional failings


Riyadh/London: When Saudi Arabia announced last week that it had found 113 more cases of the deadly Middle East Respiratory Syndrome (Mers), it didn’t just force a rethink of the threat the virus poses, it exposed institutional failings.
Saudi health sources and international virologists said poor communication and a lack of accountability in government departments, besides inadequate oversight 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, adding that the corrective measures seek “to ensure that, from now on, case information will be accurate, reliable and timely”.
The vast majority of cases of Mers — a viral infection that can cause severe cough, fever and pneumonia — have been reported in Saudi Arabia 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 the virus and fatalities continue to increase, while sporadic cases have been found outside Saudi Arabia as infected people travel. The worldwide death toll from Mers now stands at more than 313.
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.
Tareq Madani, head of the scientific advisory board at the health ministry, said 58 of the 113 cases added last week had been confirmed to have tested positive in government hospitals and laboratories, but the results had simply not been passed on 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 spokesperson 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 per cent shortfall in reported cases was not unusual in a disease outbreak.
“This can happen anywhere in the world, that 20 per cent of patients may not be reported. This is within the limit. It’s actually less than 20 per cent,” 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 sceptical about the notion that it is normal for 20 per cent 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 that, 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 Faqih 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 Faqih has also led to other changes, Madani 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 had been critical of the ministry earlier this year. He, like some others interviewed for this article, spoke on condition of anonymity because he was not authorised 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.
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 Organisation.
A spokesperson for the WHO confirmed that the organisation had received detailed information, which it was verifying with Saudi authorities to ensure there was no double counting of cases in the WHO’s global tally.
“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 patients to stay home in isolation and admitting them to hospital if they show symptoms.