WHO: Health officials meet to discuss urgent measures for control of novel coronavirus infection (MERS-CoV) #MERS #Coronavirus

Over 80 health officials from countries in the Eastern Mediterranean Region, as well as from France, Germany, Ireland, Italy, Russian Federation and the United Kingdom (UK) will meet in the WHO Regional Office in Cairo from 20 to 22 June to discuss and agree on a collective response plan to counter the threats of novel coronavirus infection to global health.

The emergence of novel coronavirus infection in September 2012, now named Middle East respiratory syndrome coronavirus (MERS-CoV), has raised a global health alert. Although, it is a new, emerging virus that is distantly related to the virus that caused SARS in 2003, the emergence of this novel virus has drawn widespread global attention and concern as the virus has caused death in about 60% of patients so far. About 75% of the cases have been in men and most have occurred in people with one or more major chronic health conditions. The majority of patients infected with the virus required intensive care treatment and currently there are no treatment options available to treat patients infected with this virus. 

As of January 2013, WHO had received reports of laboratory-confirmed cases originating in the following countries in the Region: Jordan, Qatar, Saudi Arabia, and the United Arab Emirates. France, Germany, Italy, Tunisia and the UK also reported laboratory-confirmed cases; they were either transferred there for care of the disease or returned from the Middle East and subsequently became ill. In France, Italy, Tunisia and the UK, there has been limited local transmission among patients who had not been to the Middle East but had been in close contact with the laboratory-confirmed or probable cases.

In view of the fact that the majority of the human infections with MERs-CoV are reported from the Region, the WHO Regional Office for the Eastern Mediterranean is organizing an intercountry meeting on the MERS-CoV outbreak in the Regional Office from 20 to 22 June 2013. The meeting will be attended by senior level health officials of all the countries in the Region. In addition, health officials from France, Germany, Italy and the UK, who have reported imported cases of MERS-CoV infection, are also expected to attend along with officials from Ireland and the Russian Federation.   

Dr Ala Alwan, WHO Regional Director for WHO Eastern Mediterranean is expected to inaugurate this meeting which will also be attended by WHO staff from the Regional Offices for the Eastern Mediterranean and Europe and WHO headquarters, as well as representatives of WHO collaborating centres. The meeting will discuss the current situation in the Region related to the emergence of this virus and review the current level of response and control measures being undertaken in affected countries. At the end of the meeting, countries are expected to agree on a joint action plan that can collectively improve and strengthen public health preparedness measures against MERS-CoV through regional and inter-regional collaboration and partnerships.

http://www.emro.who.int/surveillance-forecasting-response/surveillance-events/mers-cov-meeting-june-2013.html 

Indonesia: Human Case #H5N1 #Birdflu Ministry of Health Report

Translation
June 21, 2013

The Ministry of Health of Indonesia through the Directorate General of Disease Control and Environmental Health, and has been confirmed by the Center for Biomedical and Health Technology Association, Balitbangkes Strathmore University, announced a new case of H5N1 avian influenza infection, on behalf of the RBP (Male, 2 years 6 months) residents Jakamulya South Bekasi, Bekasi, West Java Province.
 
Monday (10/6) reported cases had onset of fever, then went to the doctor in private practice pediatrician and given medication for fever. Because it is still fever, concerned parents to seek treatment RSHG and taken care of by Thyphoid fever diagnosis. However, on Monday (18/6) cases of high fever, cough and progressive shortness of breath experienced. Because of this, refer to RSHB RSHG. Cases in intensive care in the ICU and ventilator. On Wednesday (19/6), based on the analysis of medical, indicated cases of bird flu. However, due to the limitations of the tool, refer the case to the RSPP RSHB Jakarta. At approximately 7:40 pm, a case of getting treatment in the ICU AI RSPP. The hospital has tried its utmost to provide medical help, but due to the deteriorating condition (coma), RBP (late) could not be saved and breathed his last on the same day at approximately 8:40 pm.

