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Worried. WHO's emergency committee says that its concern about MERS has "significantly increased."

Worried. WHO's emergency committee says that its concern about MERS has "significantly increased."

WHO/P. Virot

MERS Situation More Serious but Not an Emergency Yet, WHO Panel Says

An international committee advising the World Health Organization (WHO) today called on countries on the Arabian Peninsula to improve their hospital hygiene and help in carrying out much-needed studies on how the Middle East respiratory syndrome (MERS) virus spreads. But the panel stopped short of declaring the deadly new disease, which emerged 2 years ago, a public health emergency of international concern (PHEIC).

There has been a dramatic rise in reported MERS cases recently, and calling the outbreak a PHEIC would have given WHO the power to issue travel advisories and other recommendations under the International Health Regulations. It would also increase political pressure on the affected countries.

But after a 5-hour telephone conference yesterday, the panel decided that the criteria for a PHEIC haven't been met, Keiji Fukuda, WHO’s assistant director-general for health security and environment, announced at a press conference in Geneva, Switzerland, today. “They believe the situation had increased in terms of its seriousness and urgency but did not at this point constitute a PHEIC,” Fukuda said.

Preben Aavitsland, a Norwegian epidemiologist who helped draft the International Health Regulations, criticizes the decision. “I personally think from the information that is publicly available that the event should be declared a PHEIC,” Aavitsland tells ScienceInsider in an e-mail. "MERS is an international concern, it spreads to other countries, and there is a need for an international response.” But to David Heymann, a former executive director of communicable diseases at WHO and now head of the Centre on Global Health Security at Chatham House, it seems "a sound decision.” "We have to trust the international bodies,” Heymann says.

The emergency panel was established in July last year and it has met four times before, most recently in December. After each of those meetings it expressed concern but concluded it was too soon to call an emergency. The group will be asked to make a new assessment in a couple of weeks, Fukuda said.

In its most recent update, WHO puts the number of MERS infections at 536, including 145 deaths. But that official count lags behind the numbers announced by country governments; Saudi Arabia alone has so far announced 157 deaths. Travelers have also exported the virus to more than a dozen countries where MERS is not endemic. The United States announced a second imported case on Monday, and the Netherlands reported its first today.

"Suboptimal infection control practices” in hospitals and overcrowding in emergency rooms have contributed to the rise, Fukuda said. The number of infections acquired outside the hospital has also increased, he added; reasons for that were still unclear. But he stressed that there is "no convincing evidence right now for an increase in the transmissibility of this virus,” which was one of the main reasons the emergency committee did not declare a PHEIC. The committee evaluated genetic information available from five recent infections, three in Jeddah, one in Greece, and the first U.S. case. "The genetic sequences of these more recent viruses looked very much like the sequences of older viruses,” Fukuda said.

Aavitsland says the escalating case numbers could lead some countries to unilaterally introduce restrictions for travelers from the Middle East. "By declaring a PHEIC, WHO could put itself in the driver’s seat and give recommendations against such measures, which are very unlikely to be beneficial,” Aavitsland writes. "If someone [issues] travel restrictions against Saudi Arabia now, then Oman or Lebanon may not declare if they have new cases tomorrow.”

Declaring a PHEIC could also put increased political pressure on Saudi Arabia and other countries in the region to fully confront the crisis. The world is still waiting for critical research, such as a case-control study, to find out how the virus makes its way from the animal reservoir—likely camels—to humans, Heymann says. "That is the real issue: The study has not been done to show whether this can be prevented by simple efforts.” But declaring a PHEIC just to facilitate such studies would have been irresponsible, Fukuda says. "I hope the increased sense of urgency pushes aside any barriers,” he writes in an e-mail.

People should not interpret the panel’s decision to mean everything is under control, says Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota, Twin Cities. “It’s not.” There is clear evidence that some individuals, called supershedders, have infected a large number of other people on the Arabian Peninsula, Osterholm says. "If that emerges elsewhere, the world will take a very different view on this.”