In a surprising announcement today, Saudi Arabian officials revealed that a "rigorous" examination of all their MERS-CoV (Middle East respiratory syndrome coronavirus) data has led to an abrupt 19.6% increase in the country's official case count and a 48.4% increase in the death toll.
Yesterday the Saudi Ministry of Health (MOH) was reporting 575 MERS cases and 190 deaths. With today's announcement, the case count jumped by 113, to 688, while the death toll rose by 92, to 282. Of the nonfatal cases, 353 patients have recovered and 53 are still being treated.
Later in the day, the MOH reported another new MERS case and a death in a previously reported case, raising the totals to 689 cases and 283 deaths.
The announcement came the day after the MOH disclosed the dismissal of Deputy Health Minister Ziad Memish, MD, who has been the nation's leading investigator of and spokesman on MERS-CoV, and has also been the target of frequent criticism of the MOH's response to it. Today's news also came a few weeks after the appointment of a new health minister, Adel bin Mohammad Faqih.
Case details lacking
The MOH said the review that led to the revised numbers was designed to "ensure a more complete and accurate understanding of the MERS-CoV outbreak" in the country. But the agency did not explain why the cases originally went unreported or exactly how the review uncovered them.
Also, the MOH did not give any significant details on the added cases, such as locations, age ranges, gender balance, how many cases were sporadic, and how many involved healthcare workers or occurred in a healthcare setting,
The statement includes a bar graph depicting approximate numbers of previously reported and newly reported cases for each week since January 2013. It shows that the first newly reported ones occurred in May of last year.
The graph reveals that the proportion of unreported cases grew much larger this spring as case numbers soared. The number of additional cases was especially high in the third week of March and the last 2 weeks of April. The total case count for the third week of April is about 110, of which about 25 cases were not reported until now.
In the announcement, Dr Tariq Madani, head of the Scientific Advisory Board in the MOH Command and Control Center, stated, "The Ministry is committed to fully understanding MERS-CoV and putting in place the policies needed to protect public health and safety. To do this the Ministry has reviewed historical cases of MERS-CoV to give a more comprehensive understanding of the facts.
"While the review has resulted in higher total number of previously unreported cases, we still see a decline in the number of new cases reported over the past few weeks."
The MOH said its data review has already improved its policy development process and MERS response measures. The ministry said it has taken steps to ensure the use of best practices in data gathering, reporting, and transparency, with the aim of ensuring that "from now on, case information will be accurate, reliable, and timely."
"Measures that have been taken to ensure the reliability of information and speed of reporting include the development of an electronic case reporting system, and improving reporting mechanisms on new cases to MoH Command & Control Center," the statement said.
The MOH also announced several steps to improve the capacity and efficiency of Saudi labs and testing facilities:
- Authorization of additional labs to perform standard testing
- Standardization of testing kits across all labs and implementation of quality assurance processes
- Development and implementation of guidelines for the proper labeling and storage of samples in hospitals and labs
- Development and implementation of protocols to guarantee the integrity of samples during transport and ensure accuracy
- Improving access to authorized MOH labs through implementation of a nationwide courier system for rapid transfer of specimens to regional labs
Changes in the reporting of new cases were evident in today's announcement of the single new case. The case information is presented in a tabular format that offers more details than past reports, including the patient's nationality and whether he or she is a healthcare worker.
The new patient is a 50-year-old man who is hospitalized in Medina and is not a healthcare worker. He is of Saudi nationality and has no preexisting conditions.
Experts welcome the shift
Experts who commented on today's announcement welcomed the Saudi move toward greater transparency and expressed hope that it continues and increases.
Connie Savor Price, MD, chief of infectious diseases at Denver Health and Hospital, commented, "When the new [minister of health] came into office, I do believe one of his priorities was to re-examine the data to ensure experts were getting accurate data to inform interventions. More rigorous case findings identified the additional cases and deaths that you heard about today. My sense is that most of these cases are healthcare associated."
She denied any knowledge of the reasons for Memish's dismissal, but said she found the timing of today's announcement "interesting."
"The MOH seems to want to be clear that they are here to collaborate and value transparency. That is a step in the right direction," she added.
Michael T. Osterholm, PhD, MPH, who has done consulting work on MERS-CoV in the Middle East, said it's unclear why the additional cases were not reported earlier and what implications they have for understanding the MERS outbreak in Saudi Arabia. He is director of the University of Minnesota's Center for Infectious Disease Research and Policy, publisher of CIDRAP News.
"We welcome this new level of transparency and hope it will continue with more detailed information about these cases and what will be done so that this doesn't happen in the future," he said. "It also reinforces the point that we need much more information about the risk factors for transmission, which can be answered only by the completion of a comprehensive case control study."
"The bottom line message that we've got to understand is that this is not a Kingdom of Saudi Arabia problem or even a Middle East problem; this is an international problem," he said. "All it would take is one super-shedder of this virus to land in Tokyo or New York or London or Toronto, and this situation would turn on a dime."
Jun 3 MOH statement on new case reporting standards and numbers
Jun 3 MOH statement on new case