by random analytic
Since my last Middle Eastern Respiratory Syndrome update (21 May 2014) there have been a number of key developments and even some improvements in data quality coming out of the Kingdom of Saudi Arabia.
The big announcement since my previous post was the addition of 113 legacy cases by the KSA Ministry of Health. Of the 113-cases, 42 were Health Care Workers and are included in the following charts.
Almost as importantly, the Saudi’s are now sharing their data with the World Health Organisation (WHO). The Disease Outbreak Notifications, or DON’s, are very comprehensive, light-years away from the Health Ministries updates of the past. With some irony I was pleased to see that Iran and the Kingdom featured together in the most recent DON. Perhaps we are seeing a form of MERS diplomacy occurring.
Here are the latest MERS by Occupation charts.
***** Please note that all infographics for this MERS-CoV article are using publically sourced information to 1200hrs 4 July 2014 (EST) *****
This first chart looks at those infected with MERS by Job Title or Function.
- Retired: The largest group. There are 150-retirees (39.5% of known job titles)represented in this chart but only 2 have been confirmed (1.3%). The bulk of the retirees represented in the chart are included if they did not have a job title or function attributed to them AND if their ages are greater than the official retirement age for their home country.
- Health Care Workers (HCW): The second largest group. Includes all types of unidentified workers in the Health sector (i.e. Nurses and Doctors).
- Nurse: I have been able to identify 23-Nurses and in at least two cases, their speciality (ER & ICU).
- Farmer: Includes both Owners (9/75%) and Employees (3/25%). I suspect the higher weighting toward owners is due to the fact that they are all nationals (from KSA, Qatar and the UAE). The three farm employees that have been identified are all resident workers. Just a thought here. Rich owners get to see the doctor while residents might have a range of barriers which reduce their ability to receive primary care services or choose to work through what they might believe is a bad flu.
- Pilgrim: Of the 11-Pilgrims I have been able to identify I believe at least 8 were Umrah linked while three were potentially due to the Haj.
- Doctor: Six identified, including one surgeon and one ICU specialist.This infographic looks at those infected with MERS-CoV by Job Family. In short I think this is a key infographic for MERS as it gives you some confidence in the key narratives (i.e. that Health Care Workers are over represented in the data as an example).
Next chart, Job Families:
- With the inclusion of an additional 42 Health Care Workers the Non-Participatory (156/18.6%) group (Paediatrics, Students, Retiree’s and the Unemployed) move from the largest to the second largest Job Family.
- Health Practitioners/Technical Operations (159/19.0%) or HCW as there more commonly known become the largest Job Family represented. This number includes the Nursing Assistant that was identified in Iran (but more on that later).
- Paediatrics (18/2.1%) numbers have declined since the last update when they represented just 2.8% of the data then. Still seems low and Maia Majumderpicked up on this in a recent post.
- Pilgrim/Tourist (14/1.6%) has seen a slight increase due to some Umrah inclusions recently.
- Healthcare Support (6/0.7%) numbers remain static so not sure if the Saudi announcement of legacy cases conflates HCW and HCSpt numbers.
- Construction (2/0.2%) is a new inclusion from the previous update. Given the amount of building going on the in the Middle East, especially in Qatar this number seems on the very low side. I’d expect to see this number increase with more robust reporting.
The last chart looks at those overall main job families that are most impacted by MERS, specifically Farmers, Travellers, Paediatrics, Retirees, HCW & HCSpt (combined), Other and Unknown.
- Farmer (1.7%): With only 14 confirmed cases apart from 2013 you can barely see them across an entire year, quarter or month. Numbers seem low.
- Traveller (1.7%): Like farming, numbers seem low.
- Paediatrics (2.1%): As suggested previously, no new paediatric cases since my last update so the numbers have declined somewhat.
- HCW & HCSpt (19.7%): Health Care Workers and I have also included Health Care Support Workers in this grouping as well. Numbers up on previous update due to the additional 42-cases.
- Other (2.3%): All other occupations that have been publically released. I’ve actually reduced the number in this group by one from the last update due to improved reporting from Saudi Arabia.
- Unknown (54.7%): Unknown occupations. Up slightly but with improved reporting I’m hoping that this will reduce (over time).
Final Thoughts (on the difference between a Health Care Worker and Health Care Support
Last month I tweeted that the Iranian Nursing Assistant (FT #827) should be counted as a Health Care Support worker rather than a HCW. I then got a number of return tweets from the likes of Helen Branswell, Ian M Mackay and others who disagreed with that line of thought.
When Helen and Ian ‘guide and advise’ it’s probably worth not disregarding that advice. Upon some personal review I decided that perhaps I had taken a too hard Workforce Planning line to my job functions without fully considering the clinical implications.
I have subsequently reviewed my thinking and have re-organised my data along the following lines.
Health Practitioners/Technical Operations (nee HCW) are any job title or function that is included in the Bureau of Labor Statistics SOC Occupations 29-0000 Healthcare Practitioners and Technical Occupations PLUS any clinical function that is included within the 31-0000 Healthcare Support Occupations, such as Nursing Assistants.
