Thursday, April 24, 2014

WHO Risk Assessment: MERS-CoV (April 24th, 2014)



Coronavirus – Credit CDC PHIL



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The World Health Organization has released an updated Risk Assessment on the MERS coronavirus, which is available in PDF format on their Coronavirus Infections page.  I’ve only posted some extended excerpts, download the full pdf file to read it in its entirety.


Middle East respiratory syndrome coronavirus (MERS‐CoV)
24 April 2014

Summary of available information

Since April 2012, 254 laboratory-confirmed cases of human infection with Middle East respiratory syndrome coronavirus (MERS‐CoV) have been reported to WHO, including 93 deaths. To date, reporting countries in the Middle East include Jordan, Kuwait, Oman, Qatar,Kingdom of Saudi Arabia (KSA) and the United Arab Emirates (UAE); in Europe: France,Germany, Greece, Italy and the United Kingdom (UK); in North Africa: Tunisia; and in Asia:Malaysia and the Philippines.

The occurrence of new cases seems to follow a seasonal pattern, with increasing incidence from March-April onwards. The number of cases sharply increased since mid-March 2014, essentially n KSA and UAE, where two important healthcare-associated outbreaks are occurring.

As much as 75% of the recently reported cases appear to be secondary cases, meaning that they are considered to have acquired the infection from another ifected person. The majority of these secondary cases are mainly healthcare workers who have been infected within the healthcare setting, although several patients who were in the hospital for other reasons are also considered to have been infected with MERS‐CoV in the hospital. The majority of the infected healthcare workers presented with no or minor symptoms. Only four instances of transmission within households have been reported, and no large family cluster has been identified. When human‐to‐human transmission occurred, transmission was not sustained, and to date only two possible tertiary cases have been reported.

The number of cases who acquired the infection in the community has also increased since mid-March. These cases have no reported contacts with other laboratory confirmed cases, and some have reported contacts with animals. Although camels are suspected to be the primary source of infection for humans, the exact routes of direct or indirect exposure remain unknown.

Investigations to identify the source of infection and routes of exposure are still ongoing.Several of the recent cases acquired the infection in KSA or UAE and then travelled to another country, including Greece (1 case), Jordan (1 case), Malaysia (1 case), and the Philippines (1 case). No further transmission has been documented so far. Of note, exported cases occurred in the past that resulted in limited further human‐to‐human transmission (France and UK).

In view of the increasing number of cases – in particular secondary cases, nosocomial outbreaks and exported cases – the WHO risk assessment has been revisited to determine whether transmission pattern has changed and whether sustained community transmission is occurring.

Risk assessment
This risk assessment is based on currently available data and knowledge, and will be updated as more information is made available. The investigations are still ongoing and new findings on, for example, exposures to animal and/or environmental source, transmission chains, risk factors for infection among primary cases and healthcare workers, and serological investigations will be critical to make the risk assessment more robust.

Has the transmission pattern of MERS-CoV changed?

The majority of the cases now reported have likely acquired infection through human‐to‐human transmission and only about a quarter are considered as primary cases, which suggests slightly more human‐to‐human transmission than previously observed.

One hypothesis is that the transmission pattern and transmissibility have not changed and that the occurrence of two large nosocomial outbreaks reflects inadequate infection prevention and control measures, coupled with intensive contact tracing and screening. Several elements would support this hypothesis: i) the clinical picture appears to be similar to what was observed earlier; secondary cases tend to present with a milder disease than that of primary cases;
however, we note that many secondary cases have been reported as asymptomatic; ii) only 2 possible tertiary cases have been reported; iii) the recent exported cases did not transmit further; iv) screening of contacts revealed very few instances of household transmission; and v) no increase in the size or number of household or community clusters has been observed.

An alternative hypothesis is that transmissibility of the virus has increased and is resulting in more human‐to‐human transmission as the basis for the recent upswing in cases. It is possible that current levels of surveillance are missing cases of mild infection within the community. At this point, there is insufficient information on the recent cases to definitively exclude these hypotheses.

