The outbreak in South Korea of the deadly Middle East respiratory syndrome, or MERS, is the largest outside of Saudi Arabia, and very frightening. But here is a consolation: If a similar outbreak of MERS does land in the United States this year, our own experience with Ebola has primed the health system to respond more vigorously than we might have.
But we still have something to learn from the situation in South Korea.
So far, the MERS experience there — 10 dead, 122 infected, more than 3,800 people have been quarantined — has interesting parallels to last year’s Ebola panic. Both viruses have frighteningly high death rates (which can vary by treatment access but hover around 40%), and both lack any vaccine or definite treatment beyond supportive care and hard-to-access experimental protocols.
A series of diagnostic and treatment errors swirled around South Korea’s first MERS case, bearing a haunting similarity to our experience with the Ebola patient Thomas Eric Duncan, who left a Dallas hospital with the wrong diagnosis and useless antibiotics due in part to a failure of communication between doctors and nurses about his travel history. When Duncan returned to the hospital terminally ill, the Ebola virus he was carrying spread to two nurses caring for him.
In Dallas’ Ebola experience, hospitals received insufficient guidance from the Centers for Disease Control and Prevention about how to care for patients with the disease safely, and the public was inappropriately reassured that Ebola transmission was unlikely in hospitals in America, as opposed to West Africa. These poor communications only served to panic the general public when the virus spread to health care workers, which was a predictable scenario.
The first South Korean MERS case endured an even worse sequence of missed opportunities. The afflicted man sought care for his gradually worsening condition for nine days before he was ultimately diagnosed at Samsung Medical Center in Seoul. By that time, he had sought care at two clinics and spent three days in a smaller hospital 40 miles from Seoul.
Whereas key details of Duncan’s travel history never made its way to the emergency room physician in Dallas, the South Korean index of the patient’s history was incomplete. Perhaps due to confusion, he told his doctors only about travel to Bahrain, where MERS hasn’t yet been reported, but he had also traveled to the MERS endemic countries Saudi Arabia and United Arab Emirates.
Just as Americans were misinformed about the necessity of total body protective gear when treating Ebola patients, South Koreans are facing conflicting guidance about the airborne transmissibility of MERS. We’ve only known about MERS since 2012, and one of the biggest lingering questions about it is how it moves from human to human. Close contact seems to be important, and hospitals are clearly hot spots, but community transmission is possible. Ebola, by contrast, has been studied for 40 years.
There’s a vital difference between a lack of evidence and actual knowledge, and it’s sometimes prudent to act on our uncertainty. In the case of MERS, prominent health agencies are informing the public both that the virus is definitely not airborne and that it’s airborne. Actually, we don’t know, and it’s OK to tell the public that.
The World Health Organization said in a recent report that there is “no evidence of airborne transmission,” and it advises routine contact precautions, and airborne precautions only when performing procedures on patients that may generate aerosols.
Yet MERS has been isolated from the air before. In South Korea’s index patient, the virus was found in the poorly ventilated hospital room’s air conditioning unit, raising the likelihood that airborne transmission played a role in its rapid spread inside that hospital, where the most cases are reported.
The CDC recommends hospital workers use airborne precautions due to that uncertainty, regardless of whether performing a procedure or not. It also recommends MERS patients wear face masks to prevent spread due to aerosolization of droplets when coughing.
Yet South Korea’s Deputy Prime Minister Choi Kyung-hwan told a press conference definitively, “The infection is not airborne.”
Such conflicting messages aren’t helpful.
On the panic side however, just as officials inappropriately closed schools around Dallas after the Ebola cases there, South Korean officials are closing schools with abandon — the number is now more than 2,400. That’s probably overkill.
South Korean officials also unhelpfully kept the 24 hospitals treating MERS patients a secret matter, thinking they’d limit worry by doing so. Instead they sparked dire rumors on social media.
Unfortunately, MERS and Ebola differ quite markedly in their potential to transition into a pandemic, thanks to this question about airborne spread. MERS is quite related to the SARS virus, a member of a different lineage in the same genus of betacoronaviruses. A mutation likely occurred in MERS around 2012 that led to its jump from camels (and possibly bats) to humans.
As it spreads in humans, it’s expected to mutate to survive, and that could well lead to a strain that lives a little higher in the respiratory tract and is more easily coughed out. Betacoronaviruses such as MERS mutate far more frequently than the Ebola viruses.
South Korea is dealing with familiar problems of panic and insufficient guidance, but it is also putting into place some innovative new measures surrounding quarantine that our public health officials should consider. South Korea is monitoring cell phone signals for those under quarantine and is using monitors who frequently call and check on those under quarantine.
These steps are necessary because South Koreans don’t like to obey quarantines any more than Americans. When a MERS contact, told he shouldn’t travel, instead took a flight to China where he was diagnosed with the disease, it raised significant diplomatic concerns as well as fears of an epidemic.
The U.S. public health system leaves much to be desired. For example, even though I’m a physician working in a city that receives daily flights from Seoul, and I’m on all the right mailing lists, I’ve received no notices from the CDC or my state’s health department about the signs and symptoms of MERS and what to do if I suspect a case. This lack of early, direct communication to providers is odd.
If we learned anything from our Ebola response, it’s that no public health official should count on routine precautions to stop the spread of novel pathogens, even in highly developed nations such as South Korea and the United States. Key to the response is detailing and rolling out an upgraded level of precaution beyond the everyday, and keeping clinicians regularly updated about where the threat stands.
We may know less about MERS than Ebola, but we can be better prepared if we pay attention to Ebola’s lessons.