Epidemiological investigations have been conducted into the homes of people and the environment by the Ministry of Health Integrated Team, BBTKL-PP Jakarta, Bekasi City Health Department and the Department of Animal Husbandry Bekasi. Based searches, acquired risk factors, namely the possibility of contacts polluted environment in the market which is about 200 meters from the case, because two days before the hospital on Saturday (8/6) cases invited his mother went to the market to buy chicken pieces.

With the increase of these cases, the cumulative number of bird flu in Indonesia since 2005 until this news broadcast is 193 cases with 161 deaths. Meanwhile at the world level, the total number of cases of H5N1 infection since the beginning found to date amounted to 630 cases with 375 deaths.

"WHO data will change, there are 6 states that reported cases of H5N1 avian influenza infection in 2013", said Prof. Tjandra.
 
Previously, only 5 countries had reported cases of H5N1 avian influenza infection in 2013, namely Bangladesh (1 case, 1 death), Cambodia (11 cases, 8 deaths), China (2 cases, 2 died), Egypt (4 cases, 3 dead), Vietnam (2 cases, 1 death).
 
This information is released by Center for Public Communication, Secretariat General of the Ministry of Health. For further information, please contact Halo MOH hotline 500-567; SMS 081 281 562 620, fax: (021) 52921669, www.depkes.go.id website and e-mail address kontak@depkes.go.id.

http://translate.google.com/translate?hl=en&sl=id&tl=en&u=http%3A%2F%2Fsehatnegeriku.com%2F 

Taiwan CDC Reports Human Infection With Avian H6N1

Hat-tip to Mike Coston at Avian Flu Diary

Here's the link:   http://afludiary.blogspot.com/2013/06/taiwan-cdc-reports-human-infection-with.html

USA - Avian Influenza H7N7 - Arkansas Poultry

We have had reports of H7N3 in Mexico, all posted here at Pandemic Information News.  One previous post regarding Mexico is located here.   Now we have H7N7 in Arkansas.  Below is in excerpt from the CDC Website:

From the CDC Website: Three prominent subtypes of avian influenza A viruses that are known to infect both birds and people...

Influenza A H7

Nine potential subtypes of H7 viruses are known (H7N1, H7N2, H7N3, H7N4, H7N5, H7N6, H7N7, H7N8, and H7N9). Most H7 viruses identified worldwide in wild birds and poultry are LPAI viruses. H7 virus infection in humans is uncommon, but has been documented in persons who have direct contact with infected birds, especially during outbreaks of H7 virus among poultry. Illness in humans may include conjunctivitis and/or upper respiratory tract symptoms. In humans, LPAI (H7N2, H7N3, H7N7) virus infections have caused mild to moderate illness, and HPAI (H7N3, H7N7) virus infections have caused mild to severe and fatal illness.

Yesterday, ProMED posted:

AVIAN INFLUENZA (71): USA (ARKANSAS) POULTRY, LPAI H7N7
*******************************************************
A ProMED-mail post
http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases
http://www.isid.org

Date: Wed 19 Jun 2013
Source: KFSM, 5 News [summ., edited]
http://5newsonline.com/2013/06/18/scott-county-chicken-infected-with-bird-flu-poultry-quarantined/


A Scott County chicken has tested positive for avian influenza, commonly known as bird flu, according to the Arkansas Livestock and Poultry Commission.

The commission received confirmation of the positive test Tuesday night [18 Jun 2013] and has quarantined all poultry within a 6.2-mile [10 km] radius of the chicken house facility where the infected bird was located, according to a statement from Governor Mike Beebe's office.

The positive test poses no public health threat, and bird flu (H7N7) cannot be transmitted to people "through the consumption of properly prepared poultry," according to the statement, although bird flu can be spread to people, according to the Centers for Disease Control (CDC).

The commission is coordinating with the U.S. Department of Agriculture (USDA) on response and additional testing, according to the governor's office.

