Posted on 02ND JAN 2018
tagged MERS-CoV, Malaysia, Saudi Arabia, United Arab Emirates, Oman

A ProMED-mail post
ProMED-mail is a program of the
International Society for Infectious Diseases

In this update:
[1] Malaysia ex Saudi Arabia - media report
[2] Saudi Arabia 5 new cases - MOH 22-31 Dec 2017
[3] UAE ex Oman, 1 new case - WHO 22 Dec 2017

[1] Malaysia ex Saudi Arabia - media report
Date: Mon 1 Jan 2018
Source: Outbreak News Today [edited]

Malaysian health officials have confirmed a case of Middle East respiratory syndrome (MERS-CoV) infection in a returning Umrah pilgrim, according to a release from director-general Datuk Dr Noor Hisham Abdullah today (computer translated [original from the director general of health, available at]).

The patient, a 55 year old man from Selangor, returned home from the pilgrimage on [23 Dec 2017]. On [24 Dec 2017], he had symptoms of fever, cough, weakness, fatigue, and leg pain. The patient sought treatment from the clinic near his home, where he had been treated for fever. Later on [28 Dec 2017], he came to Tengku Ampuan Rahimah Hospital (HTAR), Klang Hospital and was admitted to the HTAR ward for further examination and treatment.

Recognizing the history of his new journey back from performing Umrah, the MERS-CoV screening test was carried out and it was positive both for the screening test conducted by the Sungai Buloh Hospital on [30 Dec 2017] and for subsequent verification tests conducted by the Institute for Medical Research (IMR) on [31 Dec 2017]. Currently, the patient is in a stable condition and has been referred to Sungai Buloh Hospital for further treatment. The patient has said that while in the Holy Land, he was taken to a camel farm, where he then drank raw camel milk and came in contact with the camels found on the farm.

The Ministry of Health is performing prevention and control activities, including detection and monitoring of close contacts such as family members, Umrah pilgrims in the same group, healthcare professionals involved in his treatment, and close contacts among patients. Prevention and control of infections among health workers has been enhanced at all levels and the health status of those involved in handling related cases is being monitored. Recent developments about those involved will be communicated from time to time.

According to the reports by World Health Organisation (WHO), it is still uncertain as to what causes the spread of MERS-CoV. "Activities such as touching camels, eating and drinking raw or not perfectly cooked camel products such as milk and meat, will [put a person at risk of contracting MERS-CoV infection]." WHO stresses that the spread of the infection is still unknown and there is no vaccine for MERS-CoV infection, or specific medicine to treat it. WHO also does not issue any travel advice or travel restrictions to the countries' involved.

The Umrah is an Islamic pilgrimage to Mecca, Hijaz, Saudi Arabia, performed by Muslims, which can be undertaken at any time of the year.

[byline: Robert Herriman]

communicated by:

[This is the 2nd case of MERS-CoV infection in a returning Umrah pilgrim to Malaysia. The 1st case was reported in April 2014 (see MERS-CoV - Eastern Mediterranean (32): Saudi Arabia, UAE, Malaysia, WHO, RFI 20140417.2411430 and MERS-CoV - Eastern Mediterranean (31): Saudi Arabia, Malaysia, UAE, Philippines 20140416.2406647). Both cases gave a history of a visit to a camel farm where there was direct contact with camels and raw camel milk was consumed.

Since the early reports of MERS-CoV in 2012, there have now been a total of 9 cases of MERS-CoV infection associated with Umrah pilgrims. In 2013 there was 1 case reported by Qatar; in 2014, 1 case each reported by Malaysia and Turkey (diagnosed in Saudi Arabia), and 2 cases each reported by Algeria and Iran (cases with contact with returning Umrah pilgrim); in 2015 another Umrah pilgrim returning to Iran; and this newly reported case from Malaysia. Of note, there have been no cases of MERS-CoV infection associated with returning Haji's (individuals attending the Haj pilgrimage). During the Haj, camels are banned from the area where Hajis are permitted to visit, and health facilities are serving individuals attending the Haj exclusively, thereby reducing the possibility of identified key high risk exposures -- contact with camels or raw camel products and contact with the health services outside the area of the Haj. Hence, Umrah pilgrims can plan their own itineraries (which clearly still include visiting camel farms) whereas the Haji's movements within the country are fairly restricted.

While it will be interesting to know the location of the camel farm visited, newly confirmed cases reported by Saudi Arabia during December 2017 have come from Riyadh (3 cases), Al Qaṣīm (2 cases), Makkah (2 cases), Al Jawf (1 case) and `Asīr (1 case), suggesting fairly widespread distribution of infections in the country. - Mod.MPP

HealthMap/ProMED map
Selangor, Malaysia:]

[2] Saudi Arabia 5 new cases - MOH 22-31 Dec 2017
Date: Sun 31 Dec 2017
Source: Saudi MOH 22-31 Dec 2017

As of Mon 1 Jan 2018, there have been a total of:
1756 laboratory-confirmed cases of MERS-CoV infection, including
710 deaths [reported case fatality rate 40.4 per cent],
1031 recoveries, and
15 currently active cases/infections.

