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Commentary
ProMED Myth On
Beta Coronavirus Transmission
Recombinomics
Commentary 00:30
February 14, 2013
1 April 2012 45 F Jordan** 30/11/2012 WHO/IHR Dead
2 April 2012 25 M Jordan** 30/11/2012 WHO/IHR Dead
3 13/06/2012 60 M KSA* 20/09/2012 KSA/Promed Dead
4 03/09/2012 49 M Qatar/KSA*** 22/09/2012 HPA/WHO Alive
5 NK NK NK KSA 04/11/2012 KSA/Promed/SMJ Alive
6 12/10/2012 45 M Qatar**** 23/11/2012 RKI/WHO Alive
7 NK NK M KSA* 19/11/2012-23/11/2012 KSA/Promed/WHO Alive
8 28/10/2012 NK M KSA* 23/11/2012 WHO Dead
9 Oct 2012 NK M KSA* 28/11/2012 WHO Dead
10 26/1/2013 60 M Pakistan/KSA 8/11/2013 EWRS Alive/Hospitalised
11 6/2/2013 NK M United Kingdom* 12/02/13 HPA Alive/Hospitalised
* Part of family cluster
** Healthcare worker and part of outbreak linked to hospital
*** Patient transferred to UK
**** Patient transferred to Germany
NK: not known
The above mentioned case of severe acute respiratory infection (SARI) is currently the 11th confirmed case of severe respiratory disease attributable to infection with the novel CoV 1st identified in a fatal case in Saudi Arabia (see prior ProMED-mail posts listed below). It is also the 3rd incident of infection with this novel CoV that occurred in a close contact of an earlier confirmed case, suggesting possible person to person transmission of the virus. There was a cluster of 3 confirmed cases in a family in Saudi Arabia in November 2012 and a cluster of 2 confirmed cases among ICU staff in a hospital in Jordan in May 2012. As stated clearly in the 3 reports of this update, evidence thus far does not seem to suggest an ease and facility of person-to-person contact of this organism as yet.
The table of cases presented in the ECDC report above is a very useful presentation and summary of the current publicly available information on the descriptive epidemiology of known confirmed cases of severe acute respiratory illness due to infection with this novel CoV. Information on exposure histories of each of the patients is not available (some of the earlier cases were reported to have had contact with farm animals in Saudi Arabia and Qatar, but similar information was not available on all cases).
The above comments from the latest ProMED update of beatcornavirus cases continue to ignore the additional cluster members who are designated as “probable" cases by WHO. There is little doubt that the probable cases are true cases, and the failure to confirm these milder cases signals a serious problem with the current betacornavirus protocols and assays. WHO has acknowledged that the coronavirus RNA concentration in the lower respiratory tract may be higher than the upper respiratory tract, which would help explain the false negatives, which are likely generated by testing nasopharyngeal swabs.
The details associated with the larger clusters have been withheld by WHO (disease onset dates, ages, and genders) of confirmed and probable cases. It is likely that the disease onset dates would strongly support human to human transmission. The dates of death for the two confirmed cases in Jordan in the above list were a week apart. Similarly the dates of death for two of the confirmed cases in the Riyadh cluster are four days apart, again signaling human to human transmission. One of the two symptomatic cases in the Riyadh cluster tested negative, as did all of the surviving cases in Jordan, even though all but one was hospitalized, and one was the son of the first fatal case (45F).
Testing details have been withheld. The large cluster linked to the ICU in Jordan created considerable concern, especially when a nurse (45F) and intern (25M) died. The cases were described as SARS-like, and samples were sent to France and Egypt for testing, but that testing was prior to the identification of the SARS-like cornoviruses as beta 2c. Egypt (NARMU-3) retested samples, but only the two fatal cases were positive. It is likely that material was available from the milder cases, but it is also likely that the collections were from the upper respiratory tract, leading to false negatives.
The above comments from ProMED, as well as the prior risk assessment and list by ECDC, largely ignore the probable cases, which approximate the number of confirmed cases. It is worth noting that 7 of the 11 confirmed cases are from the three clusters.
It is also worth noting that absence of disease onset dates in the cluster cases. However, data is also missing from individual cases. The first Riyadh case (#5 in the above list) was described in a publication of the Saudi Medical Journal (SMJ) which is cited in the above list, but apparently neither the ECDC nor ProMED actually read the article, which included the disease onset date of October 9, and as well as the age and gender (45M). All of the above are listed above as NK (not known). The case was a gym teacher and the brief visit to a farm was not considered by the authors of the paper to be relevant to the infection. The paper included sequences from the case, which were virtually identical to the public sequences from the initial fatal cases in Saudi Arabia (#3 on the list) and the first case from Qatar (#4 on the list).
Thus, ProMED is waiting for data that has been public since November of last year, and both ProMED and ECDC continue to rely on false negatives to claim that there are no mild cases and limited human to human transmission.
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