[Byline: Shain Bergan]

--
Communicated by:
ProMED-mail from HealthMap Alerts
<promed@promedmail.org>

[ProMED-mail thanks David D Caveny who submitted the same report.

This particular strain of the virus is regarded as low pathogenic. The commission is clearly acting to try and prevent any spread of the virus. However, the article does not mention any type of decontamination for personnel leaving the facility. It is important for workers not to pass the virus to back yard flocks. It is equally important to determine the source of the virus. Hopefully, as the commission conducts their investigation, they will not discover that the virus was tracked in from a back yard flock or from avian athletes.

Even low pathogenic strains of a virus can cause trade barriers to go into place from trading partners that are concerned.

The state of Arkansas can be located on the HealthMap/ProMED-mail interactive map at http://healthmap.org/r/7neY. Scott County in Western Arkansas can be seen on the map at http://geology.com/county-map/arkansas.shtml. - Mod.TG]

http://www.promedmail.org/direct.php?id=20130620.1782674

Commentary on Taif Gov. Saudi Arabia Outbreak #MERS, #Coronavirus

We have read recently that this virus spreads throughout the hospitals very easily.  A most recent example, is in Taif Governorate, Saudi Arabia. 

Taif is located not far from Mecca (click on map to enlarge)

We had a report from the Ministry of Health  in Saudi Arabia on June 14 of 2 new cases in Taif.

2 days later, on the 16th, we hear that they died:

Furthermore, MOH has announced the death of four cases, who had been previously announced to be infected of this virus; two of them in the Taif and other two in the Eastern Region,...

Then, it got real quiet.  You never like it when it's real quiet, when you're a tracker.  Today, we hear that there were 4 Healthcare workers, in Taif, that have recovered.  Very glad they did.  Very worried that somewhere between June 14 and June 20, the initial 2 cases entered the hospital and infected 4 of their staff.

​Within the framework of the ongoing monitoring and epidemiological surveillance of the novel Coronavirus (MERS-CoV), the Ministry of Health (MOH) has announced that four confirmed cases of this virus have been recorded and all of them have been recovered; bringing the total number of the recovered cases into 14 patients.

The first case was for a 42-year-old Saudi female in the Eastern region, who left the hospital. That is to be added to the three female cases of health practitioners in Taif governorate, ranging their age from 45,39 and 29, and all of them have been recovered,

Saudis say 4 people beat MERS, but another 4 died

CIDRAP
June 20, 2013
Excerpt:

Meanwhile, more than 80 health officials gathered for the 3-day MERS-CoV meeting at the WHO's Eastern Mediterranean Regional Office (EMRO) in Cairo, the office announced in a press release. All the countries in the EMRO region are represented, along with France, Germany, Ireland, Italy, Russia, and the United Kingdom (UK).

"At the end of the meeting, countries are expected to agree on a joint action plan that can collectively improve and strengthen public health preparedness measures against MERS-CoV through regional and inter-regional collaboration and partnerships," the EMRO release says.

Complete article: http://www.cidrap.umn.edu/cidrap/content/other/sars/news/jun2013corona.html

#MERS #Coronavirus Saudi Arabia Ministry of Health Update June 20, 13

[Did I miss an update?  3 Healthcare personnel from Taif?]
June 20, 2013
Translation

he Ministry of Health announces that in the framework of continuous monitoring and epidemiological investigation of the new Corona virus disease MERS-CoV for the registration of four confirmed cases, all converged to heal and thus bringing the total number of cases of God to them 14 cases of recovery.

 

Where the first case of a citizen in the eastern region of the 42-year-old and recovered and was discharged from hospital, in addition to three of the health practitioners in the province of Taif females, ages 45, 39, 29 years تماثلوا to heal. This brings the total number of confirmed cases that converged to heal the 14 cases, thankfully.

 

The ministry also announced that in the framework of the follow-up work and the epidemiological investigation carried out by the competent committees, the number of samples that have been tested over the past three days 308 samples were negative, but what has been announced.

