PHCM9788 Assessment 2 | Ruth Kusnadi
Question 1 (~ 600 words, plus one table) (40%)
MERS CoV
Originates in the Arabian
Geographic spread
Peninsula (1)
Lower likelihood of
Speed of spread
interhuman spread (2)
Those who are in contact
with the intermediate host
Locations of spread
(camels) (3) and close
contacts (1)
Higher infection rate in those
of older age, during outbreak
Risk groups week and nationality,
presence of co-morbidities
(4)
Case Fatality Ratios Approx. 40% (3)
Transmissibility and Lower transmissibility
secondary attack rates between humans (2, 6)
Respiratory (droplets) (7),
Modes of transmission
fomites (1)
Camels, which are
Reservoirs domesticated and are
central in the daily life (3)
Similar measures,
Availability of control
healthcare resources in the
measures
countries of origin differs (3)
Table 1. Differences and similarities between SARS and MERS.
MERS is less likely to cause a pandemic than SARS,(6) as MERS has a lower R0 compared
to SARS.(2, 6) In the future, it is possible that mutation can occur, which allow increased
SARS-CoV
Originates in Guangdong,
China (1)
Higher likelihood of
interhuman spread (2)
Those who are in contact
with the intermediate host
(civet cats) (3) and close
contacts (1)
Higher infection rate related
to occupational exposure,
older age, male sex,
presence of co-morbidities
(5)
Approx. 10% (3)
Relatively higher
transmissibility compared to
MERS-CoV (2, 6)
Respiratory (droplets) (7)
Civet cats, which are
nonessential in everyday life
(3)
Similar measures,
healthcare resources in the
countries of origin differs (3)
 PHCM9788 Assessment 2 | Ruth Kusnadi

virulence and survivability of the virus.(8) This hypothesis is confirmed by studies that have
found that virus that are taken from MERS patients are different from the ones isolated from
the camels.(3, 8) This means that it is possible that mutation occurs after the virus has made
the jump to humans. If the virus is able to be present in humans for a long time, it may adapt
and mutate further, and this may increase the R0 and likelihood of a pandemic.(8)
It is also important to consider the potential reservoir of MERS, a lot of which may still be
undiscovered as the transmission of this disease is yet to be fully explained.(2) An enhanced
understanding of the transmission of MERS will allow us to prevent humans from acquiring
the virus in the first place. Despite this, there are research gaps and lack of knowledge of
other intermediate hosts in which MERS-CoV can survive in. This may have fatal
consequences if the virus turns out to be able to replicate effectively in domestic animals,
such as cats or dogs.
Furthermore, limiting contact with reservoir animals is more difficult in MERS than in SARS.
Camels are an integral part of daily life in Saudi Arabia, while SARS-CoV’s intermediate host
of civet cats are not.(3) Pollack states that avoiding contact with civet cats can be more
readily achieved compared to camels, as the Middle Eastern population are dependent on
camels as transport and a source of economy.(3) Therefore, if the government were to
introduce a ban to be in direct contact with the animal reservoir, it may not be possible at all
in MERS-CoV’s case, as this can cause a major change in the population’s lifestyle and
might cause an outrage. This means preventing the viral jump to humans may be harder with
MERS compared to SARS.
A study by Park, et al states that the reproduction number (R0) of MERS differs in different
population groups and environmental settings.(4) Park mentions that the R0 of MERS was
higher in South Korea (2.05-8.09) compared to the R0 in Saudi Arabia (<1). (4) This is
compounded by the fact that South Korean cases are mostly nosocomial/secondary cases
which occur in healthcare settings. The same paper states that MERS is a slowly-transmitted
disease and this did not lead to a sense of urgency in public health awareness on the global
scale.(3) Because of this low awareness, countries that are not endemic with MERS will have
a delayed response once MERS is introduced in the country. This will allow MERS patients to
spread the virus to others, while healthcare workers may have not taken precaution when
handling patients who present with lower respiratory symptoms that are unknowingly infected
with MERS.
Lastly, even though SARS is more infectious than MERS, they are less deadly as evidenced
by its relatively low Case Fatality Rate.(3) Young people who are infected with SARS may
brush off their disease as the flu or the common cold, and continuously spread the virus to
unwitting risk groups, whereas MERS infections are more likely to cause an overt clinical
disease and this will raise the suspicion of healthcare professionals and indicate laboratory
testing and concurrent isolation and infection prevention measures. These points support the
fact that MERS-CoV has a lower chance of becoming a pandemic than SARS do.
 PHCM9788 Assessment 2 | Ruth Kusnadi

As a conclusion, there are still many unknowns in the pathophysiology and transmission of
MERS. There should be more research focused on the method of transmission of MERS. By
knowing this, policymakers and healthcare organisations can develop suitable guidelines,
and create more awareness in order to prevent a future pandemic.

