Random Analytica

Random thoughts, charts, infographics & analysis. Not in that order

Tag: Saudi Arabia

Random Analytics: 100-days of MERS

Given that we are now half-way through the annual Hajj I thought I might spend some time looking at the Middle Eastern Respiratory Syndrome Coronavirus (MERS-CoV) which has been with us for some years now but seems to have fallen off the radar in favour of the maladie de jour, Ebola.

What publically sourced data is available is limited. In the past 100-days there have only been 25-notified cases (23 in Saudi Arabia, 1 in the United Arab Emirates and an exported case to Austria). The Kingdom’s updates are as brief as ever, the World Health Organisation (WHO) has clumped together a monthly update with only high-level data while the world’s attention is completely focussed on Texas and West Africa. Not only is the data limited but the Saudi’s have again reviewed their data and found a further 17 cases prior to 3 June that were missed. Ian Mackay wrote an excellent open letter to the KSA Ministry of Health in relation to that oversight (recommended reading).

For lots of reasons I haven’t updated my rudimentary MERS-CoV Db in a couple of months and what I found during my data-entry this morning I thought was intriguing enough to do an infographic with MERS notifications going back just 100-days.

1 - MERSbyCity_141005

The 100-days of MERS infographic details the 25-cases that have been notified between the 29th June to the 6th October 2014. The Riyadh count includes the young lady who travelled from Afif to Austria and one case where the KSA Ministry of Health provided no details (thus the figure is represented as a man).

Just to cover off the basic points in the infographic, there have been 25-cases since 29 June and two notified deaths (assuming that FluTrackers case number #863 is the 76-year old male from Najran who died on 25 September, thus a provisional Case Fatality Rate (CFR) of 8%, which is extremely low compared to the current 42.4% during the outbreak in the KSA. Of the 24-cases with details, four were female, the ages ranged from 27 to 76 and the average age was 54.1

Now to the really interesting data-points, some queries and a counter-factual.

  • A quick look at my Db tells me that during the period July – September 2013 there were approximately 56-cases of MERS (not including any that formed part of the 113 that were belatedly added without details). My first question: Is MERS on the decline given that the epidemiological curve seems to have declined by half since last year?
  • Even though the cases are very low the spread of the disease is extremely widespread. Over the past 100-days MERS has cropped up in Abu Dhabi (882km west from Riyadh via Route 10), Najran (974km south via Route 10), Taif (994km south-east via Route 40) and Arar (1,157km north-east via Route 65). My next question. Can someone explain why the cases are so low but seem to be so widespread?
  • There have been seven confirmed cases in Riyadh which has a population of 4-million and six cases in Taif, population approximately 500,000. Is there any reason why Taif is currently overburdened with the limited amount of cases?
  • The provisional CFR over the past 100-days seems very low at just 8%. Is that due to better care, less cases, better surge capacity, declining potency or another reason?
  • My last data point is really a counter-factual on the data that has been presented over the past three-months. The release of a second tranche of non-notified cases (this time 17 as compared to the previous 113) has to be questioned more deeply. You can always allow for a mistake but two is either a conspiracy or a cock-up. If it is a conspiracy are the Saudi’s ‘juking the stats’ in order to protect travellers from the Hajj? Are the Saudi’s using the current Ebola outbreak to limit the amount of information they are sharing? If it’s a cock-up why was it allowed to happen a second time in the lead up to the Hajj.

In Summary

Looking at the previous 100-days of data has me asking a number of questions. Is MERS on the decline? Why is the CFR so low? Why are the cases so widespread? Why has one small city got as many cases as the capital?

There are two incontestable facts. One: During the past 100-days MERS-CoV has been widespread across Saudi Arabia and the United Arab Emirates. Two: I also know where it hasn’t officially been.

Mecca.

Make of that what you will…

QuikStats: MERS-CoV in the Arabian Peninsula (Nov 2013)

“No to slavery … That is not a world we will accept … Not here. Not overseas. Not anywhere.” Former Prime Minister of Australia, Julia Gillard (8th March 2013) who will be speaking at the 2013 WISE Summit: Reinventing Education for Life in Doha, Qatar (29-31 October 2013)

1 - MERSinMiddleEast_Infographic_131120

***** Please note that this infographic of the Middle East Respiratory Syndrome Coronavirus (MERS-CoV) was updated with public source information to 1200hrs 20 November 2013 EST *****

The world’s top virology experts have watched the recent Hajj very closely, as has the world’s media since it first came on the scene in April 2012. It initially sprung up in Jordan but was soon exported to Saudi Arabia which has taken the hardest hit from the disease. As I write this blog 125 persons are confirmed to have caught the disease in the Kingdom, with 54 of them dying).

Of concern were the 2-million pilgrims who would be travelling together to the various sites (numbers were down approximately 1/3rd on recent years, possibly due to MERS-CoV). Although sometimes cramped the Hajj is generally well organised and supported including health and vaccination facilities. Some very good writers have expressed doubts about the data coming out of Saudi Arabia but the Hajj is behind us now. It seems that outside of some individual cases, as the possible French case highlights, major concerns about Saudi Arabia and the Hajj might have overblown.

