A deliberate decision was made to wait for a period of time until the media reporting of this issue died down. It is crucial to review processes and procedures in the alerting of potential international health crises. In this particular instance, as with the previously discussed Jordan situation, the process remains... suboptimal.
First, a review of the publicly available reporting on the discovery of novel coronavirus in UK/KSA:
- Sept 20, 2012 (Day 0). Dr. Ali Mohamed Zaki, an Egyptian national, reports finding a novel coronavirus at the Virology Laboratory of Dr Soliman Fakeeh Hospital Jeddah Saudi Arabia. The non-profit organization Dr. Zaki reported to, ProMED, does not mention whether the International Health Regulations (IHRs) had been activated. In ProMED contextual comment, there is no mention that coronaviridae, a large family of viruses, are found worldwide- including in the KSA. There is no international pubic health threat assessment presented.
- September 23rd (Day 3). WHO announces they had been informed the prior day (Day 2), via the IHRs by the British, that they too had discovered a novel coronavirus. WHO does not issue travel restrictions, however acknowledges they are in the midst of a threat assessment. This report contributes to rapid media uptake of the information.
- Oct 4th (Day 14). The British report finding a novel coronavirus in a patient with unexplained severe acute respiratory illness, which was originally reported to the HPA on September 14th (Day -6). The article was submitted on September 27th (Day +7). An unknown length of time transpired in the drafting of this academic, presumably peer-reviewed article. On the same day, CDC issues a Travel Notice.
- October 21st (Day 31). The media report that Saudi officials seek to fire Dr. Zaki for breaching official public health reporting protocols.
- October 22nd (Day 32). CDC posts a link in a non-prioritized position within the Clinician Outreach and Communication Activity (COCA) / Health Alert Network (HAN) to the original CDC MMWR report. No recommendation for US physicians to actively surveil for a travel history and clinical findings is provided. On the same day, KSA officials issue a statement rebuking the decisions made by Dr. Zaki and ProMED regarding how the information was handled. Dr. Zaki was indeed fired. Officials refer to the economic damage experienced by Toronto during SARS, and state,
We do trust ProMED-mail's editors and moderators will remember that our
Ministry of Health bears ultimate responsibility for managing contagious
disease within and even outside our boundaries. We take seriously our
responsibilities to our citizens and our guests. This time of year, we
assume an enormous responsibility to our Hajj pilgrims visiting Mecca,
and then to the world community as our guests return home.
We note the title of the official who issued this statement includes "Director WHO Collaborating Center for Mass Gathering Medicine". This then would imply one of two conditions:
- Either Saudi officials truly were unaware of Dr. Zaki's findings before his note to ProMED, which happens far more often in these situations than not,
- WHO did know the situation but made a decision not to publicly report, or
- Saudi officials made the decision not to activate the IHRs based on their assessment, where the British clearly disagreed, albeit with the benefit of seeing the prior report out of KSA.
To be fair, it is a heavy political decision to issue warning of a "novel coronavirus" and invoke the fears of SARS right before the Hajj. Billions of dollars are at stake, and no public official will feel comfortable taking a career risk over such action.
The Saudi's comment is, ironically, a similar comment our team received during the emergence of H1N1 in Mexico, where Mexican officials were quoted as saying (paraphrased), "why didn't you tell us what was going on?" Our response was, "but didn't you know already?"
After 15 years of doing this work, we have found social media and human networks often tell us what is going on inside of a country, regardless of whether or not the officials truly know (or are willing to divulge). This is also readily true inside the United States. The truism is no one can know everything everytime everywhere. And this certainly includes government officials. As we have pointed out time and again (as have others) that nothing beats an astute observer proximal to an event.
On Oct 21st, one media report commented,
With SARS, it was the outbreak that came first. The virus was only discovered later.
“Now, it’s really the reverse situation... We already have the virus and we’re waiting for an epidemic to show up or not show up. It’s a much better scenario.”
We would agree with this point. But the human process within the warning sequence arguably remains broken.
Assessing whether this particular warning sequence was a success or failure is dependent on several points in the timeline:
- The availability of an individual willing to breach official protocols to report infectious disease of international disruption potential.
- The coincidental receipt of two nearly identical virus samples from two different locations by the same diagnostic laboratory.