Can we expect additional cases of MERS‐CoV infection in the Middle‐East countries?

The way humans become infected from an animal and/or environmental source is still under investigation. More individuals are likely to be infected until the mode of transmission is determined and preventive measures implemented to break transmission from the source to humans. For the third consecutive year, the number of cases increase in March‐April and it is very likely that more primary cases will occur, and consequently further transmission will occur.

Can we expect additional cases exported to other countries and further transmission?

It is very likely that cases will continue to be exported to other countries, through tourists, travellers, guestworkers or pilgrims, who might acquire the infection following an exposure to the animal or environmental source, or to other cases, in a hospital for instance. Whether these cases will further transmit will depend of the capacity of the receiving country to rapidly detect, diagnose and implement appropriate infection prevention and control measures. Of note, further transmission from exported cases did occur in the past, but transmission was not sustained.

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Eurosurveillance Journal: MERS- 2 Years Into The Epidemic


Credit Eurosurveillance



# 8524


From Eurosurveillance Journal this afternoon an editorial penned by the ECDC’s Director Marc Sprenger and  D Coulombier on the first two years of the MERS epidemic, with data current through April 23rd.


This editorial is actually just one of three articles on MERS in this weeks edition, the others focus on the recent imported case in Greece and additional findings of the MERS virus in camels.



All three reports are well worth reading, but the editorial below provides the broadest overview of the situation. I’ve included a few excerpts, but the entire editorial is worth reading.  I’ll have a final comment when you return.



Eurosurveillance, Volume 19, Issue 16, 24 April 2014


Middle East Respiratory Syndrome coronavirus – two years into the epidemic

M Sprenger1, D Coulombier ()1

  1. European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden

Euro Surveill. 2014;19(16):pii=20783. Available online: Date of submission: 24 April 2014

Two years ago, on 23 April 2012, media reported a cluster of severe respiratory infection in a hospital in Jordan [1]. Only several months later did it become evident that this was the first known occurrence of the new Middle East Respiratory Symptom coronavirus (MERS-CoV) that since then continues to puzzle scientists and public health experts alike.


MERS-CoV infections present with a high case-fatality ratio, multiple transmission routes are suspected, cases are reported among healthcare workers, multiple disease foci are affecting SA, and cases have been exported. All these facts are criteria for considering declaring a public health event of international concern listed in annex II of the WHO international health regulations [18]. Two years and 345 cases after the start of this epidemic, we remain with many unanswered questions and lack serological studies and sequences from human cases.

Currently, SA bears the main burden of managing the MERS-CoV epidemic and lately also the UAE. So far, cases detected outside the Arabian Peninsula have not resulted in sustained onward transmission. However, the recent rapid change in the epidemiological pattern of the disease should call for a change of approach to ensure a rapid understanding of the determinants of this emerging epidemic and its effective control, which will require a joint intervention from veterinary as well as human health authorities worldwide.

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Lastly, I quite happily note  that  Flutracker’s , 2012-2014 Case List of MoH/WHO Novel Coronavirus nCoV Announced Cases is among the article’s references and that a very kind hat tip was extended to the bloggers, journalists, flu forum newshounds, and researchers who gather and discuss emerging diseases like MERS on twitter, Facebook,  and elsewhere.

Saudi MOH Announces 12 New MERS Cases




# 8523


The Saudi MOH has released a new MERS-CoV update this morning, listing 12 new cases, and introducing new levels of sophistication in their report.  Gone are the parsimonious and vague 1 line summaries of each case that have caused so much ire over the past year, replaced by some very impressive detail, including onset dates and cases listed by hospital.

A very welcome change.


Once again, Jeddah (Grandmother) leads with 6 cases, followed by Riyadh with 5, and Mecca reports their 6th case in two days. Four cases are listed as working in a hospital environment, including one from Jeddah who is listed as a `hospital receptionist’.


