UK: PHE Updated Risk Assessment On MERS-CoV

Credit ECDC

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It has now been 11 weeks since the Saudi MOH last publicly reported any MERS-CoV cases, and dismantled months worth of existing data from their surveillance website.  Since mid-May we've been limited to monthly summaries from WHO EMRO, and a single WHO report.

The Saudi press has been equally silent these past couple of months, and mention of  كورونا  - aka the  `Corona' virus - has been eerily absent from Arabic social media. 

During the month of June, which is historically the most active month for MERS cases, only 4 cases were reported to the WHO. While the number of human infections may have truly fallen off a cliff, the recent lack of public reporting doesn't exactly instill confidence.

With the Hajj now less than 3 weeks away, when international visitors to the Holy sites in the Kingdom will surge, public health authorities around the world are preparing for the possible importation of MERS cases.

Overnight, Korean officials announced they were testing a nurse - recently returned from working at a Saudi Arabian hospital - for suspected MERS-CoV after she developed mild respiratory symptoms (see Korean Times Suspected MERS patient tests negative, awaits 2nd test).

While this appears to be a low probability case, South Korea's traumatic 2015 outbreak - which was sparked by a single imported case but exploded into 186 patients across 16 hospitals -  left an indelible mark on their national psyche  (see Study: Burnout & PTSD Among Nurses Working During A Large MERS-CoV Outbreak - Korea, 2015)

Since MERS can present with a wide array of symptoms - ranging from mild fever to severe pneumonia - anyone who develops respiratory symptoms or fever within two weeks of returning from the Mid-East is immediately suspect.

This complicates MERS detection greatly, as a 2012 study published in  Clinical Infectious Diseases (co-authored by former Saudi Deputy Minister of Health, Ziad Memish), called  Unmasking Masks in Makkah: Preventing Influenza at Hajj –  found:.

Each year more than 2 million people from all over the world attend the Hajj pilgrimage to Saudi Arabia. At least 60% of them develop respiratory symptoms there or during outward or homebound transit [1, 2]

While things appear relatively quiet on the MERS front, the UK's PHE (Public Health England) has published an updated Risk Assessment, including travel advice or this year's Hajj, that emphasizes the need for vigilance, stating:

travellers developing fever and a cough within 14 days of travel from the Middle East with should seek medical advice and must report their travel history so that appropriate clinical assessment, infection control measures and testing can be undertaken

All of which means - even if no MERS cases are exported - that public health entities around the world will be extra busy towards the end of August and well into September screening suspected cases.  The full guidance follows:

Guidance
PHE risk assessment of MERS-CoV

Updated 31 July 2018

Contents
1. Epidemiological update
2. MERS-CoV in Saudi Arabia
3. Risk assessment
4. Travel advice
5. The Hajj

1. Epidemiological update

As of 24 July 2018, 2,229 cases of Middle East Respiratory Syndrome (MERS-CoV) have been reported to WHO with at least 791 related deaths. The majority of MERS-CoV cases have been reported from the Arabian Peninsula, with one large outbreak outside this region involving 186 cases in the Republic of Korea (RoK) in 2015. Cases have been exported to countries outside of the Middle East, with the most recent being identified in Malaysia in January 2018. This case was a Malaysian Umrah pilgrim who had visited a camel farm while in Saudi Arabia.

Excluding the outbreak in RoK, over 90% of all reported cases of MERS-CoV have been from the Kingdom of Saudi Arabia (KSA). Dromedary camels in the Middle East are an identified host and the likely source of infection in sporadic human cases. There is currently no evidence of sustained community transmission; human-to-human transmission is most likely to occur in healthcare facilities and household clusters. Large outbreaks linked to healthcare facilities are a feature of MERS-CoV and have occurred both within the Middle East and RoK. This underlines the significance of exposure to healthcare facilities in affected countries as a risk factor for infection, but also the importance of effective and rapid implementation of infection prevention and control practices for possible cases to limit the potential for onward transmission.