 

http://www.moh.gov.sa/HealthAwareness/Corona/PressReleases/Pages/mediastatement-2013-06-20-001.aspx 

Vietnam: Add 1 room deaths from influenza A H1N1 in Vinh Long #H1N1

[This may be the 2nd death in Vinh Long.  My list names these two cases

Name:  Woman

From:  Long Tan Commune, Vinh Long Prov.

Onset:  6/11

Adm:  6/15

Note:  Bought chicken at market in commune on 6/8.

DOD:  6/16.

Name:  55yo

From:  16B Dinh Tien Hoang St., Ward 8, Vinh Long

Adm:  Gia Dinh Hospital, Vinh Long

DOD:  6/14

Note:  Was in Cancer Treatment 12.6 days (12 ½).  Showed signs of illness and went to Gia Dinh Hospital.

  

6/18/13
Translation

Dr. Nguyen Thanh Tu, director of the Center for Preventive Medicine in Vinh Long province, said Nguyen Van Luong patients (55 years old, live number 16B Dinh Tien Hoang Street, Ward 8, Vinh Long) died in Gia Dinh People's Hospital (HCMC) on 14.6.

Test results showed that patients positive for influenza A H1N1 . Thus, in the present moment, Vinh Long had 2 patients died due to influenza A H1N1 comfort.

Immediately after receiving the results, the authorities have to Luang his family to monitor, sample, spraying processing environment, instruction hygiene measures to prevent infection ...

Dr. Nguyen Thanh Tu, earlier, he Luong cancer treatment in Vietnam. 12.6 days, Mr Luong signs of illness with suspected influenza should Gia Dinh People's Hospital for tests and had a positive result for influenza A H1N1. 

http://www.thanhnien.com.vn/pages/20130618/them-1-ca-tu-vong-nghi-do-cum-a-h1n1-tai-vinh-long.aspx 

Vietnam: TPVL urgently directing prevention of influenza A #H1N1 and #H5N1

Translation
6/20/13
Faced with the evolution of influenza A/H1N1 and A/H5N1 influenza in the area of ​​Vinh Long town, afternoon 19/6 City People's Committee has convened a meeting with the health sector and 11 communes in the province to direct measures prevention measures implemented AI.

At the meeting the delegates proposed to continue to strengthen the propaganda of animal epidemic prevention and control measures, disease surveillance tight playback outbreak to immediately handle properly organized in accordance prevention . Committee also directed the city to closely monitor the health sector, the rapid deployment to areas where Ward 8 1 A H1N1 influenza cases to handle, time stamping. In addition, the city also continues to supplementary vaccination vaccine batch 1/2013 on the newly emerging flocks and herds timed immunity, vaccination conduct phase 2/2013 in accordance with regulations.

Faced with bird flu and influenza A H1N1 is complicated, besides proactive prevention measures of functional departments, people need active prevention by washing hands frequently with soap and hygiene individuals, antiseptic gargle with water, when to wear a crowded place. /.

http://thvl.vn/?p=283168 

#MERS #Coronavirus WHO Summary Update Comments on Children Infected

A few comments on the latest WHO Summary and literature update as of 20 June 2013.

The more recent cases were similar in age and sex to previously reported cases, except for a 2-year-old with chronic pulmonary disease from Jeddah.

Two recent cases also represent the first documentation of infection in children, although one previously unconfirmed probable infection occurred in a Saudi teenager.

I am to assume they are speaking of these cases (off my personal list):

Case Number—Name—From—Onset—Condition--DOD

From the Saudi Arabia List

#8—14(F)—Eastern Reg.—5/29--—Stable

#18—2—Jeddah—ICU—Reported on 6/16

From the Italy list
#2—18mos.(F)—Florence—Adm 6/1—Discharged 6/5

WHO MERS-CoV Summary and Literature Update 20 June 2013

[This will replace the Literature & Summary update of 17 May 2013.]

