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Middle East respiratory syndrome coronavirus (MERSCoV) summary

and literature updateas of 9 May 2014

SinceApril2012,536laboratoryconfirmedcasesofhumaninfectionwithMiddleEastrespiratory
syndromecoronavirus(MERSCoV)havebeenreportedtoWHO,including145deaths(Figure1).To
date,theaffectedcountriesintheMiddleEastincludeJordan,Kuwait,Oman,Qatar,SaudiArabia
(KSA),UnitedArabEmirates(UAE)andYemen;inAfrica:EgyptandTunisia;inEurope:France,
Germany,Greece,ItalyandtheUnitedKingdom;inAsia:MalaysiaandPhilippines;andinNorth
America:theUnitedStatesofAmerica(USA).AllofthecasesrecentlyreportedoutsidetheMiddle
East(Egypt,Greece,Malaysia,thePhilippinesandtheUSA)recentlytravelledfromcountriesinside
oftheMiddleEast(KSAorUAE).Overall,65.6%ofcasesaremaleandthemedianageis49yearsold
(range9months94yearsold).

Figure1.LocationofthelaboratoryconfirmedcasesofMERSCoVinfectionbycountryof
presumedexposure,March20128May2014

Sincethelastupdateof27March2014,330laboratoryconfirmedcases,including59deaths,were
reportedtoWHO.Theseinclude290casesinfectedinKSA,37casesfromUAE,1casefromYemen
and2casesfromJordan.TheseincludeonecaseeachfromEgypt,Greece,Jordan,Malaysia,USA
andthePhilippineswhowereinfectedintheMiddleEast.Nofurthertransmissionhasbeen
documentedsofarfromtherecentexportedcases.

ThenumberoflaboratoryconfirmedMERSCoVcasesreportedtoWHOhassharplyincreasedsince
midMarch2014,essentiallyinKSAandUAE,whereimportanthealthcareassociatedoutbreaksare
occurring(Figure2).Thenumberofcaseswhoacquiredtheinfectionpresumablyfromnonhuman
sourceshasalsoincreasedsincemidMarch(shownasprimarycasesinFigure3).Thesecaseshave
notreportedcontactswithotherlaboratoryconfirmedcases,andsomehavereportedcontactswith
animals,includingcamels.Althoughcamelsaresuspectedtobetheprimarysourceofinfectionfor
humans,theroutesofdirectorindirecttransmissionremainunknownandinvestigationsare
ongoing.

Figure2.Epidemiccurveof536laboratoryconfirmedcasesMERSCoVcasesbyoutcome(asof8
May2014)

Figure3.EpidemicCurveof536laboratoryconfirmedMERSCoVpatientsbycasetype(primaryvs
secondary;asof8May2014)

Saudi Arabia cases

SinceWHOslastsummaryupdateon27March2014,SaudiArabiahasreported290casesfrom
Jeddah,Mecca,Riyadh,Tabuk,Madinah,andNajran.WHOiscurrentlyworkingwiththeMinistryof
HealthofSaudiArabiatounderstandtheupsurgeincases.
Jeddah, Saudi Arabia, Hospital Outbreak
InlateApril,healthauthoritiesinKSAinvitedWHOtosendariskassessmentmissiontoreviewthe
currentsituationrelatedtotheupsurgeincasesinJeddah.TheWHOmissiontookplace28April5
May2014.
Themissionteam,workingwithlocalauthorities,analysed128laboratoryconfirmedcaseswhohad
symptomonsetbetween17Februaryand26April2014andwhoweretreatedin14hospitalsin
Jeddah.Mosthospitalstreated12patients;however,onehospitalreported45casesduringthis
timeperiod.ApproximatelyonethirdoftheseJeddahcasesareconsideredtobeprimarycases,
althoughinvestigationsarecurrentlyongoingtodeterminewhetherthesepatientshadcontactwith
anotherconfirmedcase(thesecasesarenotreflectedasprimarycases[inblue]inFigure3as
investigationsareongoing).Morethan60%ofthe128casesarepresumedtohaveacquired
infectioninahospitalsetting,including39healthcareworkers.
Themajorityofthe128Jeddahcasesweremaleandthemedianagewas48.5years.Thehealth
careworkerswhotestedpositiveforMERSCoVweremorelikelytobeyounger,female,andexhibit
mildornosymptomswhencomparedwithprimarycases.However,15%ofthehealthcareworkers
whotestedpositivepresentedwithseveredisease(resultinginadmissiontoanintensivecareunit)
ordied.HouseholdcontactsofinfectedcaseswerescreenedforMERSCoVandsevenof554
householdcontactswerePCRpositiveforMERSCoV(secondaryattackrate=1.3%).
Anadditional35caseshavebeenreportedtoWHOfromMeccaandthisoutbreakisstillongoing.
MoredetailsoftheWHOMissiontoKSAcanbefoundhere:
http://www.emro.who.int/media/news/merscovmissionsaudiarabia.html
Outside Jeddah and Mecca, Saudi Arabia
SincemidMarch,KSAreported127casesfromoutsideJeddahandMecca,including86casesfrom
Riyadh,10casesfromTabuk,15casesfromMedina,3casesinNajranand13caseswithouta
locationspecified.
Amongthese127cases,26werereportedashealthcareworkers.The10casesreportedfrom
Tabukinvolveonehospitalandsevenhealthcareworkers.Amongthe76casesreportedfrom
Riyadh,15werehealthcareworkers.OnehealthcareworkerwasalsoreportedfromMedina.
Threehealthcareworkersdidnothavealocationspecified.Investigationsintoallofthesecasesare
currentlyongoing.
UAE hospital outbreak
Sincethelastsummaryupdate,37laboratoryconfirmedcasesofMERSCoVhavebeenreported
fromUAE.AllhavebeenreportedfromAbuDhabiEmirate;70.3%aremaleandthemedianageof
casesis41(range473)years.Morethantwothirdswerehealthcareworkers(includingambulance
staff).Onlyoneexperiencedseveredisease;therestwerereportedmildornosymptoms.

