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A Discussion About Middle East Respiratory Syndrome Coronavirus in Saudi Arabia

Weiga Chen

School of Nursing, Trent University

NURS 2550H: Advanced Life Sciences

Dr. Jane Mackie

February 12, 2021

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A Discussion About Middle East Respiratory Syndrome Coronavirus in Saudi Arabia

Middle East respiratory syndrome coronavirus (MERS-CoV), first identified in 2012, is a

lethal zoonotic pathogen that could lead to respiratory illnesses ranging from asymptomatic or

mild illness to severe acute respiratory disease or even death (Memish et al., 2020). MERS-CoV,

an enveloped, single-stranded, positive-sense RNA virus, is a member of the Coronaviridae

family (Zhu et al., 2020). The basic reproductive rate (R0) for MERS-CoV is 0.9 (Petersen et al.,

2020). According to World Health Organization [WHO] (2021), as of December 2020, 2564

laboratory-confirmed cases of MERS including 881 deaths were reported globally, leading to a

case-fatality rate (CFR) of 34.4%. However, the CFR may be overestimated since patients with

no or mild symptoms might not seek medical support.

Hui et al. (2018) indicated that the origin of MERS-CoV remains undefined. MERS-CoV

is believed to originate from bats, and epidemiological and genetics research suggests that

dromedary camels might be the main intermediary animal reservoirs (Zhu et al., 2020).

According to Memish et al. (2020), the transmission from infected camels to human is not well

understood; however, MERS-CoV was detected in nasal secretions, excreta, birth products and

food products of infected camels, suggesting there might be multiple portals of exit. Memish et

al. (2020) indicated that people in close contact with camels are at an increased risk of getting

infected by inhaling camels’ respiratory droplets or by ingesting undercooked meat or raw milk,

since the host cell DPP4 receptor, which the virus binds to, is widely present on the epithelial

cells of the distal airways, alveoli, endothelium, and some organs such as intestine and liver,

suggesting various portals of entry. In addition, Zhu et al. (2020) indicated that people could

acquire MERS-CoV infection through contacting with feces, vomitus, urine, cerebrospinal fluid

of patients. While anyone can be infected by MERS-CoV, people with older age (>60 years),
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male sex, smoking history, and pre-existing illnesses such as heart disease, diabetes mellitus, and

obesity are more prone to infection and severe diseases (Memish et al., 2020).

Signs and Symptoms

Hui et al. (2018) indicated that people with MERS-CoV infection can develop illnesses of

various degrees of severity ranging from asymptomatic, mild to severe. The median incubation

period is 5.2 days, but patients with immunosuppression and comorbidities can have longer

incubation period of up to 20 days (Memish et al., 2020). Signs and symptoms of MERS-CoV

infection are non-specific. As a result, a clinical diagnosis of MERS can easily be missed. A

typical presentation of MERS is fever (>38°C), dry cough, shortness of breath, sore throat,

myalgia, vomiting, and diarrhoea (Memish et al., 2020). Some patients could develop life

threatening acute respiratory syndrome and even multiorgan failure (Memish et al., 2020). Zhu et

al. (2020) indicated that more than half of the patients experienced acute kidney injury, and

comorbidities are more common in MERS patients compared to SARS, which might contribute

to the high CFR.

Diagnosis and Treatment

Molecular tests, such as polymerase chain reaction tests which detect the virus’s genetic

material, are the primary diagnostic testing method for MERS (Zhu et al., 2020). Memish et al.

(2020) demonstrated that specimens from both the upper and lower respiratory tracts should be

collected and analyzed whenever possible. They found the upper respiratory tract have lower

virus load than the lower respiratory tract; therefore, a negative result from the upper respiratory

samples by itself is not sufficient to exclude the possibilities of infection. They recommended re-

testing at least two specimens preferably from the lower respiratory tract. While chest x-ray/CT

images show abnormalities in patients with MERS, the imaging performance is similar and
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generally non-specific for viral pneumonia (Memish et al., 2020). However, Zhu et al. (2020)

indicated that while ground-glass opacities and crazy-paving pattern are common for different

types of viral pneumonia, pleural effusion is more common in patients with MERS.

No specific vaccine or anti-MERS-CoV treatment is currently available. The clinical

management is mainly supportive care focusing on patients’ clinical conditions, such as

managing pain and fever, treating secondary infections and supporting vital organ functions.

Several treatments including convalescent plasma and antiviral agents are potentially beneficial

in treating MERS; however, more research is needed to confirm efficacy (Memish et al., 2020).

