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Eight More MERS-CoV Confirmed Cases In Jordan ICU

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    Posted: June 18 2013 at 5:18am
This is from niman, but is a little confusing.  Do we have 8 more cases in Jordan?  I agree with niman in that this raises serious transparency issues - and the situtation is most likely significantly worse.  MERS is probably somewhat out of hand.


Eight More MERS-CoV Confirmed Cases In Jordan ICU
Recombinomics Commentary 23:15
June 17, 2013

  1 25 M 3/21 4/04  4/25 Student Deceased Confirmed
  2 30 M 3/30 4/08  4/23 Apr Nurse Alive Probable
  3 40 F  4/02 4/09 4/19 Nurse Deceased Confirmed
  4 60 M 4/02 Refused admission – Physician,internist Alive Probable
  5 29 M  4/11 4/15 4/21 Nurse Alive Probable
  6 33 M  4/12 4/14 4/21 Nurse Alive Probable
  7 28 M  4/13 4/17 4/21 Nurse Alive Probable
  8 45 M  4/14 4/17 4/24 Road tech (brother of case 3) Alive Probable
  9 46 M  4/15 4/16 4/21 Nurse Alive Probable
10 25 M  4/15 4/18 4/21 Nurse Alive Probable
11 53 M  4/18 4/21 4/23 Physician, internist Alive Probable
12 28 F  4/19  Refused admission – Nurse Alive Probable
13 60 F  4/26  5/01 5/05 Housewife (mother of case 2) Alive Probable
 
The above list from EMRO supplement provides age, gender, and disease onset dates for the 13 confirmed or probable MERS-CoV cases linked to an ICU outbreak in Jordan over a year ago. The recent release of this data raises serious transparency issues, and confirms the clear human to human (H2H) over a year ago.  The gaps in disease onset dates among the health care workers (HCWs), as well as their contacts, was expected from contemporary media reports, which described a large ICU outbreak of a SARS-like illness. 

HCWs complained of a lack of protective masks, which were denied due to concerns that patients would be alarmed.  The HCW concerns and complaints increased markedly when the second death was announced.  The HCWs referred to the fatal cases as a student, as well as a colleague, suggesting he had a relationship with the ICU HCWs.  The report describing the above case was from an epidemiological investigation that happened long after the fact, and interviews were not made with relatives of either of the confirmed / fatal cases, although the lack of use of gloves was noted (which was also due to concerns that patients would be alarmed).  Similarly, the linkage of the second death to the earlier cases was denied because of cardiac involvement, which was not present in the other cases.  However, they all had pneumonia, and the cases who recovered had a wide spread in hospitalization days.

The outbreak was reported by ECDC in May of 2012, which cited the death of the nurse as well as involvement of 1 doctor and 7 nurses.  However, attempts to identify the etiological agents failed, and new cases were not reported after the early May case cited above, so interest waned until a novel coronavirus was identified in the fall.  Retesting by NAMRU-3 confirmed MERS-CoV in the two fatal cases, but due to limited samples, the surviving cases were not confirmed.  WHO issued an update and classified the cases linked to the confirmed cases as probable and noted that the infections of the two family members was likely due to human to human (H2H) transmission.

However, the number of probable cases was not released and the data displayed above was withheld.  The disease onset dates clearly supported extensive H2H transmission beginning in March with the student, leading to infection of a subset of HCWs followed by a gap and a second extended wave of infections in the ICU.  The length of the second wave supported infection of the later cases by the earlier cases, and the family member at the end of the transmission change represent further onward transmission.  The multiple transmission events in an ICU were similar to SARS-CoV HCW outbreaks in 2003.  However, this type of transmission was not described in the WHO reports, which was hidden by the withholding of the disease onset dates.  Release of the above data in 2012 would have muted the various story lines claiming no H2H transmission and sporadic cases due to animal exposures.

The Jordan cluster had no linkage to animals and was clearly due to H2H transmission, although WHO has repeatedly claimed that a common source could not be excluded.  However, none of the disease onset dates supported a common source other than the index case or other HCWs.  Similarly, ECDC produced a risk analysis that claimed there were no mild MERS-CoV cases because all cases were sporadic and due to animal exposure.  When the Jordan fatal cases were confirmed, ECDC largely ignored the probable cases, which thoroughly refuted the basic foundation of their risk analysis.  They started a list of confirmed cases, which represented the Jordan outbreak with 2 fatal cases.