Since April 2012, there have been 64 laboratory-confirmed cases of human infection with Middle East respiratory syndrome coronavirus (MERS-CoV); 72% have been male. Thirty-eight of the confirmed cases have died. Affected countries in the Middle East include Jordan, Saudi Arabia, the United Arab Emirates (UAE), and Qatar. Cases have also been reported by four countries in Europe, France, Germany, the United Kingdom (UK) and Italy, and by one country in North Africa, Tunisia. All of the European and North African cases have had a direct or indirect connection to the Middle East. However, in France, the UK, Tunisia and Italy, there has been limited local transmission among close contacts who had not been to the Middle East.

Among the new laboratory-confirmed cases of MERS-CoV reported since the last update on 31 May 2013, three have been reported by Italy. In this cluster, the index case, a 45-year-old Italian resident, travelled to Amman, Jordan in mid-April. He developed mild respiratory symptoms one day before returning home to Italy in late May. He was admitted to hospital with pneumonia 3 days after returning home. Nasopharyngeal (NP) and throat swabs taken on the day following admission were positive for MERS-CoV. He had no underlying chronic medical conditions, but was noted to be obese. He recovered and was discharged home after a week in hospital. Contact monitoring was conducted in Italy, and two developed respiratory symptoms: a 42-year-old co-worker and a 14-month-old close relative. Both tested positive for MERS-CoV. The two contacts had each been exposed to the 45-year-old man on a single day, and their illnesses began 3 and 4 days, respectively, after that exposure. Both had mild illnesses and recovered uneventfully. Follow up was also done on close contacts in Amman, Jordan. Four symptomatic and six asymptomatic contacts had NP swabs collected for testing; all were negative for MERS-COV.

The Ministry of Health in Saudi Arabia has also notified WHO of additional laboratory-confirmed cases of MERS-CoV with onset in late May and early June. These include cases from the Ta’if Governorate, Wadi Al-Dawaser, and Hafar Al-Batin; the first reported from these areas. The more recent cases were similar in age and sex to previously reported cases, except for a 2-year-old with chronic pulmonary disease from Jeddah.

Although the exact timing and nature of exposures that result in infection is usually unknown, for those cases for which exposure is known or strongly suspected, the incubation period for laboratory confirmed cases of MERS-CoV is generally less than one week. However, in at least one case the known exposure occurred 9 to 12 days prior to onset of illness. Further evidence in cases exposed over a range of time suggests that, at least in a minority of cases, the incubation period may exceed one week but is less than two weeks.

Evidence is also accumulating to suggest that nasopharyngeal swabs are less sensitive for detecting infection with MERS-CoV than specimens taken from the lower respiratory track. Currently, no head-to-head comparisons are available on the two approaches to diagnosis. However, in a number of patients, NP swabs have been negative at one point during the course of illness while lower respiratory specimens were positive at another time during the same illness. In addition, in several clusters, patients who were strongly suspected of having MERS-CoV infection because of direct exposure and severe respiratory illness had NP swabs that tested negative, while other confirmed cases in the cluster had lower respiratory track specimens that tested positive.

Recent papers/guidelines published since the last update

On 5 June 2013, WHO published updated guidance on travel recommendations for MERS-CoV (http://www.who.int/ith/updates/20130605/en/index.html). The document does not provide specific guidance for preventing MERS-CoV infection as the source of the virus is still unknown. However, it does provide general infection prevention recommendations for travelers along with recommendations for clinicians who care for travelers returning from the affected area who develop respiratory illness.

Summary assessment

The newest cases reported indicate that the source of infection, which has still not been determined, remains active in the Middle East and is present throughout a large area, including new regions in Saudi Arabia. The Italian case with history of travel to Jordan, suggests the continued risk of infection within Jordan, where no confirmed cases have been identified over 1 year despite ongoing surveillance. This cluster also represents the first time that a co-worker has become infected in a work setting other than a health care facility.

