Responding to the challenge of MERS-CoV: Development and testing of interventions to reduce risk among Bedouin populations in Southern Jordan

Middle Eastern Respiratory Syndrome coronavirus (MERS-CoV) is a recently identified 'emerging infectious disease' first seen in Jordan and Saudi Arabia in 2012. Clinical cases can present as a sudden acute respiratory infection, with rapid onset pneumonia and death, although milder infections also occur (in some cases without any symptoms at all). Since the initial outbreaks in 2012, there have been almost 2500 confirmed cases, with over a third of those infected subsequently dying from the disease (848 people to date).

Confirmed cases have been reported across 27 countries, although the majority have been in the Arabian Peninsula, with Saudi Arabia the disease epicentre (over 80% of all confirmed cases). Primary infection in humans occurs through contact with infected dromedary camels (or camel products) and camel populations act as the host reservoir for the virus, however infection in camels causes only mild symptoms, similar to a common cold (and may cause no symptoms at all). Once someone becomes infected in this way secondary human-to-human transmission of the virus can then occur (often in a hospital setting) with the potential to cause large scale outbreaks such as those seen in South Korea and Saudi Arabia in recent years.

Jordan's strategic location at the centre of current Middle Eastern crises means that its stability within the region is of global significance. Enormous influxes of displaced peoples into Jordan from the conflicts in Syria, Iraq and Yemen among others (accounting for over 30% of the population) have placed unprecedented demands on Jordan's national disease surveillance, response and health-care services and increased the risk of catastrophic disease outbreaks occurring in the future, including MERS-CoV. Jordan's long, porous border with Saudi Arabia, across which frequent movements of people and livestock occur (particularly among rural Bedouin populations in the south of the country) and large camel populations, mean that the risks posed by MERS-CoV remain high.

The World Health Organization (WHO) have designated MERS-CoV to be a Blueprint Priority Disease for Research and Development, alongside other 'emerging infectious diseases' that represent a potential global threat, including Ebola, Lassa and Nipah viruses. The development of vaccines against MERS-CoV, for use in both camels and humans, is already at an advanced stage, however knowledge regarding the diseases epidemiology and cultural context (which are essential for effective vaccine deployment) is currently lacking. A similar lack of knowledge has delayed the deployment of other vaccines in the past (e.g. recently the Lassa virus vaccine in West Africa) and so it is important that deployment of future MERS-CoV vaccines is not delayed for the same reasons. It is crucial therefore that appropriate research be conducted among high-risk populations.

With this in mind, and building on the findings of successful GRCF Foundation Award research, we aim to conduct state-of-the-art interdisciplinary research to determine the biological and sociocultural contexts of the disease among at-risk Bedouin populations in southern Jordan. In particular, we are seeking to understand which individuals, or camels, should be targeted for future vaccination, the correct seasons for the deployment of such vaccines and the sociocultural issues that are driving the infection, with consideration of these sociocultural issues vital when looking at potential control measures for the disease, including vaccination. Through this project we thus aim to develop appropriate, community based behavioural interventions that will reduce the risk of infection among these communities (as well as considering the potential role of vaccines in the future). We are also aiming to build Jordan's capacity for strategic research, surveillance and control activities to confront the challenge posed by MERS-CoV (as well as by other 'emerging infectious diseases').