Health) recorded 12 cases of infection with Corona


Daily situation report cases of Corona virus that causes respiratory syndrome Middle East

Thursday, 24 / June / 1435

• The total number of confirmed cases within 24 hours: 12 cases
• The total number of deaths within 24 hours: 2
• distribution of cases on the cities of the Kingdom:


• A summary of the health status of the cases:
 one case without symptoms
 6 cases, in stable condition and receiving treatment in the wing
 5 cases in intensive care
• distribution of cases to hospitals Kingdom:


• Details of the cases:

A - in the city of Riyadh:
1. Citizen at the age of 79 years is suffering from leukemia and cancer of the prostate security forces entered the hospital on 04.01.2014 AD complaining of abdominal pain, and developed respiratory symptoms after a week of Tnoima, and receiving treatment in the intensive care unit on an artificial respiratory system .
2. Filipina nurse nationality at the age of 40 years working in the cardiac unit at the hospital for the military contact with a confirmed case, do not show symptoms
3. Citizen at the age of 76 years suffering from diabetes, high blood pressure, previous stroke, he entered the military hospital on 04/01/2014 symptoms of pneumonia and fluid in the lungs and the suspicion he was diagnosed with tuberculosis and proven passivity of tuberculosis, and on 4/21/2014 m unit increased respiratory symptoms and tested positive for CZK, stable condition, receiving treatment in the wing
4. Citizen at the age of 62 years old, suffers from high blood pressure entered the military hospital on 04.21.2014 AD respiratory symptoms, in stable condition receiving treatment in the wing
5. Citizen at the age of 44 years old, entered the King Saud Hospital for Chest Diseases on 21/04/2014 AD respiratory symptoms, and a stable condition and receiving treatment in the suite.

B - in the Holy City:
1. Filipina nurse nationality at the age of 34 years, and working in a hospital intensive care unit of the light, contact with a confirmed case, and developed respiratory symptoms on 04/21/2014 AD and receive treatment in the wing and in stable condition.

T - in the province of Jeddah:
1. Doctor Syrian nationality at the age of 51 years working in the intensive care unit at King Fahd, developed respiratory symptoms on 19/04/2014 AD stable condition and receiving treatment in the suite.
2. Citizen at the age of 47 years, and entered the King Fahd Hospital in respiratory symptoms on 21/04/2014 AD, and receiving treatment in intensive care on a respirator.
3. Resident Indonesian citizenship at the age of 28 years, she developed respiratory symptoms on 15/04/2014 AD, and entered the hospital, King Saud on 19/04/2014 AD, and receive treatment in intensive care on a respirator.
4. Palestinian residents citizenship at the age of 68 years, developed respiratory symptoms on 20/04/2014 AD, and entered the hospital Bakhsh on 04/22/2014 AD, and receiving treatment in intensive care.
5. Resident Egyptian nationality at the age of 47 years old, works in a hospital receptionist Bakhsh developed respiratory symptoms on 04/19/2014 AD, and receiving treatment in the wing and his health condition is stable.
6. Palestinian residents citizenship at the age of 19 years, developed respiratory symptoms on 04/15/2014 AD, and entered the United Doctors Hospital on 18.04.2014 AD, and receiving treatment in intensive care.

• deaths within 24 hours:
 Two deaths from pre-recorded conditions:
1) citizen at the age of 68 years in the Holy City, God's mercy
2) a citizen at the age of 72 years in Riyadh, God rest her soul.

Saudi MOH Appoints Dr. Tariq Ahmed Madani Special MERS Advisor


Saudi MOH Twitter Account

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The new Saudi Minister of Health Adel bin Mohammed Faqih announced the appointment this morning of Dr. Tariq Ahmed Madani, as a special MERS consultant to the Health Ministry. 


Professor Madani – an infectious disease specialist - has a brief profile posted on the King Abdulaziz University website, which includes details of his discovery of a new viral hemorrhagic fever in 2001.