Two recent cases also represent the first documentation of infection in children, although one previously unconfirmed probable infection occurred in a Saudi teenager. While the virus continues to infect predominantly those who are middle aged or older, this demonstrates that children are also at risk of contracting MERS-CoV. In the two confirmed cases in children and the previous probable case, the illness was relatively mild.

WHO is currently reviewing surveillance recommendations based on recent observations that the incubation period may exceed 10 days in some patients. In addition, WHO now strongly recommends the collection of lower respiratory specimens such as sputum, endotracheal aspirate or bronchoalveolar lavage for diagnostic polymerase chain reaction (PCR) when possible. If initial testing of a nasopharyngeal swab is negative in a patient strongly suspected to have MERS-CoV infection, patients should be retested using a lower respiratory specimen or a repeat upper respiratory specimen with an additional oropharyngeal specimen if lower respiratory specimens are not possible. The addition of acute and convalescent serology should be considered as an additional diagnostic test when results of PCR testing of respiratory specimens are inconclusive.

As reported in previous updates, human-to-human transmission has not been observed to persist beyond small clusters of individuals with close contact. However, it is likely that more sporadic cases with subsequent limited transmission will occur in the near future. The large number of cases with reported co-morbidities suggests that persons with underlying medical conditions may have increased susceptibility to infection. Health care facilities dealing with patients suspected of being infected with MERS-CoV should exercise appropriate infection control measures. Clinicians should be aware that MERS-CoV infection may present atypically, and initially without respiratory symptoms, in immunocompromised individuals.

WHO continues to request that Member States report all confirmed and probable cases along with information about their exposures, testing, and clinical course to inform the most effective international preparedness and response.

 http://www.who.int/csr/disease/coronavirus_infections/update_20130620/en/index.html

Saudi MERS outbreak shows SARS-like features #Coronavirus #MERS

June 20, 2013
Editing is mine - Excerpt:

Toronto SARS doctor calls high attack rate of MERS coronavirus unnerving

A long-awaited report on a large and possibly still ongoing outbreak of MERS coronavirus in Saudi Arabia reveals the virus spreads easily within hospitals, at one point passing in a person-to-person chain that encompassed at least five generations of spread.
-snip-
"This virus is closer to SARS than anything else," McGeer, an infection control expert at Toronto's Mount Sinai Hospital, said in an interview from Cairo, where she was attending a World Health Organization meeting on MERS on Wednesday. She travelled to Al-Hasa to help investigate the outbreak in May and was on a WHO mission to Saudi Arabia earlier this month.
"If you want to think about how you're going to prevent and manage hospital outbreaks, SARS is the place that all of us would start."

Full article:  http://www.cbc.ca/news/health/story/2013/06/20/mers-coronavirus-saudi-arabia-nejm.html

Kuwait: health officials are seeking in Cairo ways to counter the virus 'Corona' #MERS #Coronavirus

