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

Plain English summary of protocol

Background and study aims
Middle East respiratory syndrome coronavirus (MERS-CoV) represents one of three deadly zoonotic betacoronaviruses (alongside SARS-CoV and SARS-CoV-2) to have emerged this century. Since initial outbreaks of MERS in Jordan and Saudi Arabia in 2012, ongoing clinical cases continue to occur, almost exclusively within the Arabian Peninsula. More than 2500 laboratory-confirmed cases have now been identified, across 27 countries, though over 80% of cases have been within the Kingdom of Saudi Arabia (KSA). The World Health Organization (WHO) has declared MERS-CoV to be a Blueprint Priority Disease for Research and Development posing a public health risk of epidemic potential, with more than a third of all confirmed cases currently resulting in death. Dromedary camels are the reservoir host for MERS-CoV, with seropositive camels first identified in 2013, in Jordan. Infection in camels is largely sub-clinical, or causing mild upper respiratory signs, while infection in humans ranges from being asymptomatic to causing potentially fatal severe acute respiratory disease. Alongside primary (camel-to-human) transmission, secondary (human-to-human) transmission also occurs, with the potential for large-scale outbreaks, particularly in hospital settings.
To date, MERS-CoV control efforts have largely focused on i) improved camel testing and surveillance strategies, ii) improved triage and biosecurity measures within healthcare settings and iii) vaccine development, though with no commercial vaccines, human or camel, currently available. However, while likely viral transmission routes and high-risk camel engagement activities have now been identified, the potential role of targeted behavioural interventions, aimed at mitigating MERS-CoV exposure among camel-owning communities, has largely been ignored. The aims of this pilot trial are therefore to i) assess the feasibility and effectiveness of employing behavioural interventions in the control of MERS-CoV, and ii) assess potential ability to scale up for wider evaluation in future trials.

Who can participate?
The study will be conducted among camel-owning households in southern Jordan – a 40,000 km2 desert area beside the KSA border. Households will be randomly selected from lists provided by the Ministry of Agriculture (MoA), and all household members present at the time of the visit will be invited to receive the intervention, except for young children (under 5 years old) and individuals without the capacity to provide informed consent. Household membership will be defined as either i) self-identifying as a household member and sleeping in the household the previous night, or ii) being a household employee.

What does the study involve?
Following a baseline survey of serological status and self-reported practices the planned behavioural interventions have been grouped into ‘packages’ that address distinct viral transmission pathways and non-communicable disease predisposing to MERS-CoV infection. These packages are as follows:
Package 1. The provision of information regarding the use of face coverings (particularly the traditional ‘kaffiyeh’) when working with camels, particularly young animals; refraining from kissing camels, particularly young animals; reducing close-quarter exposure to camel crowding (by filling feed and water troughs before allowing camels access); and hand washing after engaging with camels
Package 2. The provision of information regarding improved hand hygiene practices within the home (washing over five times per day with soap)
Package 3. The provision of information regarding the prevention and control of hypertension and diabetes, in accordance with WHO guidelines, in particular regarding smoking, dietary salt intake, dietary sugar intake and physical activity.
Package 4. The provision of information regarding minimizing camel crowding during feeding and watering times through the provision of additional troughs (facilitated by the gifting of one additional trough per five camels in the herd), and closed herd management practices, including quarantining camels (for 3 weeks) entering or re-entering the herd – particularly when used for breeding purposes.
A follow-up telephone call (to the household head) and one follow-up visit to the household home will be conducted 2 and 4 months (respectively) after the initial intervention visits, with the follow-up household visit also used for assessment of outcomes. All visits and telephone calls will be conducted by trained members of an intervention team and will include respected members of the local communities. Households within the control group will also receive the same intervention package as the intervention group, including follow-up visits, after the assessment of intervention uptake among the intervention group has been completed.

What are the possible benefits and risks of participating?
Possible benefits of participating include access to training regarding behavioural interventions with the potential to reduce exposure to MERS-CoV (and potentially serious illness), alongside additional training regarding prevention of important co-morbidities (diabetes and hypertension) and improved hygiene interventions (with the potential to reduce infection from a large range of infectious diseases).
Regarding potential risks or harms in participating, as the interventions are in the form of advice regarding potential behavioural changes (though with minor pain from blood sampling), we expect there to be little potential for harm from the study.

Where is the study run from?
The study is being run by the Royal Veterinary College (RVC) and London School of Hygiene and Tropical Medicine (LSHTM), in partnership with local partners Jordan University of Science and Technology (JUST) and Yarmouk University, Jordan.

When is the study starting and how long is it expected to run for?
October 2020 to February 2025

Who is funding the study?
UK Medical Research Council (MRC), Global Challenges Research Fund

Who is the main contact?
Prof. Javier Guitian, jguitian@rvc.ac.uk

Study website

Contact information

Prof Javier Guitian
Public, Scientific, Principal Investigator

Royal College Street
London
NW1 0TU
United Kingdom

ORCID ID	0000-0003-0799-0476
Phone	+44 (0)20 7468 5000
Email	JGuitian@RVC.AC.UK

Prof Punam Mangtani
Public, Scientific

Keppel Street
London
WC1E 7HT
United Kingdom

ORCID ID	0000-0001-7074-2999
Phone	+44 (0)20 7636 8636
Email	Punam.Mangtani@lshtm.ac.uk

Dr Peter Holloway
Scientific

Royal College Street
London
NW1 0TU
United Kingdom

ORCID ID	0000-0001-6648-9724
Phone	+44 (0)20 7468 5000
Email	pholloway3@rvc.ac.uk

Study information

Eligibility

Locations

Countries of recruitment

• Jordan

Study participating centre

Sponsor information

Royal Veterinary College
University/education

4 Royal College Street
London
NW1 0TU
England
United Kingdom

Phone	+44 (0)1707 666333
Email	vpresearchinnovation@rvc.ac.uk
Website	http://www.rvc.ac.uk/
"ROR"	https://ror.org/01wka8n18

Funders

Funder type

Government

Results and Publications

Editorial Notes

18/09/2024: Study's existence confirmed by the Medical Research Council.