Published Date: 2013-05-23 18:56:08 Subject: PRO/AH/EDR> MERS-CoV - Eastern Mediterranean (09): Saudi Arabia, WHO, Jordan Archive Number: 20130523.1733317
MERS-COV - EASTERN MEDITERRANEAN (09): SAUDI ARABIA, WHO, JORDAN **************************************************************** A ProMED-mail post http://www.promedmail.org ProMED-mail is a program of the International Society for Infectious Diseases http://www.isid.org
In this update:  Saudi Arabia - WHO  Saudi Arabia, new case in 'foreigner'; Jordan, details of 2012 outbreak
The Ministry of Health in Saudi Arabia has notified WHO of an additional laboratory-confirmed case of infection with the Middle East respiratory syndrome coronavirus (MERS-CoV).
The fatal case was reported from Al-Qaseem region in the Central part of the country and is not related to the cluster of cases reported from Al-Ahsa region in the eastern part of the country. The patient was a 63-year-old man with an underlying medical condition who was admitted to a hospital with acute respiratory distress on 15 May 2013 and died on 20 May 2013. Investigation into contacts of this case is ongoing.
The Saudi authorities are also continuing the investigation into the outbreak that began in a health care facility since the beginning of April 2013 in Al-Ahsa. To date, a total of 22 patients including 10 deaths have been reported from the outbreak.
Globally, from September 2012 to date, WHO has been informed of a total of 44 laboratory-confirmed cases of infection with MERS-CoV, including 22 deaths.
WHO has received reports of laboratory-confirmed cases from the following countries in the Middle East: Jordan, Qatar, Saudi Arabia, and the United Arab Emirates (UAE). France, Germany, Tunisia and the United Kingdom also reported laboratory-confirmed cases; they were either transferred for care of the disease or returned from the Middle East and subsequently became ill. In France, Tunisia and the United Kingdom, there has been limited local transmission among close contacts who had not been to the Middle East but had been in close contact with the laboratory-confirmed or probable cases.
Based on the current situation and available information, WHO encourages all Member States to continue their surveillance for severe acute respiratory infections (SARI) and to carefully review any unusual patterns.
Health care providers are advised to maintain vigilance. Recent travellers returning from the Middle East who develop SARI should be tested for MERS-CoV as advised in the current surveillance recommendations. Specimens from patients' lower respiratory tracts should be obtained for diagnosis where possible. Clinicians are reminded that MERS-CoV infection should be considered even with atypical signs and symptoms, such as diarrhoea, in patients who are immunocompromised.
Health care facilities are reminded of the importance of systematic implementation of infection prevention and control (IPC). Health care facilities that provide care for patients suspected or confirmed with MERS-CoV infection should take appropriate measures to decrease the risk of transmission of the virus to other patients, health care workers and visitors.
All Member States are reminded to promptly assess and notify WHO of any new case of infection with MERS-CoV, along with information about potential exposures that may have resulted in infection and a description of the clinical course. Investigation into the source of exposure should promptly be initiated to identify the mode of exposure so that further transmission of the virus can be prevented.
WHO does not advise special screening at points of entry with regard to this event nor does it currently recommend the application of any travel or trade restrictions.
[In the above update from WHO, new information includes confirmation that this newly reported case is not part of the ongoing outbreak associated with the health care facility in the Eastern Province (Al-Ahsa). In addition, there is mention that at least one of the laboratory confirmed cases in Tunisia had not travelled to Saudi Arabia and Qatar and, therefore, was presumably infected through contact with an individual who had returned from Saudi Arabia and Qatar. Of note, the individual who had travelled to the Middle East and died of SARI [severe acute respiratory illness], was not laboratory confirmed to be infected with the MERS-CoV, but is considered to be a probable case given the history of exposure, the clinical presentation and the identification of MERS-CoV infection in 2 of his [adult] children who were laboratory confirmed.
As of today, 23 May 2013, there have been 44 laboratory confirmed cases of SARI related to MERS-CoV transmission with 22 deaths with a case fatality rate of 50 percent. If one includes "probable" cases in which there was no laboratory confirmation but that clinically and epidemiologically match the case definition (this would include the fatality in Tunisia and the 11 additional cases in Jordan discussed in more detail below), the global tally of known SARI cases associated with MERS-CoV could be at least 56 including 23 deaths (case fatality rate of 41.1 percent).
Given the documented identification of person-to-person spread, including nosocomial, it seems prudent to recommend that all patients presenting with SARI should be approached as potential spreaders of virologic agents of concern and should be treated accordingly in the healthcare setting, even during "epidemiologic quiet periods" (when there aren't global alerts on known new agents or as yet unknown new agents). In the past 10 years, we have seen several newly identified human pathogens producing SARI, 2 of which have been associated with nosocomial transmission enhancement (SARS-CoV and MERS-CoV) and others with limited person-to-person transmission but potential pandemic spread if genetic reassortment of the virus occurs to enhance person-to-person transmission (influenza A-H5N1 and influenza A-H7N9). Mother Nature continues to flex her muscles and demonstrate that she has more up her sleeves to challenge us with, and to this moderator, it seems prudent to consider/implement respiratory precautions when approaching patients presenting with a clinical picture consistent with a diagnosis of SARI until an etiology is clearly identified that does not have potential nosocomial transmission enhancement.
Saudi Arabia reported today [22 May 2013] that a foreigner [non-Saudi Arabian national] died yesterday [21 May 2013] of a MERS-CoV (Middle East respiratory syndrome coronavirus) infection, while health officials in Jordan offered new details-- some of them puzzling -- about a hospital cluster of cases that occurred there in April 2012.