Perhaps those same concerns should be directed at Qatar and the conditions of those who are building the FIFA World Cup stadiums for 2022?

Qatar has a population of just 1.9-million, of which only 15% are Qatari. In 2012, the country’s Gross Domestic Product per capita was the richest in the world at $89,736 (compare that to Australia $62,003, Canada $51,554, US $48,113, KSA $24,116 or Yemen $1,361). Yet a lot of the country is actually populated by very poor foreign workers who make up 94% of its total workforce.

Recently The Guardian newspaper has highlighted the abject conditions of those working on construction sites. In the first article the International Trade Union Confederation has estimated that at current numbers the construction of FIFA World Cup facilities will cost around 4,000-lives mostly via heat related illness or workplace incidents, although the data is sketchy at best (and non-existent at worst).

In another article Revealed: Qatar’s World Cup ‘slaves’ the newspaper investigates and documents multiple cases of workers being abused and living in awful conditions. Excerpt:

According to documents obtained from the Nepalese embassy in Doha, at least 44 workers died between 4 June and 8 August. More than half died of heart attacks, heart failure or workplace accidents.

The investigation also reveals:

  • Evidence of forced labour on a huge World Cup infrastructure project.
  • Some Nepalese men have alleged that they have not been paid for months and have had their salaries retained to stop them running away.
  • Some workers on other sites say employers routinely confiscate passports and refuse to issue ID cards, in effect reducing them to the status of illegal aliens.
  • Some labourers say they have been denied access to free drinking water in the desert heat.
  • About 30 Nepalese sought refuge at their embassy in Doha to escape the brutal conditions of their employment.

And another excerpt which mentions the living conditions:

The Guardian’s investigation also found men throughout the wider Qatari construction industry sleeping 12 to a room in places and getting sick through repulsive conditions in filthy hostels. Some say they have been forced to work without pay and left begging for food.

“We were working on an empty stomach for 24 hours; 12 hours’ work and then no food all night,” said Ram Kumar Mahara, 27. “When I complained, my manager assaulted me, kicked me out of the labour camp I lived in and refused to pay me anything. I had to beg for food from other workers.”

For those working and living in cramped filthy conditions or working long arduous days without proper food or hydration would be more at risk to just a seasonal flu. What about the practice of going to work when ill or ‘presenteeism’? How many of the 85% of non-Qatari’s in the monarchy have access to decent medical help.

With 44 Nepalese dying in just 66-days and a further 82 Indians dying in the first five months of this year in work related incidents it seems trite to concern ourselves with a relatively small outbreak of a disease which only caused two deaths in 2013.

As I write this post in late October MERS-CoV has been confirmed in just seven cases in Qatar with two onsets in recent weeks.

I’m not trying to suggest that all migrant workers in that country are going to get the virus it does seem a more likely vector than the better organised and supported Hajj pilgrimage.

As I did with the recent MERS-CoV infographics I’ll keep the infographic updated as new information comes to hand through to the end of November. Here is a copy of the original infographic posted with data to 29 October 2013:

2 - MERSinMiddleEast_Infographic_131029

Acknowledgements: Data for this infographic was sourced largely from CIDRAP, H5N1, FluTrackers and the WHO. Background reading supplied mainly via Pandemic Information News, Ian at Virology Down Under and Helen Branswell.

Updates

30 Oct 2013 – Via H5N1Oman: Sultanate reports first MERS case;

1 Nov 2013 – Via H5N1: Dr. Mackay reflects on the latest MERS cases;

3 Nov 2013 – Amendments to infographic as suggested by Crawford Kilian (detailing methodology);

7 Nov 2013 – Via H5N1: Dr. Mackay has questions about the Spanish MERS case;

8 Nov 2013 – Via CIDRAP: UAE, Saudi Arabia report 3 more MERS cases;

9 Nov 2013 – Via H5N1: Qatar: New MERS case is an expatriate;

11 Nov 2013 – Via H5N1: Oman reports first MERS death;

12 Nov 2013 – Via GulfNews.com: Omani visitor dies from Mers virus in Abu Dhabi emirate (h/t Helen Branswell);

17 Nov 2013 – Via H5N1: CIDRAP: MERS death toll rises as WHO confirms 2 cases and Kuwait: Some details on the second MERS case;

20 Nov 2013 – Via H5N1: CIDRAP: Saudi Arabia reports 2 more MERS cases;

QuikStats: MERS-CoV in the KSA (October 2013)

“People need to be careful in a very generic way, such as ensuring good hand hygiene. We would normally tell people to avoid very crowded situations, but obviously in this case, with the Hajj, that is unrealistic.” (Richard Brown, Regional adviser for communicable disease surveillance and epidemiology for WHO’s South East Asia Regional Office, 4 October 2013)

1 - MERSinKSA_Infographic_131101

***** Please note that this infographic of the Middle East Respiratory Syndrome Coronavirus (MERS-CoV) was updated with public source information to 1200hrs 1 November 2013 EST *****

With just days to go until the HAJJ, the largest gathering of Muslims in one place each year and more than a year after the first cases of MERS-CoV came to our attention I thought it might be worthwhile concentrating on the Kingdom of Saudi Arabia this month.