However recently Jordan sent to the US CDC serum samples from 124 people linked to the ICU outbreak.  Media reports note that there were 8 additional positives (in addition to the 2 previously confirmed cases).  The 8 newly confirmed cases include 6 who were symptomatic as well as a health care worker and a contact.  Since all of the probable cases were symptomatic, it seems that the 6 cases were from the above list and the 2 asymptomatic cases would represent new cases which were neither confirmed nor probable.  Alternatively, the 6 symptomatic cases may have been other patients who were not identified by the epidemiological study and the 2 cases which were HCWs or contacts were included in the above list.

Clarification of the relationship of the 8 newly confirmed cases with the probable cases listed above would be useful.
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Post Options Post Options   Thanks (0) Thanks(0)   Quote Albert Quote  Post ReplyReply Direct Link To This Post Posted: June 18 2013 at 5:35am

MERS cases, deaths climb; study examines viral loads

Robert Roos * News Editor

Jun 17, 2013 (CIDRAP News) – Saudi Arabia reported three more MERS-CoV (Middle East Respiratory syndrome coronavirus) cases and four more deaths yesterday, raising the global tally to 64 cases and 38 deaths.

In addition, a Jordanian official said today that antibody tests showed that the first known MERS-CoV case cluster, which occurred in a Jordanian hospital in April 2012, involved 10 cases, 8 more than previously confirmed, according to a Canadian Press (CP) report.

Meanwhile, a report in Lancet Infectious Diseases today described the MERS viral load in a patient who was treated in Germany, yielding data that may help explain why the virus seems to spread less readily than did its cousin, the SARS (severe acute respiratory syndrome) virus.

New Saudi cases
The Saudi Ministry of Health (MOH) announced the three new cases and four deaths yesterday, and the World Health Organization (WHO) noted them in a statement today. The deaths came in previously reported cases.

The MOH and WHO said one of the new cases involved a 42-year-old male Saudi citizen in the Eastern region who has chronic asthma and is hospitalized. A second case-patient is a 63-year-old Saudi woman who is from the Riyadh region, has chronic diseases, and is in an intensive care unit (ICU).

Also in an ICU is the third patient, a 2-year-old who is from Jeddah and has chronic pulmonary disease, the MOH and WHO said.

The four patients who died include two from Taif, which is near Mecca, and two from the Eastern region, the MOH announced. The agency had announced two cases in Taif on Jun 14, in a 65-year-old man and a 68-year-old woman, saying both were in intensive care. The MOH has not said whether the two Taif cases were linked or separate.

In another development, Saudi authorities have urged domestic and foreign Muslim pilgrims to postpone their Hajj and Umrah visits to Mecca this year, according to media reports. The authorities cited ongoing expansion at Mecca's Grand Mosque as the reason for the advisory, but it seems likely to prompt speculation that MERS may be a factor.

In announcements on the Holy Qur'an television channel, based in Mecca, authorities advised pilgrims to postpone their plans in the interest of reducing congestion at the Grand Mosque, according to an AllAfrica.com report today.

An official with the Hajj and Umrah Committee of the Mecca Chamber of Commerce and Industry said the area where pilgrims congregate can now accommodate only 39,000 people per hour, but that will increase to 130,000 per hour after the expansion is completed, the story said. He advised pilgrims to postpone their visits for a year or two.

Eight more in Jordan outbreak
Concerning the Jordan case cluster, Dr. Mohammad Al-Abdallat of Jordan's Ministry of Health said tests of blood samples from 124 people revealed that eight had antibodies to MERS-CoV, according to the CP report. Previously only two cases, both of them fatal, in the cluster had been confirmed.

The Jordanian outbreak was a mystery when it occurred in April of last year. But samples from the patients were stored, and after MERS-CoV was described in September, tests led to confirmation of the two fatal cases.

In an initial report on the illnesses, the European Centre for Disease Prevention and Control had said they occurred in a hospital ICU and involved 11 people, including 8 healthcare workers.