TwentyeightcaseswereidentifiedinahospitalclusterinAlAinCityintheEmirateofAbuDhabi.
Thefirstcasereportedinthisclusterwasa45yearoldmaleshopkeeperwhodiedinUAEon10
April2014.Hehadnorecenttravelhistoryorcontactwithanimals,andthesourceofhisinfectionis
currentlyunknown.Contacttracingidentifiedanadditional27caseswhowerehealthcareworkers
andsocialcontactsresidinginUAE.Iitisunclearwhethertransmissionoccurredfromtheindexcase
orfromnonhumansources.InvestigationsinUAEareongoing.Oneofthosecontacts,amale
nurse,travelledtothePhilippineson15April2014.Contacttracingonhisflightsandinthe
Philippinesidentifiednoadditionalcases.
Theremainingfivecasesincludetwosporadiccases,one2personfamily(motheranddaughter)
clusterandanonrelatedfouryearoldchildwhotestedpositive.Themotherofthefouryearold
childhadrecentlyperformedUmrahinSaudiArabia,butwasnevertestedforMERSCoV.
AnadditionalfourcaseswerereportedfromAbuDhabion8May2014,butitisunclearwhether
thesearelinkedwiththeAlAinCitycluster.
Newly affected country: Yemen
YemenreporteditsfirstlaboratoryconfirmedMERSCoVcaseon15April2014.Thecasewasa44
yearoldmaleresidinginShibam,Yemen.Hedevelopedsymptomson17March2014anddiedon
31March.PreliminaryinvestigationsfoundthatthecasehadnocontactwithotherMERSCoVcases
andnorecenthistoryoftraveloutsideofYemen,buthadmadeweeklyvisitstoacamelfarmwhere
hereporteddrinkingfreshcamelmilk.Noadditionalcaseswereidentifiedduringcontacttracing.
WHO MERSCoV related activities and upcoming guidance
WHOwillconveneameetingoflaboratoryexpertsinJuneinLyon,France,tofinalizeupdated
recommendationsonlaboratorytestingforMERSCoV.Therecommendationswilltakeinto
accountthelatestinformationonserologicaltestingwhichwillbecomemoreimportantasthe
numberofasymptomaticandmildlyillcasesincreases.

On28April2014,WHOpublishedguidelinesforInfectionpreventionandcontrolofepidemic
andpandemicproneacuterespiratoryinfectionsinhealthcare.Theseupdatedguidelinesare
fullyapplicabletoMERSCoVandweredevelopedfollowingtheprocessestablishedintheWHO
handbookforguidelinedevelopment,2010.ThisinvolvedtheactiveparticipationofaWHO
SteeringGroupandmembersoftheGlobalInfectionPreventionandControlNetwork(GIPCN).
Theresultingrecommendationswerepeerreviewedbyinternalandexternalexpertsandcanbe
foundhere:http://www.who.int/csr/bioriskreduction/infection_control/publication/en/

WHOhasupdatedFrequentlyAskedQuestionsonMERSCoV:
http://www.who.int/csr/disease/coronavirus_infections/faq/en/

Selected MERSCoV Literature

AteamfromUSAandKingSaudUniversityisolatedMERSCoVfromnasalswabsofdromedary
camelsinSaudiArabiaanddemonstratedthatwholegenomesequencesofhumansandcamels
areindistinguishable.Theyalsoreportedthatcamelscanbeinfectedsimultaneouslywithmore
thanoneMERSCoV.