The above infographic shows the distribution of MERS-CoV by onset province in the Kingdom. I have chosen to use the FluTrackers.com methodology and include one of the first victims who was actually a UK citizen, thus my numbers won’t match those that are officially noted by the Kingdom of Saudi Arabia Ministry of Health.

Two points that were made clear to me during my research into the KSA MERS-CoV figures is that the basic data is awful; a far cry from what has been made available from the Chinese during their H7N9 outbreak. I won’t say too much more on that as many including Helen Branswell, Crawford Kilian and Ian M. Mackay have all commented about this for some months now but I would ask if anyone can see an error in the infographic please correct me and I’ll remedy ASAP.

A lot of discussion has taken place about the potential for MERS-CoV to utilise the HAJJ as a springboard for a rapid escalation of spread. The second point and key take-away from the infographic has been that the Kingdom is a very large country with a concentration of cases in the Eastern side of the country. At the date of initial publishing (8 October) 92 of the cases were in the Eastern and Riyadh regions, making up 78% of the cases with at least 21 of those cases involving the Al-Ahsa medical facility cluster which should be a singular event. That’s not to say that MERS-CoV will not spread but certainly to date the axis of the disease in removed from the massive concentration of peoples in the Western part of the country.

Here is a copy of the original infographic posted with data to 8 October 2013:

1 - MERSinKSA_Infographic_131008_2of2

As I did last month with the global MERS-CoV I’ll keep the infographic updated as new information comes to hand.

For those that are travelling for HAJJ, safe travels and let’s hope there is not much in the way of news.

Inshallah.

Acknowledgements: Data for this infographic was sourced largely from CIDRAP, H5N1, FluTrackers and the WHO. Background reading supplied mainly via Pandemic Information News, Ian at Virology Down Under and Helen Branswell.

QuikStats: MERS-CoV (September 2013)

“I think the take-home message is: MERS is not SARS” (Zaid Memish, Deputy Health Minister, Kingdom of Saudi Arabia, 30th August 2013).

1 - MERS_Infographic_131001

***** Please note that this infographic of the Middle East Respiratory Syndrome Coronavirus (MERS-CoV) was updated with public source information to 1200hrs 1 October 2013 EST *****

The above infographic shows the distribution of MERS-CoV by onset country. The Kingdom of Saudi Arabia (KSA) has had the most cases and the numbers are reflective of the latest KSA Ministry of Health figures. The most recent fatality outside of the KSA that I have included in my data was from Tunisia. Some countries, such as France and the UK have had fatalities that are not shown above due to the fact that the onset occurred elsewhere in the Middle East. The Tunisia index case seems to have occurred in Qatar or the KSA but at this time is still included under that countries flag. Italy initially reported two cases but these were later amended to probably by WHO due to testing issues. A number of fatalities are not shown as their details have not been made public.

Ian M. Mackay, via his VDU blog has been discussing the spike in case numbers during the month of September. To emphasise his point here is the index chart that I published on the 4th September 2013 (110-cases & 50-deaths).

1 - MERS_Infographic_130904

Data can be many things to many people. For health investigators it is a critical resource to build a story about new or emerging diseases, for medical professionals it is a tool to inform while for the public it is a way to tell a complex epidemiological story in a more manageable format.

It has its drawbacks though. Data alone often tells a non-contextual story only.

Reading the back story on MERS-CoV I couldn’t help but reflect on the story of Abid Hussain (case number 10). Abid had travelled to his former home of Pakistan then visited Mecca to pray for his 39-year old son who had been diagnosed with cancer and was in the process of receiving chemotherapy. Upon his return to the UK he became unwell with severe flu like symptoms and either prior to being hospitalised or during his hospitalisation managed to pass on the disease to both of his adult children. The daughter only showed mild symptoms, did not require hospital admission and made a full recovery. The son, Khalid, a father of two and in the battle of his life could not stop a second assault on his system by MERS-CoV and succumbed to the disease just eight days after being admitted to hospital.

What terrible luck.

Acknowledgements: Data for this infographic was sourced largely from CIDRAP, H5N1, FluTrackers and the WHO. Background reading supplied mainly via Pandemic Information News, Ian at Virology Down Under and Helen Branswell.

Updates

  • Case numbers and fatalities have been updated regularly by multiple agencies. Here are the CIDRAP daily overviews which included case updates for the 3rd – 4th – 6th – 9th – 11th – 17th18th – 20th and the 30th of September 2013.