In a report last December, the WHO said the cases in the Jordanian healthcare workers were probably caused by the novel virus. The cases suggested that MERS-CoV illnesses are not always severe, the agency said

Al-Abdallat said the eight newly confirmed cases involved 6 people who were sick at the time of the outbreak, 1 healthcare worker, and 1 household contact of a confirmed case, according to the CP story.

The antibody study was a joint effort of the Jordanian health ministry and US Centers for Disease Control and Prevention, the story said.

The story noted that if the WHO adds the 8 cases to its MERS-CoV count, the tally will increase to 72, with the death toll staying at 38.

Analysis of viral loads
The Lancet Infectious Diseases report describes the case of a 73-year-old man from the United Arab Emirates who was treated in Munich in March. The researchers, led by Christian Drosten, MD, found the virus in the man's stool and urine, but at low levels that don't suggest a high infection risk from those sources.

The man, who had been diagnosed as having multiple myeloma in 2008, fell ill with a fever and cough on Mar 8, the report says. Relatives said he owned camels and had taken care of a sick one shortly before his symptoms appeared, but the authors were unable to obtain any animal samples or other details about possible exposures.

The man was transferred to Klinikum Schwabing in Munich on Mar 19, the 11th day of his illness. On day 14 he had renal failure and required dialysis, and 4 days later he died of septic shock.

Fourteen healthcare workers who had contact with the patient reported mild respiratory symptoms during or shortly after his treatment, but none tested positive for MERS-CoV.

In studying the patient's viral loads, the authors found that levels of viral RNA were highest in samples from his lower respiratory tract, a finding also reported in other MERS-CoV case reports. Viral material was found in urine on days 12 and 13 of his illness, but not on day 14, after renal failure.

In addition, viral RNA was found in stool samples taken on days 12 and 16, and one of two oronasal samples taken on day 16 contained evidence of the virus, but at low levels. The virus was not found in his blood. Also, the investigators were unable to isolate the virus.

"Our data for stool, urine, and blood samples suggest a fairly low infection risk during non-respiratory care procedures," the authors write. But they caution that the patient had an underlying disease that could affect virus shedding and that their virologic monitoring began late in the patient's disease course. Data from many patients will be needed to better define shedding patterns, they comment.

They also observe that SARS patients often had high viral loads and prolonged shedding of virus in stools, which led to the routine use of stool samples for diagnostic tests. In contrast, the viral load in their patient's stool was close to the lowest detectable level. SARS spread quickly to dozens of countries in early 2003, resulting in more than 8,000 cases and about 800 deaths.

"Stool samples from many patients, including those with early stages of disease, should be tested to assess whether faecal sources could have a role in transmission, or whether MERS-CoV differs from SARS in this respect," the authors write.

In other efforts, the authors sequenced the virus's genome and ran a phylogenetic analysis based on it and four other available MERS-CoV genomes. From this, they concluded that the common ancestor of the five isolates dates to mid-2011, about a year before the first known cases occurred in Jordan.

In an accompanying editorial, two French experts, Benoit Guery, PhD, and Sylvie van der Werf, PhD, say this finding suggests that the virus could have spread unnoticed during that interval.

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Post Options Post Options   Thanks (0) Thanks(0)   Quote coyote Quote  Post ReplyReply Direct Link To This Post Posted: June 18 2013 at 6:15am
ProMED: MERS-CoV - Eastern Mediterranean (31): Jordan, retro. case ID, WHO, RFI
A retrospective study has shown that the earliest known outbreak of the MERS coronavirus infected at least 10 people (Snip). Two of those cases, from an outbreak in Jordan in April of 2012, have been previously reported [Novel coronavirus - Eastern Mediterranean: WHO, Jordan, conf., RFI 20121130.1432498].

An official of Jordan's Ministry of Health revealed the news today [17 Jun 2013] in an interview from Amman. Dr. Mohammad Al-Abdallat says blood samples from 124 people were tested for antibodies to the Middle Eastern respiratory syndrome coronavirus.

He says 8 people tested positive, including 6 people who had been known to be sick at the time of the outbreak, one health-care worker and one household contact of a confirmed case.

The 2 previously confirmed cases died at the time of the outbreak but were confirmed later using samples that had been stored.

