Experts say flawed response fueled Saudi virus outbreak
Saudi officials know how urgently they need to beat MERS, and with the number of cases and deaths tripling since the end of 2013, health experts cite grave flaws in the way this ultraconservative and staunchly private monarchy has handled the crisis.
The New York Times
JIDDAH, Saudi Arabia — As the virus tore through the city’s largest hospital, jumping from bed to bed and afflicting scores of people, terror filled the wards.
Some doctors and nurses refused to treat the sick or stopped coming to work altogether. Patients panicked. One surgeon recalled a man with a broken limb trying to flee the emergency room so he would not catch it, too.
“Everyone was afraid,” the surgeon, Dr. Mohammed Ahmed, said of the spike in cases this spring.
It was the darkest hour since the new illness, known as Middle East Respiratory Syndrome, or MERS, first appeared in Saudi Arabia late in 2012. In all, more than 700 cases have been documented in 20 countries, nearly all of them linked to Saudi Arabia. More than 250 people have died.
The sudden spread of a mysterious and fatal new virus is reminiscent of the early days of SARS, or severe acute respiratory syndrome, a related disease that appeared in dozens of countries and killed more than 770 people, principally in Asia in 2003.
MERS circulates most heavily in a region that is the nexus for Islam.
This port city, Jiddah, is the arrival point for most of the 2 to 3 million pilgrims who make the hajj to Mecca each year. Riyadh, the Saudi capital, has had the second-largest outbreak after Jiddah, and cases have also appeared in Mecca.
The hajj will not take place until October, but many Muslims travel to Mecca during the holy month of Ramadan, which most Muslims began observing Sunday. And offseason pilgrims have spread the disease to Iran, Jordan and Algeria.
Saudi officials know how urgently they need to beat the disease, and they say they now have the latest outbreak under control. But that the number of cases and deaths have more than tripled since the end of 2013 has led health experts to cite grave flaws in the way this ultraconservative and staunchly private monarchy has handled the crisis.
Handling the crisis
King Abdullah fired the country’s health minister and his deputy in April, leaving experts wondering whether the shake-up would bring greater transparency and international cooperation. “In the U.S., when you have a crisis like the Veterans Administration scandal, the new head is in front of the TV cameras explaining what the new plan is,” said Dr. Peter Daszak, president of EcoHealth Alliance, a veterinary organization that tracked the disease in animals. “There is no tradition of openness in Saudi Arabia.”
A World Health Organization panel said this month that the surge in cases that began in April had fallen off, but that “the situation remains serious” and that hospital outbreaks should be investigated for breaches in safety protocols.
“I am not saying we’re not worried, but this is something that can be controlled,” said Hanan Balkhy, executive director for infection prevention and control at Saudi Arabia’s National Guard hospitals. “If this were Ebola, I would go the king myself and tell him, ‘We need to isolate the kingdom.’ ”
Both SARS and MERS are coronaviruses, named for their shapes. Both are thought to have originated in bats and then spread through other animals to people. But while SARS circulated in obscure forest animals like palm civets that are eaten in southern China, MERS infects camels, which are common in the Middle East. MERS seems to jump more easily to humans, possibly in raw camel milk, but it spreads less readily between people than SARS did.
One theory gaining popularity is that MERS cases peak in the spring because camel calves are born at that time. So until a human or veterinary vaccine is developed, people in contact with camels must be careful, especially in the spring.
Yet the outbreak this year suggested that lapses in the kingdom’s health system played a bigger role in spreading the virus than camels did. Most of the hundreds of new infections were linked to hospitals, dialysis clinics or other health facilities, and many were among staff members. Two health workers from Saudi clinics were hospitalized in Indiana and Florida.
The greatest number of new cases was at the King Fahd Hospital in Jiddah. Doctors said a mix of bad management, crowding and lax hygiene helped spread the virus there.
The outbreak came during the busiest time of year, when many Saudis were on vacation, leading to more car accidents, sports injuries and other mishaps, doctors said. New emergency patients were registered in a crowded area, and hospital rooms meant for four people often held 12.
Suspected MERS cases were not always identified and isolated, and patients unwittingly spread the virus around the hospital — one in the cardiac ward, and another among dialysis patients, according to Dr. Ahmed Ragab, chief of the hospital’s intensive care unit.
“If one patient came in with the virus, all the others would get it, because they were all next to each other,” Ragab said.
Some medical staff were lax with sanitary measures, not wearing masks or infrequently sanitizing their hands. Many fell ill.
When the king fired the health minister, Abdullah al-Rabeeah, in April, he gave the job to the labor minister, Adel Fakieh, who is known for bypassing the kingdom’s bloated and inefficient bureaucracy. Fakieh enlisted McKinsey & Co., the corporate consulting firm, and opened a command center in Jiddah to track cases.
The changes at the top soon filtered down to the King Fahd Hospital, where Dr. Imad al-Jahdali became director in May.
“The scene at the time was panic, from the public and from the media,” al-Jahdali recalled. “King Fahd Hospital was the spotlight for everything.”
He divided the hospital in two, with one half exclusively for MERS patients. Anyone with a fever and breathing problems is quickly isolated for testing.