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Conversations with the Director: Daniel Payne

November 21, 2013

Discussing 'Art of Collaboration' in Jordan MERS-CoV Investigation

Daniel Payne, CDC Director Tom Frieden

Daniel Payne walked into the conference room with CDC Director Thomas Frieden, MD, MPH, ready to share stories and answer tough questions during a Conversation with the Director.

Daniel Payne walked into the conference room with CDC Director Thomas Frieden, MD, MPH, ready to share stories and answer tough questions during a Conversation with the Director. With his razor stubble and open collar, Payne looks more like Hollywood's casting choice for the role of a private eye or crusading journalist rather than an epidemiologist. But looks are deceiving.

Payne is an expert in his field, and he came prepared. He brought scientific articles that he and colleagues had published earlier in the year in The New England Journal of Medicine and Clinical Infectious Diseases, and the current edition of Emerging Infectious Diseases, for which he has served as a guest editor. He also gave Frieden materials from a Middle East Respiratory Syndrome Coronavirus (MERS-CoV) outbreak investigation that he led in Jordan in the spring.

Frieden listened intently, and occasionally jumped in with questions. Payne described the fruits of investing in scientific collaboration. He currently leads a large, pediatric viral disease surveillance system called the New Vaccine Surveillance Network. This network of research sites is now in its ninth year of studying the burden of pediatric viruses, including gastrointestinal viruses on young children, and the impact and effectiveness of vaccination in protecting children against these viruses. The many pediatricians, virologists, laboratory specialists, and epidemiologists who are part of the seven participating research sites have published more than 50 studies using NVSN data.

Payne said that, "Since many gastrointestinal viruses are not commonly detected in routine clinical practice, we proactively collect data on them through a surveillance system. With about a dozen CDC staff working on the project and about 100 staff at large US medical institutions contributing their efforts, just managing the network provides an incredible opportunity for scientific collaboration."

After a half hour of this discussion, Payne launched into what had driven his invitation to talk with Frieden: a sero-epidemiologic field investigation for MERS-CoV that he led in Jordan.

"It really was a successful mission," Payne said. "And obtaining any new knowledge of this emerging and elusive virus is a success in itself."

"Well, Jordan has been a very good collaborator, right?" Frieden commented.

"Fantastic. We were warmly received, and it was a productive work environment for our investigation team. We felt that anything that we asked for, we were provided. Overall, we had a wonderful collaboration with the Jordan Ministry of Health, as well as with several important regional partners."

An outbreak of severe, unexplained respiratory disease had occurred at a northern Jordanian hospital in 2012. "Only upon the discovery of the new virus later that year, and the subsequent testing of archived specimens, did we retrospectively determine that this respiratory disease outbreak in Jordan had been associated with MERS-CoV," Payne said. "We realize now that this was the first known instance of a MERS-CoV outbreak." The finding was important, because ten years prior, another coronavirus called Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV) caused a global epidemic of severe respiratory illness. The Jordanians invited CDC to join this investigation after serologic tools had been developed. "The only way to really retrospectively determine what had happened during this first known MERS outbreak was through serological antibody tests. And those tests were rapidly produced here by a team of CDC laboratory experts led by Dr. Lia Haynes and were ready by the time we were invited."

Payne recounted the difficulty of retracing the outbreak's progress amid less than ideal infection control conditions in Zarqa, a major industrial city northeast of Jordan's capital of Amman. He described how the investigation team toured the hospital wards on the first day in the field. They walked into a patient care room and, upon hearing the Arabic translation, they realized they were standing where the first people with MERS-CoV infection had received care. For a disease that kills over half of those known to be infected, it was a chilling visit and had him lying awake for the next few nights at the slightest sense of a cough. He praised the public health response of the Jordanian Ministry of Health once they grasped the severity of the outbreak.

"If you look back at the local press reports from the time, there actually were concerns that SARS had returned," Payne said. "They knew they had something infectious and severe."

"So, they controlled it without knowing what it was," Frieden said. "What did they do?"

"In order to halt transmission, they referred their entire critical and intensive care patient population in one fell swoop to a facility where the patients could be isolated."

Frieden was interested in the first identified MERS-CoV case and the possibility that the virus can jump from animals to humans.

"No one really knows how the first cases were exposed," Payne said. "There are new reports of camels that have tested positive for antibodies to MERS-CoV. However, many of the patients from the outbreak live in industrial areas and do not have contact with camels, sheep, or any other animals."

Bats provided a possibility, but proved difficult to determine.

"There is bat genome in MERS-CoV," Payne said. "So, we were asking everyone during our interviews, 'Have you seen bats nearby?' Usually people had not, until the husband of one of the first cases responded that, 'Yes, there is a bridge near our house [that housed a bat colony].' His wife would often go by it on her way in to work. So, after the interview we went directly to this site, peering into recesses in the bridge, looking for signs of animal habitation, and taking photos of possible bat nesting areas that we could send to veterinary epidemiologists for their review. But, we couldn't find any apparent link there, and hit a dead end zoonotically."

Frieden pointed to another mystery: Why didn't the disease take root in any of the hospitals that transferred MERS-CoV patients? The team took blood samples from 89 healthcare workers, both at the outbreak hospital and at the transfer hospitals. "We found no other evidence of infections among healthcare workers at the transfer hospitals," Payne said.

"That's interesting and encouraging," Frieden said. "So, you had cases among outbreak hospital workers but none at the transfer hospitals where patients were isolated. That's an important finding: if you do a good job with infection control, things can turn out okay."

"Exactly," Payne said. "Although we may not yet know the source of the cases, if you follow proper infection control procedures, you may be able to keep transmission under control. One conclusion that we drew from this experience is it wasn't just an investigation and not just surveillance. The most important aspect to successful missions, like this one, lies in the art of collaboration—of listening carefully to scientists, key informants, and experts in the field, and making good judgments and taking decisive action. I think our investigation team hit that on the head."

This Inside Story by Luis M. Luque