The study was a joint effort by the Jordanian health ministry and scientists from the U.S. Centers for Diseases Control [and Prevention] [CDC] in Atlanta.

The additional cases, if added to the World Health Organization's global tally, would bring the global count to 72 cases, 38 of which have been fatal.

The cases in Jordan occurred at Zarqa, southwest of Amman. The outbreak happened before the existence of the new virus was recognized. At the time, no cause for the cluster of severe pneumonias was identified.

Continued with lots more information: http://www.promedmail.org/
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Post Options Post Options   Thanks (0) Thanks(0)   Quote Albert Quote  Post ReplyReply Direct Link To This Post Posted: June 18 2013 at 6:30am
We updated the totals to reflect 72 / 38.  No sense in waiting for the WHO to catch up with updating the totals in this case.   For the WHO to add the other 8 could take a day or two as they're probably really busy, doing something. 

CIDRAP is doing a good job staying on top of it. 


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Post Options Post Options   Thanks (0) Thanks(0)   Quote Pixie Quote  Post ReplyReply Direct Link To This Post Posted: June 18 2013 at 11:42am
Info on the 2012 outbreak Jordan...
Hospital injuries rise to 16 cases of blue
 


Amman, Zarqa, Irbid Constitution Kausar Sawalha and Zahi Raja and Suhaib hill escalated the crisis pneumonia that appeared in the hospital blue state, while continued assurances to the Ministry of Health that it is worrying, recorded new cases of the disease for a doctors in the Department of Internal Medicine at the hospital yesterday morning. was symptoms, the doctor is the same that appeared on the injured ex-medical staff, where the transfer of the doctor patient to deal in Prince Hamzah Hospital, while showing injury a close brother nurse deceased which also receives the necessary treatment, according to medical sources, in addition to wounding a third one of the workers in the the hospital and receiving treatment in a hospital in the Mount of Olives. Based on the repercussions of the position held and the Minister of Health, Dr. Abdul Latif Wreikat a press conference today at noon to talk about the subject and مستجداته and clarify many things about what happened and what the nature of the disease. Secretary-General of the Ministry of Health, Dr. Daifallah Lozi between that the results of laboratory tests will appear - at the latest - within 48 hours, and aims to know the type of virus and the severity and seriousness. announced Lozi in a press statement that all pneumonia from a cadre Hospital blue state fully recovered from the disease. said that nurses six who were transferred treatment at Prince Hamzah Hospital discharged from hospital after recovery complete. added that the health status of the brother of a nurse who died of good and it will leave the hospital after testing the final confirmation of full recovery. pointed Lozi that the ministry has taken all preventive measures and treatment since the registration of the disease among the cadre Hospital blue state . stressed that the procedures for infection control implemented strictly in the hospital, assured that the situation in which good and it receives patients on a regular basis and it is not dangerous for them or the staff working in the hospital. stresses the Ministry of Health that pneumonia disease seasonal can appear cases of multiple like this season and that the ministry is able to deal with this disease and the treatments available to it, describing the injuries as an uncontrollable pandemic. Underscoring the number of medical staff that the situation «troubling and flawless misty». While confirming the Ministry of Health that laboratory tests performed in the central laboratory and university laboratories, sources confirm other medical conditions that the samples sent to the three countries in order to ensure the examinations and show cause real illness, which suggests a number of signs that the problem in the disease (pneumonia) that resistant to treatment. among Followers of the state nurse deceased, which was the first infected, the symptoms appeared in the second of this month, has suffered from high temperature, cough and stayed ten days they suffer without that there will be no improvement in the condition, noting that they were treated with antibiotics without there being any result remember or improvement occurs to the condition, which led to the transition to a private hospital for treatment, but they moved to the mercy of God after the failure to control the progression of the disease. The Ministry seeks to know the basis of the transmission, indicates workers in a hospital in blue to the possibility that the infection has moved from the status of a migrant Asian, had entered the hospital in bad condition and very suffering from similar symptoms in high temperature, where it remained in intensive care and died without is to know the real reasons behind her death. among hospital staff to what is likely the health of this possibility is that the staff with the disease is the staff who oversaw the treatment expatriate Asian. Several of the hospital staff that «the slow pace of the Ministry of Health» - as described - is what led to an increase in the incidence of the fact that the nurse was the first infected and then rolled injuries one after the other, asserting that the injuries exceeded the 15 cases, and it exceeded the medical staff and went to the injury of one workers