What’s going on in Iran’s Kerman Province?

If you have been following developments in the outbreak of MERS — Middle East Respiratory Syndrome — you probably think of Saudi Arabia when the topic of the new virus comes up. The Kingdom of Saudi Arabia has diagnosed far more cases of the disease than any other affected country, 721 to date. (297 of those cases have been fatal.)

But the huge surge of cases that KSA experienced between March and June appears to be subsiding. For the first time in months, the Saudis have gone two straight weeks without reporting a new case.

While that’s good news, there are some concerning developments across the Persian Gulf. In Iran’s Kerman Province, to be specific. If you look at a Google map of the Middle East, the peninsula that is Dubai points across the Gulf towards Kerman Province. (If you follow that link, Kerman’s borders are outlined in pink.)

Since mid-May there have been five confirmed MERS cases in the southcentral-Iranian province, the first reported in the country since the virus first emerged in 2012. That’s not a huge number. Still, there are worrisome features about these cases.

For starters, none of the people who’ve tested positive for MERS travelled outside the country in the lead-up to their infection. That means they caught the virus in Iran. Up till now, Iran hasn’t been seen as a place where MERS can be contracted.

What is considered most likely is that these people were infected by someone who had been to one of the countries where MERS cases are seen, places like Saudi Arabia or the United Arab Emirates or Jordan. And at least four of the cases can be linked to two people who had recently returned from religious pilgrimages to Mecca.

In one instance, two sisters — Iran’s first declared cases — reportedly had contact with a female pilgrim who had returned with a flu-like illness. Later, a female nursing assistant who treated one of the sisters was diagnosed with MERS.

Then in a seemingly separate event, a male health-care worker was diagnosed with MERS. He had no known contact with confirmed MERS cases, but he did help care for a man who returned from performing a pilgrimage in the first half of May. The male pilgrim was admitted to hospital May 17 with a severe respiratory illness. The pilgrim, who died, tested negative for MERS. But experts know false negatives can be a problem with MERS. If doctors swab a patient’s nostril when the virus is already deep in the lungs, they can get a false result. This man’s negative test, then, can’t be taken as a guarantee he didn’t have MERS.

Did the two pilgrims know one another? Were they part of the same travel group? Or did Iran see two independent importations of MERS in the same province within a period of a couple of  weeks? Answers to those questions aren’t currently available.

And this week there was news of a fifth confirmed case, in a 67-year old woman who suffered from chronic obstructive pulmonary disease, a debilitating lung condition. In early June, she spent eight days in hospital. While there, she was in contact with a patient who was suffering from a severe respiratory infection. The woman was sent home on June 14, but was readmitted to hospital on June 25. On July 5 she tested positive for MERS and died that same day.

Like the other confirmed cases, she had not travelled outside of Iran. So how did she get infected? Was it the patient with the respiratory illness? If that person had MERS, how did he or she catch it? Was he or she tested? If not, why not?

There are far more questions than answers at this point and the World Health Organization is asking them of health authorities in Iran.

Kerman Province is large and it’s not clear if all these infections have taken place in the same part of the province. If they all happened at the same hospital, the events might suggest the facility had an outbreak it hadn’t detected. As was seen in Toronto during the 2003 SARS outbreak, unrecognized cases can spread disease through a facility; finding the links between cases can be a real challenge. But until health officials find and isolate all cases in an outbreak, they can’t prevent onward transmission.

It’s important, therefore, to find out what is happening in Kerman Province. Perhaps there was limited spread that has since died out. After all, the most recent confirmed case, the 67-year old woman, was probably infected in the first half of June. But until authorities figure out how these patients contracted the virus, they cannot be sure there aren’t other infected people who haven’t yet been detected. If there is ongoing transmission of MERS in Kerman Province, even at low levels, that spread needs to be found and stopped.

I’ve put together a timeline of the Iranian MERS cases. You can see it here.