I am continuing to track Health Care Support personnel (there are four job titles already identified in the MERS data including Health Clinic Admin Officer, Health Domain Worker, Hospital Employee, Hospital Receptionist) as I believe the differentiation from HCW is important but I am including their data in job family charts and infographics.
In the end, I made a bad call and I thank those of you who took the time to correct my thinking.
Flublogia is certainly a community and one I truly appreciate being involved in.
***** Please note that this infographic of the Middle East Respiratory Syndrome Coronavirus (MERS-CoV) was updated with public source information to 1800 4 June 2014 EST *****
I was always planning on updating my MERS-CoV infographic at the end of May but the own-goal by the Saudi Ministry of Health, having suppressed the details of at least113-cases and 92-deaths and the sacking of the deputy Health Minister Professor Ziad A. Memish made this update an absolute necessity.
The MERS-CoV in the Middle East infographic displays cases and deaths according to each reporting country (rather than onset country which has become confused over the course of the disease). The primary data source is the latest ECDC update and the most recent figures released by the Saudi Arabian MoH (to 3 June 2014).
Many journalists and flublogists have already started to comment on the deeper meanings behind the ‘exemption’ of Professor Memish from work and the suppression of data over a very long period. One of the best articles I have read on it today came from Crawford Kilian via H5N1. How MERS Could Topple the House of Saud, and Beyond. Excerpt:
A recent book argues that Saudi Arabia and its Gulf neighbours are “rentier states,” living off the revenues from oil. Some of the oil money is distributed in a kind of ethnic socialism: native-born Saudis and Emiratis get cheap housing, education and fuel, as well as undemanding government jobs. In return, they allow the monarchies to do as they please.
Part of this “ruling bargain” is to import cheap labour in vast numbers, for everything from housecleaning to business management. The money and working conditions are atrocious, but usually better than those available at home. One of the benefits of the ruling bargain is a good health-care system, and the Saudis have an extensive one. In many ways, it is indeed good. The previous health minister, Abdullah Al-Rabiah, is a Canadian-trained surgeon who recently separated conjoined twins.
But that was after he got the sack. As health minister, Al-Rabiah had presided over the rise and spread of MERS as a Saudi disease. While cases were seen in Jordan in March and April of 2012, the virus was first identified in a Saudi patient a few months later. Ever since then, the vast majority of cases have affected either Saudis or visitors to the Kingdom; the other Gulf monarchies have seen cases too, but far fewer.
Al-Rabiah’s strategy was to say as little as possible about the cases and to spin what he couldn’t conceal. While the World Health Organization and other agencies worried about what was going on, the Saudi Ministry of Health stonewalled them. But the minister couldn’t conceal the fact that cases were breaking out right inside Saudi hospitals.
I would agree with most of what Crawford is saying with the exception that the previous health Minister Abdullah Al-Rabiah wasn’t spinning the data, he was ‘Juking the Stats’.
So, what is the difference between spinning the data and juking the stats and why is this important in our understanding of MERS?
The answer is that when a government, organisation, company or individual spins the data what they are doing is looking at relatively ‘clean’ data and then using that information to either spin the results or emphasise a point for a positive or negative outcome. You might not realise this but most Western governments spend a lot of time and treasure on doing this as they try to drive home a political message. A fair amount of my time as a Workforce Planner was spent spinning data (aggressive forecasting of human resources in future quarters as an example).
What the House of Saud has been doing is the authorisation and implementation of ‘Juked Stats’ policy.
In my humble opinion, what this effectively means is that the Minister, the deputy Minister, various minions, governmental hospitals and private hospitals that receive government funding were given a number of MERS reports to state for official publication and that the World Health Organisation would not be informed of the real numbers (which would then become a Disease Outbreak Notification).
Two key points:
Point 1: The fact that we now find that 20% of cases and >30% of deaths went unreported since May 2013 is a clear indication that the Saudi’s had a clear policy of underreporting for political reasons. The fact that Professor Memish got sacked a day after the juked figures were revised was (again IMO) a way to quietly point the figure at the patsy so the regime could say it had cleaned house.
Yet, even as a doctor, Professor Memish was a very highly placed bureaucrat who had been politically vetted by the regime who asked him to deliver a result. When the disease spun out of his control and Memish couldn’t deliver the requirement the regime quietly ‘exempted’ him from the story. Having myself been involved in the ‘Juking of Stats’ I can state without qualification that if my numbers had of been bad my boss would have been quietly let go (with a decent payout) and the CEO would have moved on. That’s the game.
Point 2: The data errors go back as far as May 2013 yet it is interesting that the Saudi’s have ‘come clean’ on their data errors just a month after the first case hit America. That detail alone might be worthy of some deeper investigative journalism.
To finalise, the Saudi’s are telling us that they have now come clean on their data errors. Given they have never been clean to date I still don’t believe them.
Post Note: As Ian Mackay just reminded me, I should also state that I don’t believe the new Saudi data because of a conspiracy theory, because conspiracies require a brain-trust and this looks like just an ongoing cock-up!