A formal statement of his appointment was posted a short while ago on the Saudi MOH website:


Health Minister-designate issued a decree appointing Dr. Tariq Madani independent medical consultant to the Ministry of Health

24 June 1435

His Excellency Engineer Adel bin Mohammed Faqih and Health Minister-designate, today, a decree appointing Dr Tariq Ahmed Madani independent medical consultant to the Ministry of Health, part of the ministry's efforts to contain the incidence of HIV Corona Kingdom.

The decision was based on a statement by His Excellency the Minister of Health in charge issued immediately after assuming office, in which he pledged to communicate with permanent society, and coordination with health care experts to gather all the information that was able to stand on the current situation, and determine the extent of the seriousness of the situation and the potential dangers.

And Dr. Tariq Madani took office immediately after the decision of His Excellency the Minister, which will provide specialized consultancy to the Ministry of Health based on long experience in the field of infectious diseases. The work of Dr. Madani as a professor of internal medicine and infectious diseases at the Department of Internal Medicine, Faculty of Medicine - King Abdulaziz University, and has experience of over 20 years in dealing with infectious diseases.

HE Adel Al-Faqih, the Minister of Health in charge: "Based on what is owned by the expertise of medical and wide, will Dr. Tarek to coordinate the plan of urgent medical response to HIV Corona., And we aim to use the expertise and talent to help us to implement our plan effectively, which will enable us to ensure the safety of the public. "

He added: "I wish to reiterate my commitment to the ongoing work to address the Corona virus, is the decision to appoint Dr. Tarek is an important step towards achieving this goal."

So, said Dr. Tariq Madani: "I first would like to thank the Minister of Health in charge of giving me this opportunity. The virus Coruna health challenge facing the Kingdom and a number of countries around the world. For my part, I will do my best to help ensure the health and safety of the public in Saudi Arabia. " It is expected that the Minister of Health in charge of more appointments during the next week.

MERS, Mecca & Umrah



Credit Wikipedia


# 8522


The announcement yesterday of 5 MERS cases detected in and around Mecca has raised renewed concerns over the potential for international visitors to contract, and return home with, the MERS coronavirus.


Earlier this month we learned of a Malaysian pilgrim who died after performing Umrah in late March (see Malaysian MOH Statement On Imported (Fatal) Case Of MERS-CoV), which has resulted in the quarantine of dozens of contacts, and the implementation of ongoing MERS screening at Malaysian airports.


Despite this well reported incident, and recent MERS cases reported in Mecca, Saudi Arabia's Hajj Ministry continues to maintain that no pilgrims have been affected, and dismisses concerns over the risks posed by the MERS virus.


This, published five hours ago,  from Trade Arabia:


'No Umrah cancellations due to Mers'


Saudi Arabia's Haj Ministry denied any cancellation of Umrah reservations in the wake of the Mers virus attacks in the kingdom, an official was quoted as saying.


Abdullah Marghalani, undersecretary at the Haj Ministry, said in an Arab News report that the Saudi Health Ministry is the only official body responsible for issuing health advice for the pilgrimage. “We do not take into account rumours circulating on social networking sites,” he said.


The Health Ministry has reassured residents that the virus has not reached an epidemic stage, he said. This is why the Haj Ministry has not taken precautionary measures so far, he added in the report.


The virus has not affected Umrah pilgrims so far, nor has it had any effect on applications for the Haj and Umrah pilgrimages, he said.


There have been 3.8 million Umrah pilgrims since the beginning of this season, a 30 percent increase from the 2.5 million pilgrims performing Umrah this time last year, the report quoted Marghalani as saying.


All able bodied Muslims are required to make at least one major pilgrimage to Mecca during their lifetime, at the time of the hajj. This is known as the fifth pillar of Islam, and is one of the duties incumbent upon all Muslims.


The faithful may also make `lesser pilgrimages’, called  omra (or Umrah), at other times of the year. These minor pilgrimages don’t absolve the faithful of making the hajj journey unless they take place during Ramadan (this year: June 28th-July 28th).


As a result, the Kingdom of Saudi Arabia (KSA) receives more than 7 million visitors each year, with most of them arriving during the month of Ramadan and during the Hajj ( begins the 1st week of October this year).