Translation

Kuwait participates in the meetings of the Eastern Mediterranean Region of the World Health Organization in Cairo to discuss measures and actions needed to cope with the virus, "Corona." 
Kuwait delegation headed by Undersecretary of the Ministry of Health Assistant Undersecretary for Public Health d. Qais Douiri and membership of the Director of the Department Dr. laboratories. Ibrahim Almaziraei and Director of Infection Prevention d. Haifa Al-Mousa and Associate Laboratory Director for the World Health Organization (WHO) d. WA captain and head of public health laboratories d. Arrows mufti and head of the health department ports and borders d. Sami Nasser, Head of the Epidemiology Unit d. Musab al-Saleh. 80 officials from his part, said Regional Director of World Health Organization (WHO) d.Ala Alwan said that "more than 80 health officials in the countries of the Eastern Mediterranean Region, in addition to France, Germany, Ireland, Italy, the Russian Federation and the United Kingdom will meet in the Regional Office of the World Health Organization in Cairo during the period from 20 to 22 June to discuss and agree on a plan collective response to threats from virus infection Koruna. " He said that the meeting will be attended by officials from the WHO regional office for the Eastern Mediterranean, Europe and the headquarters of the Organization, as well as representatives of the collaborating centers with the World Health Organization for the Eastern Mediterranean Health Organization Global, adding that he will discuss the current situation in the region where she appeared infected cases and deaths from the virus, and reconsider the current level of response and control measures being undertaken in the affected countries. predicted Alwan agree participating States to a joint action plan can improve collectively and strengthen preparedness measures against the virus through cooperation and regional partnerships and among regions. virus, the Middle East and noted a statement issued by the organization that the "virus infection Koruna appeared in September 2012, and now named virus Middle East coronavirus pneumonia," noting that "this virus has raised the case alert WHO and drew worldwide attention and widespread and of great concern, and caused the death of about 60% of patients who have had so far, "and was about 75% of cases in men. statement said that "with effect from the first of January, WHO has received Global reports of laboratory confirmed the emerging countries in the region, namely Jordan, Qatar, Saudi Arabia, and United Arab Emirates. was also informed France, Germany, Italy, Tunisia and the United Kingdom laboratory-confirmed cases, indicating that the infected cases in those countries are either returning from the Middle East or I moved to them where she was in close contact with a laboratory-confirmed cases or potential.

http://tinyurl.com/mk8kx4m

New England Journal of Medicine Report: Hospital outbreak of Middle East respiratory syndrome coronavirus - bullet points

So many things were divulged from this report, I'll put them down below.  CIDRAP has posted the most information, and their article is located here.  These facts are from that article.  We are speaking of the Al-Hufuf cluster that took place in Al-Ahsa Saudi Arabia earlier this year.  It was a cluster of 23 people and has been listed and reported on thoroughly here at the blog.  A recent post regarding this study, with comments and lists of cases is  located here.

• The report covers 23 confirmed cases that were identified between from Apr 1 to May 23; 11 probable cases also are considered part of the outbreak.
• 21 of 23 cases involved person-to-person transmission in healthcare facilities
• As of Jun 12, 15 of the 23 patients (65%) had died, 6 had recovered, and 2 remained hospitalized
• Most of the patients were men, and the median age was 56
• The team monitored 217 household contacts of patients with confirmed cases. They found only five cases—three confirmed and two probable—in adult relatives of three of the patients
• In mapping transmission chains, the team found that one patient passed the infection to seven other people, one passed it to three others, and four transmitted it to two persons each.
• The median incubation period in the outbreak was 5.2 days (95% confidence interval, 1.9 to 14.7 days).
• they couldn't answer another key question about the virus: whether person-to-person transmission occurred through respiratory droplets or direct or indirect contact and whether aerosol transmission occurred over a distance of more than 1 meter

• The report says the pattern of the outbreak is consistent with the assumption that patients were infectious only when they had symptoms, but this doesn't rule out transmission during the incubation period or during asymptomatic infection.       

 
The article can be found here:  http://www.nejm.org/doi/full/10.1056/NEJMoa1306742

CIDRAP: Report: Saudi MERS hospital outbreak had some SARS-like traits

[CIDRAP posts an excellent informative article on the NEJM document, previously commented on at this blog here and here.  The bolding and editing below is mine.  This report is chock full of information.]

Robert Roos  News Editor

Jun 19, 2013 (CIDRAP News) – A study of the recent hospital outbreak of MERS-CoV (Middle East respiratory syndrome coronavirus) in Saudi Arabia reveals, among other things, that the virus spread in three hospitals and that some patients transmit it much more than others do.

The report, published today in the New England Journal of Medicine, shows that 21 of 23 cases involved person-to-person transmission in healthcare facilities, and that 9 cases were in hemodialysis patients.

Testing of more than 400 healthcare workers and household contacts of MERS patients turned up only 7 additional cases, the report says, which supports previous findings that the virus doesn’t spread very readily. Investigators found that some patients didn't spread the virus to anyone else, but one of them infected seven others.