Citation:Brieseetal.2014.MiddleEastrespiratorysyndromecoronavirusquasispeciesthat
includehomologuesofhumanisolatesrevealedthroughwholegenomeanalysisandvirus
culturedfromdromedarycamelsinSaudiArabia.mBio5(3):e0114614.
doi:10.1128/mBio.0114614.Availableat:http://mbio.asm.org/content/5/3/e0114614

AnexperimentalstudyevaluatedthestabilityofMERSCoVinmilkfromcamels,goatsandcows,
beforeandafterpasteurization.ResultsdemonstratedthatMERSCoVcouldsurvivefor
prolongedperiodsinmilkbutviableviruswasnotdetectableafterpasteurization.Furtherstudy
isneededtodeterminewhetherMERSCoVisexcretedintothemilkofinfecteddromedary
camelsand,ifso,whetherhandlingorconsumingcontaminatedrawmilkisassociatedwith
MERSCoVinfectioninhumans.

Citation:vanDoremalenN,etalStabilityofMiddleEastrespiratorysyndromecoronavirusinmilk
[letter].EmergInfectDis[Internet].2014Jul].http://dx.doi.org/10.3201/eid2007.140500

ApapersummarizingthegeographicdistributionofserologicevidenceforMERSCoVorMERS
likeCoVindromedariesinAfricaandtheArabianPeninsulahasbeenpublishedbyReuskenetal.
Theauthorsnotethereisevidenceofcirculationcoveringawidegeographicarea,including
CanaryIslands,Egypt,Tunisia,Nigeria,SudanandEthiopiainAfricaandJordan,Oman,Qatar,
KSA,andUAEintheMiddleEast.Theyreporteddifferencesinseropositivitybetweenadultand
juvenile(<3yearsofage)camels.

Citation:ReuskenCBEM,etal.GeographicdistributionofMERScoronavirusamongdromedary
camels,Africa.EmergInfectDis.2014Jul[earlypub].http://dx.doi.org/10.3201/eid2007.140590

ResearchersfromOmanandViennareportedonanationwidesurveyofMERSCoVin
dromedarycamelsconductedinDecember2013inOman.TheyfoundMERSCoVnucleicacidin
5of76camelssampled.TheOmanicamelsequenceswerecomparedwithavailablehuman
MERSCoVsequencesandcamelMERSCoVsequencesfromQatarandEgypt.Thecamel
sequenceswerecloselyrelatedtohumanMERSCoVsequencesfromthesamegeographic
areas,suggestingthatlocaltransmissionfromcamelstohumanshadoccurred.

Citation:NowotnyN,KolodziejekJ.MiddleEastrespiratorysyndromecoronavirus(MERSCoV)in
dromedarycamels,Oman,2013.EuroSurveill.2014;19(16):pii=20781.Availableonline:
http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20781

AnexperimentalstudyevaluatedthestabilityofMERSCoVusingcombinationsoftemperature
andhumidity.MERSCoVwasmorestableatlowtemperature/lowhumidityconditions(20C
40%relativehumidityandcouldstillberecoveredafter48hours.DuringaerosolisationofMERS
CoV,nodecreaseinstabilitywasobservedat20C/40%relativehumidity,suggestingthe
potentialofMERSCoVtobetransmittedviacontactorfomitetransmissionowingtoprolonged
presenceintheenvironment.

Citation:vanDoremalenN,etal.StabilityofMiddleEastrespiratorysyndromecoronavirus
(MERSCoV)underdifferentenvironmentalconditions.EuroSurveill.2013;18(38):pii=20590.
Availableat:http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20590

TwostudiesreportedtheresultsofPCRscreeningforMERSCoVin2013Hajjpilgrims.Thefirst
study(Memishetal.,2014)reportedresultsfromnasopharyngealsamplesfrompilgrimsfrom
22countriestakenbefore(n=3210)andafter(n=2025)theHajj.Thesecond(Gautretetal.,
2014)reportedresultsfrompreandpostHajjnasalswabsfrom129Frenchpilgrims.Neither
foundanyevidenceofMERSCoVinfectionamongsubjects.