Question 2 (~300 words) (20%)

PREVENT: Setting policies in order to reduce zoonotic transmission (9) and

developing effective primary preventions (such as vaccines)
Out of the methods of prevention outlined by Frieden, methods that might be effective in
preventing MERS infections are through setting policies to reduce zoonotic-acquired infection
and to give immunity to those who are in contact with animal reservoirs in the form of
vaccines. (9, 10) As mentioned in the previous question, setting policies to reduce contact
with camels might be drastic, given how important camels are in the daily life of the
population of Saudi Arabia. (3) Therefore, it may be more plausible to develop vaccine either
for the reservoir animals or for humans, as this do not alter the cultural practice and perhaps
is more acceptable to the public.

DETECT: Lack of awareness of MERS among healthcare workers (11) and the general
public (12)
A study by Lee finds that the knowledge of MERS among healthcare professionals is
poor.(12) This can be improved by ensuring that all health professionals take travel history for
every patient they see, as suggested by the study by Al-Tawfiq, et al.(11) Therefore, it is
crucial that health professionals are made aware of MERS through their Continuing
Professional Development or through announcements made by the Department of Health.
Additionally, we can also educate the people at risk of being in contact with dromedary
camels to actively inform healthcare professionals of their travel and contact history.

RESPOND: Improved national and international preparedness plans (13)

Avoiding person-to-person transmission is crucial in preventing a MERS pandemic, as the
reservoir animal is not globally-spread. It is crucial that countries have a preparedness plan in
the case of a MERS case being identified.(13) This will limit the risk of spread within the
community and allow countries to contain the outbreak as soon as possible.
 PHCM9788 Assessment 2 | Ruth Kusnadi

Question 3 (~ 600 words, plus one table/ figure) (40%)

HAZARD ASSESSMENT
Hazard assessment can be undertaken by taking the patient’s complete history and through
the PCR results. From the latter, the risk assessment team should determine the genotype of
the virus and the virulence of the virus.(14) Both of these should be used to confirm the
source of infection.
Furthermore, the genotype sequencing should be compared to both human cases and virus
strains found in camels in Saudi Arabia. If the virus strains are found to be similar, we can
assume that the virulence and rate of spread and severity of disease to be the same as
cases from Saudi Arabia. Despite this assumption, this is not a foolproof way to predict the
virulence of a virus strain, as a study has shown that the R0 varies in different country
settings and demographics.(4) A study by Breban shows that even at its most pessimistic the
R0 remains below 1 and an epidemic is unlikely to occur.

EXPOSURE ASSESSMENT
Spread of MERS can only occur from person-to-person contact in Australia. It is therefore
crucial to perform contact tracing and regular monitoring (or isolation of) the contacts. Those
who are in close contact with the patient should be monitored closely as they are likely to
have been inoculated a large number of virus. Although the patient was asymptomatic during
the flight to Sydney and cannot transmit the disease during these times, (15) the healthcare
professionals treating the patient and people who were waiting in the general practice waiting
room and in the emergency department could have been transmitted MERS if they had been
in close contact with the patient.(16) A South Korean study found that R0 ranges from 2.5 to
8.09 in the early stages of the disease,(4) and this may have dire consequences as the
people who are visiting the GP and Emergency Room may have co-morbidities which
increase their chances of being infected with MERS.(17)
 PHCM9788 Assessment 2 | Ruth Kusnadi

CONTEXT ASSESSMENT
In the technical aspect of STEEEP, the Department of Health have delineated appropriate
measures to take when there is a suspected case of MERS.(15) It may be safe to assume
that the Sydney Local Health Districts have adequate infrastructure and funding to carry out
these measures and prevent further spread of MERS once the diagnosis was made.
The Australian Department of Health have guidelines regarding screening travel history from
patients who have lower respiratory symptoms and fever,(15) but it is unknown whether
healthcare professionals are aware of this or not. As evidenced in this case, there had been 3
GPs and an emergency room physician (or triage team) who had failed to put MERS-CoV
infection on their differential diagnosis lists. This proves that the knowledge of MERS-CoV is
poor within the Australian health professionals and there could be more cases of MERS-CoV
in the future, unless something is to be done.
The social, economic, environmental, ethical and policy/political factors would have minor
impact. The patient would be isolated for a time, and possibly without any out-of-pocket fees.

OVERALL RISK OF A LARGE OUTBREAK OF MERS IN AUSTRALIA

Figure 1. Risk Characterisation of a MERS outbreak in Australia showing a moderate overall risk.
 PHCM9788 Assessment 2 | Ruth Kusnadi

Despite the poor awareness of MERS among healthcare professionals, Australia’s healthcare
infrastructure is adequate to contain outbreaks and conduct surveillance. Additionally, MERS-
CoV itself has a low R0 and does not have a potential to become an epidemic. As a
conclusion, there is moderate risk to a large outbreak of MERS-CoV in Australia if the
Department of Health does not respond adequately to the situation.

CONFIDENCE IN ESTIMATE
Hazard assessment and exposure assessment have high level of confidence as they are
based on official genetic database and peer-reviewed studies. It is important to note that the
R0 study was conducted in South Korea and may have limited applicability in Australia due to
different healthcare systems and demographics.
Context assessment for this risk assessment are based on inference as it was based on
presumption that the knowledge of the 3 GPs who the patient visited are representative of all
GPs in Australia. Context assessment can be considered as low-level confidence.
 PHCM9788 Assessment 2 | Ruth Kusnadi

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