security and protection and cleaners, that «the virus spread in the hospital». Insiders said Hospital in blue state that turned into a «ghost town», where during the hospital who had to review it, and have not been the only one process for those injured in a car accident, after it was normal for a surgical procedure ranges between 20 to 25 surgeries a day, as saying. In this context, confirms citizens and hospital staff blue need to «remove the hospital out of existence» he became «focus and B», pointing out that hygiene non-existent in all its facilities, in addition to the poor condition of the hospital building, which said it will not work with any kind of Maintenance and restoration. They pointed to me that often overflowing sewage on the sections of the hospital without being disinfected or cleaned properly, which makes it natural - as they say - that the place is full of diseases and viruses. hospital blue, which became empty except for a few cadres medical and staff after he was full of energy and movement and activity by the reviewers patients and visitors, abandoned patients and fled from the precincts and corridors visitors and reviewers for fear of contracting the disease pulmonary mysterious, which hit 8 of its cadres medical and nursing staff and led to the death of a nurse working. While disappeared the movement of reviewers, active the movement of medical personnel from the Ministry of Health after it was isolated many departments and initiated work sterilizing different sections in an attempt preventive action in order to control the situation which triggered panic among the citizens, employees and medical staff alike. was last steps that were made ​​yesterday that it was evacuating all injured to a hospital in Prince Hamzah Although laboratory tests still did not specify the type of disease that leads to disruption of the lungs and the concomitant rise in temperatures, which led to a state of confusion and frustration among reviewers and patients. was rumored among citizens in the blue state of fear similar to prevail in inside the hospital, citizens fear that the disease is transmitted to the outside of the hospital to become a community. The rumors began to move among the people about the sources of the disease. news spread of the disease and the death of the nurse pushed a large number of people of the blue to evacuate their patients and take them to hospitals in the private sector, where the contraction or almost uninterrupted number of patients to emergency clinics, which are almost empty for fear of the pandemic virus, and now the majority conditions heading into the top overall health or outpatient clinics of the hospital in the neighborhood of Prince Mohammed and the Batrawi. practiced medical staff of the remaining work amid great keenness to wear protectors Wellness (masks) as a precautionary measure to prevent infection, while declined to some medical personnel for Following the announcement of the work the event of death. known for its blue Hospital which was built about sixty years ago, it testifies populous in the number of patients being the only public hospital that serves the city of Zarqa estimated population of about one million people. He used the hospital to record the largest number of Alemrajaan to divisions and private clinics, where she was Adkhalath experiencing percentages exceed 100% of its capacity. Moreover, Al «constitution» from medical sources informed that a report prepared about injuries Hospital blue state handed over to the competent authorities, and that the information Initial nominated report attributed the causes of injuries the hospital to the non-application of procedures for infection control in it and that the development of sterilization in the unit intensive care where the situation is very bad, and does not apply the protocol sterilization adopted in such units. The report stated that the injuries are considered an outbreak is limited and not « pandemic », which requires follow-up and verification and vigilance to prevent the transformation of this outbreak limited to a pandemic. The report indicated that causes germ that hit the cases of hospital blue state is not clearly defined, and that there is laboratory testing conducted in the laboratories of several in the kingdom, including laboratories Hospital founder King Abdullah University at the University of Science and Technology of Jordan and laboratories of the Ministry of Health and laboratories outside the Kingdom, likely the results of these tests in the near future to determine the nature of the bacterium. The report pointed out that in the event to keep the proceedings infection control in many hospitals for what it is, it threatens the emergence of pandemics future unknown parameters can not be predict Bmdaha and its repercussions on the health of citizens. Meanwhile, well-informed medical sources said that there was a marked increase in the number of pneumonia cases in various hospitals in the Kingdom for various reasons, including the volatility of weather developments. She drew these sources should not be confused with what happened in the hospital Ramtha Hospital and blue government, stressing that the link between them is the link time only and it is nothing to do with medical between what happened in the two hospitals. asked these medical sources capacity of health systems used in hospitals and the Ministry of Health conduct epidemiological surveys and post-effective linking of cases recorded different germ causes that could lead to a pandemic.


