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Why the panic? South Korea’s MERS response questioned

BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h3403 (Published 24 June 2015) Cite this as: BMJ 2015;350:h3403

Rapid Response:

Preparedness of MERS outbreak in Nepal in low setting situation

It has already been established that MERS is a highly fatal respiratory disease caused by a novel single strained, positive sense RNA Betacoronavirus (MERS-CoV) which was first isolated in June 2012 in Saudi Arabia[1]. It has been spreading from the Middle East and in South Korea in May 2015 and now in China [2,3] and has already been established as a global outbreak threat, which can transfer from one person to another via direct or indirect source of human beings; however, the main mode of transmission is still unknown[1].

An estimated 500,000 Nepali migrants are working in Saudi Arabia and thousands more in other gulf countries[4] and South Korea as well (regions where there is MERS outbreak) and return back to Nepal every day. Nepal is a neighbour, as well as cross border country of China, where direct flights and direct transportation facilities are available. Therefore, there is more chance of MERS transfer from these populations, who travel via airlines or any other way to Nepal. However, the Tribhuvan International Airport (TIA), the countries only international airport lacks a proper quarantine health desk.Staffs of EDCD (Epidemiology and Disease Control Division) accuse the government for not providing an enough financial support to build a standard quarantine health desk at the TIA[5].

Nepal, where recent earthquakes killed nearly nine thousand people, displaced more than ten thousand, and destroyed a huge infrastructure[6]. No any considerable risk of infectious diseases has been noted to date[7]. The question that arises is can Nepal handle another outbreak? EDCD is the main responsible body for epidemic outbreak surveillance, outbreak preparedness, and control of disease in the country[8]. There is also one rapid response team (RRT) under the EDCD to control the outbreak. EDCD is getting technical as well as financial support by WHO, USAID, DFID and Global Fund to reduce the epidemic burden in the country[7]. However, the lack of trained human resources and epidemiologists to launch disease outbreak interventions are major drawbacks towards preventing the epidemic.

At present, Nepal has only one communicable disease hospital in Kathmandu. This national level hospital is run by the state, Sukraraj Tropical and Infectious Disease Hospital (STIDH)[9], which has not sufficient capacity to handle such kind of outbreak cases due to lack of infrastructure, insufficient drugs, and less equipped with a lack of well trained human resources. Almost a year before during the Ebola outbreak, doctors at STIDH stated that they lacked the diagnostic kits and separate quarantine wards for a possible outbreak, confirmed on even not having an ICU in the hospital and the financial aid provided by WHO 4 years ago for building an isolation ward was still unavailable to them[10]. Moreover, the staff are not well trained for these kinds of situations.

There is no any specific treatment for virus infection (MERC-CoV) till date. Therefore, preventive measures should be applied before incidences. Medical staffs should be properly trained about approaching the diseases. In addition, general public awareness program on preventive measures of the disease should be vigorously implemented. If MERS-CoV is suspected, there should be a proper policy, procedure available for rapid screening and assessment of disease and maintain the place to ensure rapid care of the patient and also minimize contact with other patients, relatives and family members along with health workers as suggested by the World Health Organization[1]. WHO has given more emphasis on those who are returning from the Middle East[1]. The number of migrant workers from the Middle East and South Korea returning to Nepal to see their beloved ones is increasing after the recent earthquake crisis. The country should focus more on screening of these populations and be prepared for a possible outbreak scenario.

References:
1) WHO. Middle East respiratory syndrome coronavirus (MERS CoV). (2015) http://www.who.int/mediacentre/factsheets/mers-cov/en ((accessed July 03, 2015).)
2) Su S., Wong G., Liu Y., Gao G.F., Li S., Bi Y. MERS in South Korea and China: A potential outbreak threat? (2015) The Lancet, 385 (9985) , pp. 2349-2350.
3) Andrew Jack.Why the panic? South Korea’s MERS response questioned, BMJ 2015;350:h3403
4) Kantipur Newspaper. Government to Sign Labour Pact with Saudi Arabia. 2014. http://www.ekantipur.com/2014/02/21/business/government-to-sign-labour-p... [Accessed on 05, July 2015]
5) Poudel Arjun. Nepal ill-prepared for the possible Ebola outbreak. 2015. http://myrepublica.com/portal/index.php?action=news_details&news_id=80880. [Accessed on 05 July 2015]
6) Neupane S.P. Immediate lessons from the Nepal earthquake (2015). The Lancet, 385 (9982) , pp. 2041-2042.
7) Basnyat B., Dalton H.R., Kamar N., Rein D.B., Labrique A., Farrar J., Piot P. Nepali earthquakes and the risk of an epidemic of hepatitis E (2015) The Lancet,
8) Department of Health Services (DOHS). Ministry of Health, Nepal. 2015. http://dohs.gov.np/divisions/edcd/ [Accessed on 07July 2015]
9) Sukraraj Tropical & Infectious Disease Hospital Teku, Kathmandu, (2015). http://www.istidh.org/ [Accessed 07 July 2015]
10) The Kathmandu Post. Plans need funding from the beginning, not when outbreak occurs. (2015) http://www.ekantipur.com/the-kathmandu post/2015/04/19/interview/plans-need-funding-from-the-beginning-not-when-outbreak-occurs/275569.html

Competing interests: No competing interests

02 August 2015
Gehendra B Mahara
PhD Research Fellow
Chhetri ,Jagadish K, MD - Department of Geriatrics, XuanWu, Hospital of Capital Medical University, Beijing, China
Capital Medical University, department of epidemiology and health statistics
10, xitoutiao, youanmen, fengtai district, beijing 100069. PR China