In a brief statement, the Saudi Ministry of Health (MOH) announced "the demise of a non-Saudi case of novel coronavirus in al-Qassim region," a province in the central part of the country. The person was hospitalized a few days ago with a severe respiratory illness and died yesterday [21 May 2013], the statement said.
The MOH gave no information on the patient's age, gender, nationality, previous health status, occupation, residency status, or possible exposures to the virus. The statement noted that no new cases have emerged in the past 5 days in the Al-Ahsa region in Eastern province, site of a hospital-centered MERS-CoV outbreak involving 22 cases.
The announcement comes a day after a press report that a World Health Organization (WHO) expert, Anthony Mounts, MD, expressed concern that guest workers in the Middle East could spread the novel virus to their home countries, particularly India and the Philippines.
The WHO said today [22 May 2013] that the death toll in the Al-Ahsa outbreak has increased to 10 with the death of a patient whose case was announced earlier. The WHO gave no other information about the patient, and it wasn't immediately clear whether the death is the same one that was noted by the Saudi MOH in a [20 May 2013] statement.
Today's [22 May 2013] WHO statement also offered some details on the 2 confirmed MERS-CoV cases and one probable case in a Tunisian family, which were 1st reported by the media 2 days ago. They were the 1st known cases in Tunisia.
The probable case was in a 66-year-old man who fell ill 3 days after returning from a trip to Qatar and Saudi Arabia on [3 May 2013], the WHO said. After being hospitalized, he died on [10 May 2013]. Initial lab tests for the virus were negative, the agency reported.
The 2 confirmed cases involved the man's 34-year-old son and 35-year-old daughter, who had mild respiratory illnesses and were not hospitalized, the WHO said. Officials are still investigating the outbreak and monitoring the patients' close contacts for signs of illness.
The WHO said the global count for MERS-CoV stood at 43 cases with 21 deaths, the same as cited by a WHO official via Twitter yesterday [21 May 2013]. As of this writing, the agency has not yet noted the fatal case announced by the Saudi health ministry today [22 May 2013].
Jordanian cluster ----------------- Details on the Jordanian case cluster were provided yesterday [21 May 2013] in an online report from the Eastern Mediterranean Health Journal, published by the WHO's Regional Office for the Eastern Mediterranean.
The hospital cluster involved 2 confirmed and 11 probable cases in April 2012 [last year]. They marked the emergence of MERS-CoV, but they were not identified as such until about 7 months later, after the discovery of the virus in a Saudi Arabian man and a Qatari in September  [see prior ProMED-mail posts listed below for sequence of cases, reports and confirmations - Mod.MPP].
After the virus was discovered, Jordanian officials sent stored samples from some of the patients to a US Navy laboratory in Cairo, and 2 of them tested positive in November . Both of the confirmed case-patients died, while all the probable cases survived.
Of the 13 confirmed and probable cases, 10 were in healthcare workers (HCWs), and 2 were in family contacts of patients, according to the report by Jordanian Ministry of Health officials. They occurred in the public hospital in Zarqa, Jordan's 2nd-largest city.
Investigators found that the illnesses came in 2 waves or phases: 4 with onset between [21 Mar 2012 and 2 Apr 2012], and 9 with onset between [11 and 26 Apr 2012]. Only 3 patients were women, which is in line with the findings for MERS-CoV cases in general. But the median age was only 33, as compared with a median of 56 years for the recent Saudi case cluster.
The 1st (index) case in the cluster was in a 25-year-old university student who fell ill on [21 Mar 2012] but was not hospitalized until [4 Apr 2012], according to the report. The 2nd and 3rd cases involved a 30-year-old male nurse who fell ill on [30 Mar 2012] and a 40-year-old female nurse who fell ill on [2 Apr 2012]. The 25-year-old and the 40-year-old were the patients who died and whose cases were later confirmed.
The index patient, who died on [25 Apr 2012], had no travel history and no reported contact with animals in the 10 days before his 1st symptoms. His contacts included the 2nd and 3rd case-patients, as well as his mother, who remained healthy.
Oddly, however, the 2nd and 3rd patients fell ill before the 1st case-patient was hospitalized, leaving it unclear how the 2nd patient became infected. Among other possibilities, the authors speculate that the 2 nurses might have been exposed to the index case in an outpatient clinic before he was admitted to the hospital.
The 9 patients in the 2nd phase of the cluster all had probable cases, and all but one were likely to have had significant contact with at least one of the 2 confirmed case-patients, according to the report.
In other findings, the report says:
To prevent "stigmatization of patients," the HCWs didn't use any personal protective equipment except gloves when caring for them.
The HCWs had no recent travel history or reported contact with animals.
None of the patients had renal failure, a condition that has been reported in several MERS-CoV cases elsewhere, though the index case had pericarditis.
The apparent incubation period for the illness was no more than 10 days.
Overall, the findings "suggest that although person-to-person infection is possible, there is no evidence at present of sustained person-to-person transmission of nCoV [novel coronavirus] in relation to this cluster," the authors write.
It has become clear throughout the investigations thus far that the current tests available to identify infection with MERS-CoV are more successful when lower respiratory tract specimens are obtained. When there are mild clinical presentations (not true SARI, but mild respiratory infections) in contacts of known MERS-CoV infected individuals, or when there are retrospectively identified cases who have recovered (as in the cluster in Jordan), current testing available does not seem to permit laboratory confirmation of MERS-CoV infection. Given this observation, while the Public Health community is waiting for results of baseline serosurveys in geographic areas where there have been confirmed MERS-CoV transmission, one wonders how to appropriately interpret results showing "minimal background evidence of MERS-CoV circulation," a clear hurdle to be crossed. A similar situation may be occurring with respect to veterinary samples in the attempt to identify a possible intermediate, veterinary reservoir of this organism. Clearly, there are challenges to be confronted. - Mod.MPP