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Post Options Post Options   Thanks (0) Thanks(0)   Quote Pixie Quote  Post ReplyReply Direct Link To This Post Posted: June 18 2013 at 12:06pm
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Time: 11:01 pm
The death of a child mysterious illness in Ajloun ..!

Rum - Rakan Gaddah
Child died at the age of 8 years yesterday evening in the Kufranja Brigade Ajloun Governorate after bird flu sharp rise in temperatures and severe pneumonia as confirmed by medical sources Rum's Health Directorate in the province.
The sources said that the child اسعفت to a Kufranja health center after being struck with acute pneumonia accompanied by a significant rise in temperatures, but it has reached متوفية.
Other sources confirmed that the symptoms that appeared on Alotflhy similar to those symptoms that appeared on some of the nurses in the hospital blue state wondering about the procedures carried out by the Ministry of Health to find out the cause of death and precautionary measures undertaken by with her family to make sure not diagnosed with the same disease, God forbid.
Indicated that the disease vague appeared in recent Alakhirhy suffers Massaboh of severe pneumonia and high temperatures were wounded by 8 of the workers in the hospital blue state and died on its impact on one of the nurses infected and died a child in Ramtha and wounded 5 others with the same disease and that person doctors case of the girl in recent Hospital Ramtha Balshaaa the only one that has not been explained so far is a disease that has become kills Ppalardnin and victims a day goes ..

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Post Options Post Options   Thanks (0) Thanks(0)   Quote Pixie Quote  Post ReplyReply Direct Link To This Post Posted: June 19 2013 at 5:42am
 
JEDDAH: ARAB NEWS
Wednesday 19 June 2013
Last Update 19 June 2013 3:02 am
A Jeddah health official rejected a report that a two-year-old boy in the city has fallen prey to the deadly Middle East Respiratory Syndrome Coronavirus (MERS).
This denial from the Director of Health Affairs in Jeddah Dr. Sami Badawood is contrary to the statement issued by the Ministry of Health on Monday on its website that a boy was undergoing treatment for the disease at a hospital in Jeddah.
“If any person is found to have contracted the disease, he will be admitted to the isolation wards found at all hospitals in Jeddah to treat patients with contagious diseases,” a local newspaper reported Badawood as saying.
He said that private hospitals were instructed to refer any patient with MERS to a government hospital.
The disease has killed 32 people out of 49 infected in the Kingdom, according to the statement from the ministry. It said that three new infection cases were reported in Riyadh, Jeddah and the Eastern Province.
Supervisor General of the Regional Laboratory and Blood Banks in Jeddah Dr. Saeed Al-Amoudi said the laboratory did not receive blood samples of any two-year-old child affected by the virus. “None of the samples of suspected cases sent to the laboratory from government and private hospitals tested positive for MERS,” he said.
He added that the laboratory received between four to 15 blood samples sent from different parts of the Kingdom daily. “It takes eight hours to test a sample, while including routine formalities it could take up to 16 hours,” he said.
Examining doctors refer patients for blood tests if they suspect they are infected
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Post Options Post Options   Thanks (0) Thanks(0)   Quote EdwinSm, Quote  Post ReplyReply Direct Link To This Post Posted: June 21 2013 at 10:22pm
These 8 cases, retrospectively found because of anti-bodies in their system, had been entered into the WHO statistics as 'probable'.  The tests should have resulted in WHO recording them as confirmed, but this has not happened.

Have these cases fallen foul of the very strict ruling of WHO that there needs to be confirmation from two laboratories?   If the Jordan samples have only had one test there is no way they will be accepted as 'confirmed' cases unless someone else tests them. 

The WHO rules are a very clever way to a) keep numbers down, while disclaiming any responsiblity for under-reporting (as they are only repeating what the various countries'  Health Ministries haave said) b) delaying any bad news as the second test would only be carried out after the first.  c) insured that in a pandemic situation we would never know the numbers because the labs could not keep up with the demand for testing.

I would love to see the lists that WHO has of what they think is happening including their 'probable cases' .


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