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25 Jun 2013

Middle East respiratory syndrome- coronavirus (MERS CoV)–Multistate (ECDC/CDTR, June 25 2013, edited)

[Source: European Centre for Disease Prevention and Control (ECDC), full PDF document: (LINK). Edited.]


Week 25, 16-22 June 2013



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

Opening date: 24 September 2012 Latest update: 13 June 2013


Epidemiological summary

The first confirmed case was reported in a 60-year-old male who lived in Saudi Arabia. He died from severe pneumonia complicated by renal failure in Jeddah on 24 June 2012. The genome of the new coronavirus was isolated from this case, sequenced and the genetic code put in the public domain.

In September 2012, a 49-year-old male living in Qatar presented with symptoms similar to the first case. He was transferred to Europe for further care. A virus was isolated from this case, sequenced and the genetic code put in the public domain by the UK authorities. It was found to be almost identical to the virus from the case in Saudi Arabia. The emergence of a novel coronavirus causing severe respiratory disease in two separate parts of the Middle East led to notifications through the International Health Regulations (IHR) and the EU Early Warning and Response System (EWRS) on 22 September 2012.

In November 2012, four additional cases with similar symptomatology were diagnosed in Saudi Arabia, including a family cluster of three confirmed cases, one probable case and a second imported case to Europe (from Qatar to Germany) reported on 23 November.

Subsequently, two fatal cases were confirmed retrospectively in Jordan. Both cases came from a cluster of 11 people with severe lower respiratory infections associated with a hospital in April 2012. Although the other nine persons also matched the WHO definition for probable novel coronavirus infections, the cases were less severe than the two confirmed cases. It has not yet been possible to undertake confirmatory virological or serological testing for these probable cases.

Three additional cases were diagnosed in February 2013 in the UK in a family cluster associated with an index case who had a travel history to Saudi Arabia and Pakistan. These cases included the first two transmissions in Europe. These cases resulted in four cases identified and reported by the UK to date.

At the end of March, a second imported case to Germany was reported: a person seeking medical care arriving from the United Arab Emirates. The patient, a 73-year-old male with underlying clinical conditions, had been hospitalised in United Arab Emirates and was transferred for clinical care to a hospital in Germany where the diagnosis of MERS-CoV infection was confirmed. Despite intensive-care treatment, the patient died on 26 March.

In the beginning of May, twenty-two cases including 10 deaths were reported by Saudi Arabia. All cases belonged to a cluster in Al Ahsa in the Eastern Province of Saudi Arabia, which may be linked to a single healthcare facility. This outbreak was later described in detail in a NEJM article on 19 June.

The first case reported by France on 7 May 2013 was in a French resident with a history of travel to Dubai, United Arab Emirates, in the two weeks prior to onset of illness in France (9–17 April). The 65-year-old man had a history of renal impairment and had sought medical care in France for fever, diarrhoea and lumbar pain on 23 April. Though he did not initially present with respiratory symptoms, pneumonia was subsequently diagnosed and laboratory tests were undertaken for novel coronavirus infection, as recommended by national and ECDC guidance. A naso-pharyngeal specimen was negative for MERS-CoV on 3 May. A bronchoalveolar lavage (BAL) specimen taken on 26 April arrived at the Reference Laboratory on 7 May and tested positive for MERS-CoV. He died on 28 May. On 12 May, France informed ECDC of an additional laboratory-confirmed case. The case is an immunosuppressed male in his fifties who, from 27 to 29 April 2013, shared a hospital room with the first laboratory-confirmed patient in France. This secondary case was identified as part of the epidemiological investigation initiated by the French authorities, following laboratory confirmation of the first case on 7 May 2013. The patient is currently hospitalised. An epidemiological investigation and contact identification was performed. No other cases of MERS-CoV infection were identified among the index case’s 123 contacts, nor among 39 contacts of the secondary case, during the 10-day follow-up period.



ECDC assessment

The additional recent novel coronavirus cases reported by the Saudi Arabian authorities indicate an ongoing source of infection present in the Arabian Peninsula.

The French index case who presented with diarrhoea is a reminder of the possibility that initial presentations may not necessarily include respiratory symptoms, especially in those with immunosuppression or underlying chronic conditions. This needs be taken into account when revising case-finding strategies. This case in France was the second nosocomial transmission in Europe following one reported in the UK in February 2013, highlighting the risk of onward transmission in Europe, in particular in healthcare settings. Both French patients had underlying conditions, and a degree of immunosuppression. One of the transmissions in the UK was also to an immunosuppressed person. These underlying conditions may be increasing the vulnerability and the risk of transmission. Specimens from the upper respiratory tract tested negative for some patients who were later confirmed to be infected by MERS-CoV in samples collected from the lower respiratory tract. Therefore, specimens from patients’ lower respiratory tracts should be obtained for diagnosis where possible.

Information on many of the basic epidemiological indicators required for determining effective control measures are still missing for most cases that occurred in the Middle East, e.g. the reservoir of infection, risk groups, incubation period, period of infectivity and settings where infection has occurred.

The imported cases reported by Germany, France and Italy, following medical evacuation and travel, suggest that more imported cases may be expected in the EU in the future.

Due to the large number of guest workers in Saudi Arabia attention must also be drawn to the possible importation of MERS-CoV to the South East and Pacific Asia.



ECDC published an updated rapid risk assessment on 17 June 2013. The results of an ECDC-coordinated survey on laboratory capacity for testing the novel coronavirus in Europe were published in EuroSurveillance. ECDC is closely monitoring the situation in collaboration with WHO and the European Union Member States.