Community Context

The cases from Saudi Arabia (2163 cases, 803 deaths) account for 84% of the cases and

91% of the deaths globally (WHO, 2021). Since dromedary camels are a reservoir for MERS-

CoV, exposure to camels and consumption of camel products such as camel milk and camel meat

increases susceptibility to MERS (Hui et al., 2018). Müller et al. (2015) found out that the

MERS-CoV antibody levels in slaughter-house workers and camel shepherds are 23 times and

15 times higher, respectively, than the general public in Saudi Arabia. Additionally, sleeping in

an index patient’s room and being exposed to a patient’s respiratory secretion and waste, such as

urine, stool, and sputum are risk factors for household transmission (Hui et al., 2018). However,

Hui et al. (2018) suggested that although human-to-human transmission is possible, it does not

seem to occur very easily unless having close contact with the infected person. Thus, more

research is needed to confirm the precise mode of the transmission of MERS-CoV. Advanced

age and pre-existing illness are risk factors for MERS-CoV infection; interestingly, male sex is

also associated with higher risk in getting infected (Hui et al., 2018). Despite that there is not

enough evidence in explaining what role gender dynamics plays in MERS, Ali (2016) suggested
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that it might be due to religious practice such as Hajj in Saudi Arabia, cultural practice such as

shisha smoking, and social roles that males are generally more involved in managing livestock.

Compared to transmission within household and community, nosocomial outbreak, which

accounts for approximately half of the cases, is a hallmark of MERS-CoV infection (Memish et

al., 2020). MERS-CoV is more stable under cold (20°C) and dry conditions (40% relative

humidity) and can still be found on surfaces after 48 hours; this feature could explain the spread

of MERS-CoV in health-care facilities equipped with central air conditioning (Hui et al., 2018).

Furthermore, late diagnosis of MERS-CoV infection due to non-specific symptoms, lack of

awareness of health-care workers about the infection, poor compliance with infection control

guidelines such as hand hygiene and the use of personal protective equipment, overcrowded

healthcare facilities with family members staying in as caregivers, and absence of proper

isolation rooms all contribute to nosocomial outbreaks and increase the public’s susceptibility to

infection (Hui et al., 2018; Memish et al., 2020).

Disease Prevention and Management Based on Social Determinants of Health

High quality health care is one of the social determinants of health, which aims at

protecting every citizen’s health (Mikkonen & Raphael, 2010). Although Saudi Arabia provides

free health care services to its citizens (Al Asmri et al., 2020), various factors including late

diagnosis of the infection, delayed implementation of infection control measures, and the use of

positive pressure ventilation allow superspreading event to occur in health care setting (Memish

et al., 2020). Thus, it is essential for health care institutions to implement stringent infection

control measures to manage and prevent the spread, for example, by establishing high degree of

awareness of MERS-CoV infection among healthcare workers, isolating confirmed or suspected

cases early preferably in negative pressure isolation rooms followed by proactive surveillance,
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increasing environmental cleaning, limiting the use of aerosol-generating procedures and

applying droplet and airborne precautions when managing infected patients including ensuring

mask-wearing for patients and health care workers (Hui et al., 2018). Furthermore, vaccines

should be developed and distributed to protect people at high exposure risk and the most

vulnerable population. Three types of vaccines are currently called for development, including

two human vaccines for long-term protection and reactive use in outbreak settings, and an animal

vaccine for preventing zoonotic transmission (Memish et al., 2020).

Education is another social determinant of health. One of the ways in which education

leads to better health is through understanding how to promote one’s own health through

individual effort (Mikkonen & Raphael, 2010). On an individual level, being aware of the harm

MERS-CoV infection could produce and knowing how to reduce risk can prevent transmission

within household and community (Hui et al., 2018). People, especially the ones with

comorbidities, should avoid close contacts with camels, practice regular hand hygiene, and avoid

drinking raw camel milk and ingesting undercooked camel meat. In addition, people should alert

their physician regarding the possibility of MERS-CoV infection if they experience suspicious

symptoms (Hui et al., 2018).

On a societal level, I believe nurses should urge the government to take measures in

implementing contact tracing, enact policy regarding quarantine and assist the most vulnerable

individuals in financial and mental crisis. Since spread cannot be controlled adequately by health

care system alone, in addition to working as a health care provider, nurses should also devote

their efforts in delivering public education and promote changes on a larger scale based on their

unique expertise to enhance the well-being of the whole society.

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References

Al Asmri, M., Almalki, M., Fitzgerald, G., & Clark, M. (2020). The public health care system

and primary care services in Saudi Arabia: A system in transition. Eastern

Mediterranean Health Journal, 26(4), 468–476. https://doi.org/10.26719/emhj.19.049

Ali, M. A. (2016). Gender dynamics and socio-cultural determinants of Middle East respiratory

syndrome coronavirus (MERS-CoV) in Saudi Arabia. University of Toronto Medical

Journal, 94(1): 32-37. https://utmj.org/index.php/UTMJ/article/view/258/223

Hui, D. S., Azhar, E. I., Kim, Y. J., Memish, Z. A., Oh, M. D., & Zumla, A. (2018). Middle East

respiratory syndrome coronavirus: Risk factors and determinants of primary, household,

and nosocomial transmission. The Lancet Infectious Diseases, 18, e217–e227.

https://doi.org/10.1016/S1473-3099(18)30127-0

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Mikkonen, J., & Raphael, D. (2010). Social Determinants of Health: The Canadian Facts.

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Müller, M., Meyer, B., Corman, V., Al-Masri, M., Turkestani, A., Ritz, D., Sieberg, A.,

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Khalili, S., & Simonsen, L. (2020). Comparing SARS-CoV-2 with SARS-CoV and
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World Health Organization. (2021). Middle East respiratory syndrome.

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