MERS Virus Migrates to One More Country. What Will Contain It?

A respiratory virus that originates in the Middle East and has been hopscotching the globe for three years has today landed in yet another country, just as international health officials are raising concerns about the conditions that allow it to spread.

The virus is called MERS, Middle East Respiratory Syndrome coronavirus, and this morning Thai officials revealed that it has landed there via a medical tourist from the Persian Gulf state of Oman, who arrived in Bangkok to be treated for a heart condition. Three family members traveled with him, and all four are under quarantine, while passengers who sat near them on their flight are being sought and watched.

MERS originates in the Middle East (if you’d like to catch up, here are some past posts about it, plus a piece I wrote for WIRED magazine); it may cross to people from camels, and was first spotted in a hospital patient in Saudi Arabia. It has spread so slowly that most concern about it has bubbled at a fairly low level, even though, according to the World Health Organization, it has reached two dozen countries so far: 25 as of last week, plus Thailand today.

But the Thai discovery happens to come one day after an emergency committee empaneled by the WHO expressed concern over how quickly MERS blew up in another of those countries, South Korea. Except among disease obsessives, that outbreak has not been much noticed—but just since May, 164 people in South Korea have been confirmed ill and 23 have died, and a known-infected patient has migrated from South Korea to China. More than 10,000 Koreans were or are in quarantine either in hospitals or at home, including a village that was shut off from the world despite experiencing just one case.

In a report and press conference yesterday, the WHO committee—which despite having “emergency” in its name was meeting for the 9th time in two years—said that the virus spread mostly through hospital contact because of inadequate protective measures.

“In some instances there was close and prolonged contact between people who had infection and people who did not have infection, so for example other patients, visitors, healthcare workers in emergency rooms, so under crowded conditions and for prolonged periods of time,” Dr. Keiji Fukuda, an assistant director general at the WHO, said. “And then we also saw that there were similar mixing of infected and uninfected patients in multi-bed hospital rooms, so where patients are kept. And so these kinds of things made it easier for the virus to hop from an infected person to an uninfected person.”

Fukuda added that the virus also spread when patients carried it from hospital to hospital in what he termed “doctor shopping,” and also was conveyed to uninfected family members who were in hospitals to bring treats and keep patients company.

But the biggest mistake, he said, was a simple one: South Korea did not expect MERS to arrive.

“There was a lack of awareness about MERS both among health providers and also the general public in the Republic of Korea before the MERS outbreak occurred there, so it really took everybody by surprise,” Fukuda said in the press conference. “This probably contributed somewhat to a delay in knowing what was going on.”

In that observation, he encapsulated one of the most stubborn and enduring vulnerabilities to diseases: forgetting that they cross borders. It’s a lesson that we used to know; the word “quarantine” originates in the “quarantina giorni,” 40 days, during which 14th-century Venice forced ships to hold position at sea so outbreaks on board could burn themselves out. Paradoxically, though, awareness that diseases can travel rapidly across the globe has dropped as the speed and ease of travel have risen.

And, thus—in just a few examples—SARS, a viral relative of MERS, circled the globe in a week in 2003. Malaria traveled to Washington, DC via mosquitoes that wandered into an aircraft’s cargo compartment. H5N1 avian flu sneaked over the border between China and Vietnam in smuggled chickens. The multi-drug resistance factor NDM-1, which renders common infections almost untreatable, went to multiple countries in the guts of medical tourists. And just last year, Ebola walked back and forth across West African borders, transported by guests at a funeral.

An epidemiologist would say that it is inevitable we identify outbreaks retrospectively: We don’t detect Patient Zero until there is a Patient One, or 10, or 125. And that would be correct. But it’s vital to remember that, if we paid attention, we might have a better chance of stopping outbreaks at low numbers. The most important defense against the spread of disease isn’t quarantine, or high technology, or even good health care practice. It’s awareness that the possibility of importation is always present. And that can never be allowed to lapse.