With more than 1.5 billion Muslims around the world, the wait for a visa to partake in the Hajj or Umrah can literally take a decade or longer, and many devout save for much their lives in order to make this pilgrimage.  For many, the opportunity to do the Hajj only comes late in life, and any decision to postpone that pilgrimage is a serious one.


Last summer, during Ramadan, the KSA MOH Updated Health Protection Advice For Umrah & Hajj, where they urged the elderly, those with chronic illnesses, immune dysfunctions, as well as pregnant women and children not to make a pilgrimage last year.


This, however, was only a suggestion – not a mandate.   And many people ignored the recommendations.  Luckily, the MERS virus was still only circulating at low levels, and no spike in cases occurred.


We’ll have wait to see what, if any, changes will be made to this year’s Umrah & Hajj recommendations as Ramada grows nearer.  For now, individual countries have begun issuing travel advice, such as the following released by Singapore’s Ministry of Health last week:


Health advisory for Umrah and Haj pilgrims

The World Health Organization (WHO)1 has reported cases of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) infection in Saudi Arabia, Qatar, Jordan and United Arab Emirates. The Ministry of Health (MOH) would like to advise Umrah and Haj pilgrims of the following:

  • Get vaccinated against influenza and meningitis. MOH also recommends pneumococcal vaccination for persons aged 65 years and above, or with chronic medical conditions.
  • Pilgrims with pre-existing chronic medical conditions (e.g. diabetes, chronic bronchitis) should consult a medical practitioner before travelling to assess whether making the pilgrimage is medically advisable.
  • Avoid close contact with persons suffering from acute respiratory infections (e.g. someone who is coughing).
  • Avoid contact with live farm or wild animals.
  • Observe good personal hygiene at all times, and practise frequent hand washing with soap and water, before handling food or eating, after going to toilet, or when hands are dirtied by respiratory secretions after coughing or sneezing and in particular, after direct contact with ill persons or their environment. Persons who are sick are reminded to cover their nose and mouth with tissue when sneezing or coughing, and to dispose of the tissue properly.
  • Wear masks (i.e. surgical masks), especially when in crowded places.
  • Adopt good food safety and hygiene practices and avoid taking undercooked meats, raw fruits and vegetables (unless they have been peeled), or unsafe water.
  • Wear a mask and seek medical attention promptly if you become unwell with fever and cough and/or breathlessness while travelling or within 2 weeks after returning to Singapore, and inform the doctor of your travel history.

Updated: 17 Apr 2014

1 For the latest update, please refer to WHO’s website at:

WHO MERS-CoV Update – Saudi Hospitalized In Jordan


Photo Credit WHO



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The World Health Organization has released an update on the MERS case detected in Jordan earlier this week (see Saudi Hospitalized With MERS In Jordan).  Although he had been hospitalized in the northern city of prior to his diagnosis in Jordan, he had also had recent travel history to Jeddah and Mecca.



Global Alert and Response (GAR)

Middle East respiratory syndrome coronavirus (MERS-CoV) – update

Disease Outbreak News

24 April 2014 - On 22 April 2014, the Ministry of Health of Jordan reported an additional laboratory-confirmed case of infection with Middle East respiratory syndrome coronavirus (MERS-CoV).

The patient is a 25 year-old man from Al Grayat City, Saudi Arabia. He became ill on 9 April, was admitted to a hospital in Saudi Arabia on 10 April and discharged from the hospital on 15 April, against medical advice. As his condition did not improve, he sought medical care at another hospital in Zarka City, Jordan on 19 April, where he was tested positive for MERS-CoV. The patient has underlying medical conditions and has a history of travel to Abha Mecca and Jeddah, Saudi Arabia from 3 to 8 April. He has history of contact with camels and is also reported to have consumed camel milk.

Globally, from September 2012 to date, WHO has been informed of a total of 254 laboratory-confirmed cases of infection with MERS-CoV, including 93 deaths.

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