The report was prepared by a large international team with members from Saudi Arabia, Canada, the United Kingdom, and the United States.

All the hospitals involved are in Al-Hufuf (also spelled Al-Hofuf) in Al-Ahsa governorate of eastern Saudi Arabia. The report covers 23 confirmed cases that were identified between from Apr 1 to May 23; 11 probable cases also are considered part of the outbreak.

As of Jun 12, 15 of the 23 patients (65%) had died, 6 had recovered, and 2 remained hospitalized, the report says. Most of the patients were men, and the median age was 56. Disease manifestations included fever in 20 patients, cough in 20, shortness of breath in 11, and gastrointestinal symptoms in 8.

Most of the cases occurred at one general hospital, called hospital A, which has 150 beds, plus a dialysis unit. The event began on Apr 5 with admission of a patient with dizziness and sweating, followed by a fever 3 days later. He was not tested for MERS-CoV, but his son later had a confirmed case.

Another patient, who was on dialysis, was admitted Apr 6 and put in a room next to the first patient. By Apr 11 he had a fever, and he underwent dialysis in the hospital on Apr 11 and 13. Between Apr 14 and 30, MERS-Cov was confirmed in nine more patients who were receiving dialysis in hospital A. Eight of these cases developed before or within 1 day after infection control steps were taken in the dialysis unit.

One dialysis patient who had a confirmed MERS-CoV infection was admitted to a medical ward on Apr 21. In the following week, two other patients, located two and three rooms away from the dialysis patient, fell ill with the infection.

The virus spread to "hospital C" when a patient who was infected at hospital A underwent dialysis at hospital C while sick. Two other patients at the latter hospital subsequently were infected.

In addition, eight MERS-CoV patients were transferred to "hospital D," a regional referral hospital. One of those patients passed the virus to two others at hospital D, and another passed it to a physician there, the authors concluded.

The team monitored 217 household contacts of patients with confirmed cases. They found only five cases—three confirmed and two probable—in adult relatives of three of the patients. One of them was treated at another hospital, "hospital B," where the report lists no other cases.

Only two confirmed cases were detected among more than 200 healthcare workers who were monitored after exposure, according to the report.

In mapping transmission chains, the team found that one patient passed the infection to seven other people, one passed it to three others, and four transmitted it to two persons each. The authors say this variability in transmission is "reminiscent of SARS" (severe acute respiratory syndrome), which is caused by another coronavirus. Some patients in the SARS epidemic in 2003 were described as "super spreaders."

The median incubation period in the outbreak was 5.2 days (95% confidence interval, 1.9 to 14.7 days). On the basis of recent MERS cases, the World Health Organization has said the incubation time may run as long as 10 to 14 days.

The investigators obtained full genome sequences from isolates from four patients. From a phylogenetic analysis of these sequences and from other data, they estimated that the date of the most recent common ancestor of MERS-CoV was Aug 18, 2011. This broadly agrees with the conclusion of a German team that, in a Lancet Infectious Diseases report this week, estimated the date of the most recent common ancestor as mid-2011.

The authors were unable to determine if the hospital outbreak involved just one, or more than one, transmission of the virus from the community.

Also, they couldn't answer another key question about the virus: whether person-to-person transmission occurred through respiratory droplets or direct or indirect contact and whether aerosol transmission occurred over a distance of more than 1 meter.

The report says the pattern of the outbreak is consistent with the assumption that patients were infectious only when they had symptoms, but this doesn't rule out transmission during the incubation period or during asymptomatic infection.

In other findings, the authors note that the survival rate was higher for patients who were identified through active surveillance than for those who were identified clinically. They say the likely reason was that active surveillance was better at picking up less-severe disease.

Assiri A, McGeer A, Perl RM, et al. Hospital outbreak of Middle East respiratory syndrome coronavirus. N Engl J Med 2013 (Early online publication). [Abstract]

http://www.cidrap.umn.edu/cidrap/content/other/sars/news/jun1913hospital.html