- The availability of diagnostic technology to rapidly identify the agent coupled to laboratory personnel with prior experience with the given family of viruses.
In other words, it was an extraordinary amount of luck that provided the world report of this novel coronavirus. Conversely, it is utterly unknown how many times an unrecognized coronavirus killed someone either individually or in a cluster in the world in the last year, where the event went unreported for whatever reason. We only know what is reported. And we are now most certainly "at risk" of scaring ourselves more often since SARS due to an enhanced ability (thanks to newer diagnostic technology) to recognize pathogens that were probably always endemically there but unrecognized. We are fortunate the novel coronavirus did not transmit efficiently during the Hajj. Of course, we are fortunate to have the luxury of relaxed hindsight.
One would surmise that if the situation was solely in their hands (and not Dr. Zaki's), Saudi officials would not have activated the IHRs in a timely fashion due to concerns about response reprocussions during the Hajj. In hindsight, the world can agree the outcome was a non-issue and no global response was required. But this is said in hindsight, as similar "not a big deal" statements were made after SARS and the 2009 influenza pandemic. Complacency yields surprise, which typically contributes to far more socio-economic disruption than most nations appreciate.
In being critical of the process, we propose the following:
- That the International Health Regulations still are not robust, despite official assurances to the contrary, and the position we take is the IHRs were activated outside of official channels thanks to public exposure through non-official channels. The questions raised about the warning sequence during the emergence of H1N1 in Mexico, which caught the United States and Canada by surprise, remain valid today. One will note these are precisely the same issues as raised during the emergence of SARS (see below, attached). To go several steps further, there is little difference from the warning sequence observed during the 1957 or 1968 pandemics. Interestingly, our experience exposing the UN as the source of the cholera disaster in Haiti also hightlights this tremendous capacity of officials to not be transparent, where UN officials continue to hesitate to admit fault despite evidence to the contrary.
- The linkage between global situational awareness for public health threats and local healthcare providers continues to be de-emphasized in the United States. No state or local HAN was issued that discussed the situation in the UK or KSA despite the fact that our country is tremendously connected to these countries by international air traffic- even more so than China during the time of SARS. This works against the promotion of that one astute clinician reporting a possible translocation of a poorly understood novel pathogen. In the days of SARS, most US physicians first heard of the crisis through CNN or other news media outlets. There is little difference today. The implication is potential for rapid translocation, vis a vie the Toronto experience. This leaves one with the impression that public health culture continues to be remarkably dis-integrated from daily clinical medicine, despite "lessons learned". And no, most assuredly we do not have faith CDC/public health understood this particular pathogen well enough to make the call not to inform local clinicians. The evidence resides in how the 1957, 1968 and 2009 influenza pandemics, SARS, HIV/AIDS, and the translocation of West Nile virus to the United States were handled during the initial recognition phase.
- There continues to be a fear of instigating "panic" via the issuance of official warnings. This was true during the early days of Tornado forecasting, when commercial interests did not want the public to associate a given community with tornado activity. The concern was a decrease in business activity. Of course, failure to warn on a high Fujita Scale tornado would mean far more severe morbidity and mortality because the opportunity to be proactive in response would be lost. How would tourists' impression of that community change if they knew the community deliberately witheld such information? Once meteorological forecast and warning processes became imbedded in the fabric of our society, one could argue it created more social resilience, to include the viability of the economy.
It is the opinion of this team that the United States has taken at least ten year step backwards in biosurveillance R&D, operations, and global public health surveillance operations. This is revealed in the complete duplication of effort reviewing the status of the DHS National Biosurveillance Integration Center through the National Laboratories. And the International Health Regulations continue to be a suboptimal construct for rapid reporting of international health threats.
Perhaps the axiom is true that it takes mass, geotemporally concentrated death that presents itself unexpectedly before a society decides to be outraged enough to force the installation of a proper forecast and warning capability for these kinds of threats. In this, we perhaps find ourselves in the coil of Cassandra's Curse.
In this, we find the creation of an international infectious disease forecast and warning center to be... essential.
Download Appendix 1 (Emergence of Severe Acute Respiratory Syndrome (SARS) in the People's Republic of China, 2002-2003: A Case Study to Define Requirements for Detection and Assessment of International Biological Threats)