Building on a successful GCRF Foundation Award, we aim to: i) Address knowledge gaps required to inform future vaccination strategies for MERS-CoV, ii) Develop and implement contextualized behavioural public health interventions to mitigate risk of MERS-CoV infection and iii) Build capacity for research, surveillance and control activities targeted at MERS-CoV.
Two parallel longitudinal studies of camel owning households and their camel herds, together with an ethnographic survey, will be conducted in southern Jordan (Ma'an and Aqaba governorates). These studies will address knowledge gaps identified through the Foundation Award as important to inform future vaccination strategies such as who should be targeted for vaccination and the sociocultural issues, including vaccine acceptability, that are likely to be faced. Appropriate hygiene education interventions will be introduced as part of a randomized pilot feasibility trial in which half of the households will be randomly selected at month 18th of the project, with the other half remaining as 'control arm' during the following 6 months. Primary outcomes of the trial will be obtained from interviews on acceptability, perceived difficulty in implementing together with reported and observed behaviour related to avoiding camel oral and nasal secretions. Secondary outcomes will be based on serology in humans and camels in those having had the intervention in first half of year two compared to those who have not yet had the intervention. We will exploit opportunities for capacity building through grass-roots and higher-level workshops and engagement activities with the support of Jordan's Royal Scientific Society and US NIH.
The importance , timeliness and opportunity of this project resides on the global public health threat posed by MERS-CoV, with Jordan as one of its epicenters, and the work carried out with the Foundation Award, which has generated knowledge and conditions that allow piloting of interventions.

In this project we address the challenge posed by Middle East Respiratory Syndrome Coronavirus (MERS-CoV) to Jordan, a strategically significant 'lower/middle income country' (LMIC), which lies at the heart of current Middle Eastern Crises and who's stability within the region of is global significance. In particular, this project will address the risk posed by MERS-CoV to Bedouin communities in southern Jordan, a population at high risk of infection due to the large number of camel herds, close camel contact and frequent cross-border movement into neighbouring Saudi Arabia - the epicentre of current MERS-CoV outbreak.

With this in mind, the primary research beneficiaries will be the people of Jordan (including refugee populations), though particularly rural Bedouin populations in southern Jordan, many of whom live in extreme poverty and face high levels of exposure to, and infection from, MERS-CoV (as identified through previous GCRF Foundation Award research conducted among the same population). This research will however also benefit the wider international community by promoting peace and stability in Jordan through safeguarding its biosecurity against MERS-CoV, as well reducing the biological threat posed by MERS-CoV globally (with MERS-CoV demonstrating ability to cause to cause outbreaks worldwide, such as that seen in South Korea in 2015).

Beneficiaries, or 'users', of the research outputs will be:
i) multidisciplinary governmental and non-governmental stakeholders and regulators, both nationally and internationally, with research outputs able to inform policy regarding effective MERS-CoV control,
ii) the public-private sector, with research outputs informing development and deployment protocols for vaccines against MERS-CoV,
iii) the interdisciplinary academic community represented under the umbrella 'One Health' (both in Jordan, the UK and globally) who, collectively, are working towards a more comprehensive understanding of the ecology, epidemiology, and socio-cultural context of emerging infectious diseases. This research will promote research excellence in Jordan as well as enhancing the UK's reputation (and thus economic performance through increased investment) as a global leader in state-of-the-art multidisciplinary public health research, including emerging infectious diseases.

Our research seeks to impact the following United Nations Sustainable Development Goals:
1) No poverty, by promoting health, stability and economic growth in Jordan through delivering outcomes that significantly impact Jordan's welfare and economic development, 2) Zero Hunger, supporting the food and agriculture sector in Jordan by promoting food safety, particularly safe camel's milk - a vital food source among Bedouin families who are living in poverty among harsh climatic conditions increasingly impacted by climate change, 3) Good health and well-being by mitigating the risk of MERS-CoV among high-risk communities, including raising awareness of significant comorbidities for MERS-CoV infection, such as diabetes, high blood pressure and smoking related diseases (also representing important non-communicable diseases (NCDs), 8) Decent work and economic growth, agriculture and tourism play a vital role in Jordan's fragile economy, which this project seeks to protect, by building capacity for effective biosecurity measures designed to safeguard human and livestock health, 16) Peace, justice and strong institutions, by building capacity within Jordanian governmental, non-governmental, academic and third sector organizations for integrated disease surveillance and control activities, particularly in the field of zoonoses and emerging infectious diseases, 17) Partnerships for the goals by promoting global partnerships that fulfil sustainable development goals, such as the development of robust public health systems and infrastructures capable of withstanding the challenge from emerging infectious disease including MERS-CoV.