2. MERS-CoV in Saudi Arabia

In KSA, cases of MERS-CoV occur throughout the year, with occasional peaks which are a result of large hospital outbreaks; for example, 3 hospital outbreaks were reported from Riyadh in June 2017 leading to a peak in cases. Outside of these hospital outbreaks, the majority of cases are sporadic and usually occur in individuals with a history of contact with camels or camel products such as consumption of raw camel milk. PHE will continue to monitor the situation in KSA.
3. Risk assessment

There continues to be a risk of imported cases to the UK, and health professionals should remain vigilant. Early identification and rapid implementation of appropriate infection control measures for suspected cases is crucial.

The risk of infection with MERS-CoV to UK residents in the UK remains very low.

The risk of infection with MERS-CoV to UK residents travelling to the Middle East is very low but may be higher in those with exposure to specific risk factors within the region, such as camels (or camel products) or the local health care system.

Although the risk of MERS-CoV in individuals who meet the case definition for a possible case in the UK following travel to/from the Middle East is low, testing for MERS-CoV is warranted together with rapid implementation of appropriate infection control measures while awaiting results of testing.

The probability that a cluster in the UK of cases of severe acute respiratory infection of unexplained aetiology requiring intensive care admission is due to MERS-CoV remains very low but warrants investigation and testing. A history of travel to the Middle East would increase the likelihood of MERS-CoV.

The majority of outbreaks of MERS-CoV in the Middle East have been linked to healthcare settings. A previous WHO mission to Saudi Arabia concluded that gaps in infection control measures have most likely contributed to these outbreaks; this reinforced the importance of strict adherence to recommended infection control measures in healthcare facilities.

Where UK infection control procedures have been followed, the probability that a case of acute respiratory infection in a healthcare worker caring for a MERS-CoV case or a case of severe acute respiratory infection of unknown aetiology in ICU, is due to MERS-CoV is very low, but warrants testing; any healthcare worker who had recent contact with a confirmed case developing an acute respiratory illness would be tested for MERS-CoV. The risk will be higher for healthcare workers exposed to MERS-CoV who have not adhered to UK infection control procedures such as use of adequate personal protective equipment.

The risk to contacts of confirmed cases of MERS-CoV infection is low but contacts should be followed up for 14 days following last exposure and any new febrile or respiratory illness investigated urgently for MERS-CoV.

Further information and guidance on MERS-CoV is available on online

4. Travel advice

All travellers to the Middle East are advised to avoid contact with camels as much as possible:

• travellers should practice good general hygiene measures, such as regular hand washing with soap and water at all times, but especially before and after visiting farms, barns or market areas
• travellers are advised to avoid raw camel milk and/or camel products from the Middle East
• more generally, travellers are also advised to avoid consumption of any type of raw milk, raw milk products and any food that may be contaminated with animal secretions unless peeled and cleaned and/or thoroughly cooked
• travellers should follow the advice of local health authorities; there are currently no travel restrictions in place
• travellers developing fever and a cough within 14 days of travel from the Middle East with should seek medical advice and must report their travel history so that appropriate clinical assessment, infection control measures and testing can be undertaken
• people who are acutely ill with an infectious disease are advised not to travel but to seek health advice immediately

5. The Hajj

The most recent annual Muslim pilgrimage to Mecca in Saudi Arabia, known as the Hajj, took place between 30 August and 4 September 2017. This took place with no reported increase in travel related cases. However, cases of MERS-CoV have been imported to countries outside of Saudi Arabia following return from Umrah, a minor pilgrimage, as illustrated by the most recent Malaysian case. The Foreign and Commonwealth Office has stated that the 2018 Hajj is expected to take place between 19 August and 24 August 2018.

PHE remains vigilant and closely monitors developments in the Middle East and in the rest of the world where new cases have emerged and continues to liaise with international colleagues to assess whether our recommendations need to change.

PHE has published infographics for people travelling to or returning from the Middle East. These are available in a range of languages online.

NaTHNaC publishes travel health advice for Hajj and Umrah

Health professionals can access the possible MERS case definition online

While 99.999% of all returning travelers from the Middle East with respiratory symptoms will undoubtedly have something far less exotic or dangerous than MERS, the 2015 outbreak in South Korea is proof that it only takes one getting through to spark a national crisis.

For more on the Korean experience, and how France handled their clinical management of suspected MERS cases in Paris between 2013 and 2016, you may wish to revisit last week's BMC Inf. Dis.: Clinical Management Of Suspected MERS-CoV Cases.