Citations:MemishZA,etal.PrevalenceofMERSCoVNasalCarriageandCompliancewiththe
SaudiHealthRecommendationsAmongPilgrimsAttendingthe2013Hajj.JInfectDis.2014Apr
15.[Epubaheadofprint]andGautretP,etal.LackofMERScoronavirusbutprevalenceof
influenzavirusinFrenchpilgrimsafter2013Hajj.EmergInfectDis.2014Apr;20(4):72830.
Summary and Risk Assessment
WHOiscurrentlyworkingwiththeMinistriesofHealthinSaudiArabiaandotheraffectedcountries
andinternationalpartnerstobetterunderstandthereasonsfortheincreaseincasesreportedsince
March2014.FrompreliminaryinvestigationsinKSA,itisclearthatcasescontinuetobereportedin
anumberoflocationsacrossthecountry.Importantly,healthcareworkershavebeeninfected
acrossthecountry,includinginJeddah,Riyadh,Tabuk,AsirandMedinainrecentweeks.
ThelargenumberoftherecentlyreportedcasesfromKSAreflectsinfectionacquiredthrough
transmissioninhealthcaresettings.ThelargeoutbreaksinJeddahandRiyadh,andthereportsof
smallerhospitalassociatedcasesinotherpartsofthecountry,emphasisetheimportanceof
infectioncontrolstrategiesandpractices,notonlywhencaringforsuspectedMERSCoVpatientsbut
alsoandmostimportantlywhencaringforpatientsinallcircumstances.Itisthereforeimportant
toemphasizetheimplementationofstandardprecautionsatalllevelsandalsotoapplyadditional
precautionsaccordingtotheriskassessment.
TheWHOmissionfoundthattheupsurgeincasesinJeddahisexplainedbyanincreaseinthe
numberofprimarycases,amplifiedbyseveralhospitalacquiredoutbreaksthatresultedfromalack
ofsystematicimplementationofinfectionpreventionandcontrolmeasures.Theapparentseasonal
increaseinprimarycasesoccurringforunknownreasonsmayberelatedtotheweaningofyoung
camelsfromtheirmothersinthespringofeachyear.Recentphylogeneticanalysisusingthree
humansequencesfromJeddahsuggeststhatthevirushasnotchangedfrompreviouslyrecovered
strains.

BasedonavailableinformationfromrecentcasesinKSA,inparticular,fromJeddah,andfromall
recentlyaffectedcountries,thereiscurrentlynoevidenceofsustainedhumantohuman
transmissioninthecommunity.Theoveralltransmissionpatternspreviouslyobservedremain
unchanged.WHObasesthisassessmentontheevidencethat:
I. Theclinicalpictureappearstobesimilartowhatwasobservedpreviously;secondarycases
tendtopresentwithamilderdiseasethanprimarycases,andmanyoftherecentlyreported
secondarycaseshavebeenmild,orwerepeoplewhosetestswerepositiveforMERSCoV
butwereasymptomatic;
II. TherecentlyexportedcasestoGreece,Malaysia,thePhilippinesandtheUSAhavenot
resultedinonwardtransmissiontopersonsinclosecontactwiththesecasesonairplanesor
intherespectivecountriesoutsidetheMiddleEast(contacttracingisstillongoing);
III. IntensivescreeningofMERSCoVcontactsrevealedveryfewinstancesofhousehold
transmission;and
IV. Therehasbeennoincreaseinthesizeornumberofobservedhouseholdclusters.
Theincreaseinthecommunitycasesmightreflectaseasonalincreaseinzoonoticinfectionsfroman
animalpopulationsuchasdromedarycamels.Alternatively,asmanyofthecommunitycaseshadno
reportedanimalexposures,itisalsopossiblethatsuchcasesreflectedeitherpersontoperson
transmissionorexposuretoanothersource.Furtherepidemiologicalinvestigationsareurgently
neededtoconfirmorrefutethesehypotheses.
WHOexpectsthatadditionalcasesofMERSCoVinfectionwillbereportedfromtheMiddleEast,and
thatitislikelythatcaseswillcontinuetobeexportedtoothercountriesbytourists,travellers,guest
workersorpilgrimswhomightacquireinfectionfollowingexposuretoananimal(forexample,while
visitingfarmsormarkets)orhumansource(possiblyinahealthcaresetting).Untilmoreis
understoodabouttheexposurestononhumansourcesinthecommunity,orhumanor
environmentalexposuresinhealthcaresettingsandimplementationofpreventivemeasures,cases
willcontinuetobereported.
Urgentinvestigationsarerequiredtobetterunderstandthetransmissionpatternsofthisvirus.The
mosturgentneedsincludedetailedoutbreakinvestigations,understandinghowhumansbecome
infectedfromanimalorenvironmentalsource(s)throughcasecontrolstudies,identifyingrisk
factorsforinfectioninhealthcaresettings,andenhancingcommunitystudiesandsurveillancefor
communityacquiredpneumonia.Collaborationbetweenhumanandanimalhealthsectorsis
essentialtounderstandtheriskoftransmissionbetweenanimalsandhumans.WHOguidelinesand
toolsoninvestigationscanbefoundhere:
WHOguidelinesforinvestigationofcasesofhumaninfectionwithMiddleEastRespiratory
SyndromeCoronavirus(MERSCoV)
pdf,359kb
MiddleEastRespiratorySyndromeCoronavirus(MERSCoV)InitialInterviewQuestionnaire
ofCases
pdf,114kb
CasecontrolstudytoassesspotentialriskfactorsrelatedtohumanillnesscausedbyMiddle
EastRespiratorySyndromeCoronavirus(MERSCoV)
pdf,257kb

SeroepidemiologicalInvestigationofContactsofMiddleEastRespiratorySyndrome
Coronavirus(MERSCoV)Patients

Enhancinginfectionpreventionandcontrolawarenessandimplementationmeasuresiscriticalto
preventthepossiblespreadofMERSCoVinhealthcarefacilities.Healthcarefacilitiesthatprovide
careforpatientssuspectedorconfirmedtobeinfectedwithMERSCoVinfectionshouldtake
appropriatemeasurestodecreasetheriskoftransmissionofthevirusfromaninfectedpatientto
otherpatients,healthcareworkersandvisitors.Itisnotalwayspossibletoidentifypatientswith
MERSCoVearlybecausesomehavemildorunusualsymptoms.Forthisreason,itisimportantthat
healthcareworkersapplystandardprecautionsconsistentlywithallpatients,regardlessoftheir
diagnosis,inallworkpracticesallthetime.
Dropletprecautionsshouldbeaddedtothestandardprecautionswhenprovidingcaretoany
patientwithsymptomsofacuterespiratoryinfection.Contactprecautionsandeyeprotection
shouldbeaddedwhencaringforprobableorconfirmedcasesofMERSCoVinfection.Airborne
precautionsshouldbeappliedwhenperformingaerosolgeneratingprocedures.
UntilmoreisunderstoodaboutMERS,peopleathighriskofseveredisease(thosewithdiabetes,
renalfailure,chroniclungdisease,andimmunocompromisedpersons),shouldtakeprecautions
whenvisitingfarmsandmarketswherecamelsarepresent.Theseprecautionsinclude:avoiding
contactwithcamels;notdrinkingrawcamelmilkorcamelurine;andnoteatingmeatthathasnot
beenthoroughlycooked.
Camelfarmandslaughterhouseworkersshouldpracticegoodpersonalandhandhygiene,with
frequenthandwashingaftertouchinganimals,facialprotectionwherefeasibleandthewearingof
protectiveclothing,whichshouldberemovedafterworkandwasheddaily.Workersshouldalso
avoidexposingfamilymemberstosoiledworkclothing,shoes,orotheritemsthatmayhavecome
intocontactwithcamelsorcamelexcretions.Sickanimalsshouldneverbeslaughteredfor
consumption;incaseswhereaparticularanimalhasbeentestedandconfirmedpositiveforMERS
CoV,peopleshouldavoiddirectcontactwithsuchanimals.
Countriesoutsidetheaffectedregionshouldmaintainahighlevelofvigilance,especiallythosewith
largenumbersoftravellersorguestworkersreturningfromtheMiddleEast.Surveillanceshould
continuetobeenhancedinthesecountriesaccordingtoWHOguidelines,alongwithinfection
controlproceduresinhealthcarefacilities.WHOcontinuestorequestthatMemberStatesreportall
confirmedandprobablecasesalongwithinformationabouttheirexposures,testing,andclinical
coursetoinformthemosteffectiveinternationalpreparednessandresponse.
WHOdoesnotadvisespecialscreeningatpointsofentrywithregardtothiseventnordoesit
currentlyrecommendtheapplicationofanytravelortraderestrictions.