[As previously mentioned, the numbers of deaths, recoveries, and currently active cases come from my spreadsheet tallies and differ from those listed on the Saudi MOH website; my spreadsheet counts asymptomatic infections as they are reported. One complication is the reporting of cases as either recoveries or deaths that cannot be confirmed as previously reported newly confirmed cases. Another complication is delayed reporting of cases. During the period from 22 Dec 2017 - 1 Jan 2018, there were no official reports provided on 24 and 27 Dec 2017. There were reports available on the Arabic language pages for verification.- Mod.MPP]

Since the last ProMED-mail update, through 21 Dec 2017, there have been a total of:
5 newly confirmed cases,
1 newly reported fatality, and
1 newly reported recovery.

Information on newly confirmed cases:
- all 5 cases were classified as primary cases (1 with history of exposure to camels, the other 4 still under investigation)
- none of the cases were healthcare workers

Date: 30 Dec 2017

1 - a 55 year old expat male from Khamis Mushayet [`Asīr region] noted to be in a critical condition. Classified as a primary case with high risk exposure history still under investigation.

Date: 28 Dec 2017

2 - a 60 year old Saudi male from Riyadh [Riyadh region] noted to be in a stable condition. Classified as a primary case with high risk exposure history still under investigation.

Date: 27 Dec 2017

3 - a 50 year old Saudi male from Albukaria (AlBukayriyah) [Al Qaṣīm region] noted to be in a critical condition. Classified as a primary case with high risk exposure history still under investigation. [This case was reported on the Arabic pages of the MOH website but not on the English website.- Mod.MPP]

Date: 25 Dec 2017

4 - a 28 year old Saudi male from Afeef [Riyadh region] noted to be in a stable condition. Classified as a primary case with history of direct contact with camels in the 14 days preceding onset of illness.

Date: 22 Dec 2017

5 - a 60 year old Saudi male from Taif [Makkah region] noted to be in a critical condition. Classified as a primary case with high risk exposure history still under investigation.

Information on newly reported fatality (1 fatality)
[see newly reported case no. 3 above] Additional information is that the patient had a history of pre-existing co-morbidities.

Information on newly reported recoveries (1 recovery)
Date: 29 Dec 2017

- a 45 year old Saudi female, non-healthcare worker from Taif [Makkah region] with a history of pre-existing co-morbidities. [reported as a newly confirmed case on 21 Dec 2017 at which time she was noted to be in a stable condition. Classified as a primary case with high risk exposure history still under investigation. - Mod.MPP]

communicated by:

[Newly confirmed sporadic MERS-CoV infections continue to be reported by Saudi Arabia, albeit at a slower rate than when nosocomially acquired cases were reported. During 2017, a total of 236 cases of newly confirmed MERS-CoV infections were reported by Saudi Arabia.

Monthly reporting of cases during 2017 included:
January: 24
February: 18
March: 17
April: 16
May: 17
June: 57
July: 6
August: 33
September: 11
October: 11
November: 15
December: 9

There were nosocomial associated cases January through August 2017, but since then there were no further reports of nosocomial transmission. Cases occurred throughout the country with reports of cases from 12 out of the 13 regions - cases were reported from Al Bāhah, Al Jawf, Al Madinah, Al Qaṣīm, Ash Sharqīyah, `Asīr, Ḥā'il, Jīzan, Makkah, Najran, Riyadh, and Tabūk, (all but Al Ḥudūd ash Shamāliyah).

Maps showing the locations of the newly reported cases, fatality and recovery can be found at the source URLs. The HealthMap/ProMED map of Saudi Arabia can be found at - Mod.MPP]

[3] UAE ex Oman, 1 new case - WHO 22 Dec 2017
Date: 22 Dec 2017
Source: WHO Emergencies preparedness, response, Disease Outbreak News (DONs) [edited]

[ProMED-mail apologizes for the delay in posting this report. - Mod.MPP]

Middle East respiratory syndrome coronavirus (MERS-CoV) - United Arab Emirates [22 Dec 2017]
On [11 Dec 2017], the National IHR Focal Point of the United Arab Emirates (UAE) reported one additional case of Middle East respiratory syndrome (MERS-CoV) infection.

Details of the case and public health response
Detailed information concerning the case reported, a 39 year old male residing in Hemma region, Oman can be found in a separate document (see link below [link not available at the time of preparation of this report - Mod.MPP]). The case is currently asymptomatic, is in home isolation in Oman, and is being monitored for the development of symptoms.

On [2 Dec 2017], the case transported camels through the Al Ain-Mezyed entry point. A total of 10 dromedary camels were screened for MERS-CoV, 5 of whom tested PCR positive. The Ministry of Agriculture and Fisheries are investigating the camels in the affected farm and infected camels have been quarantined. The case was identified as part of follow up MERS-CoV screening activities conducted by the Disease Prevention and Screening Center in Al Ain, Abu Dhabi.

The Abu Dhabi Public Health Division has communicated with the Ministry of Health in Oman and with the MERS-CoV infected case. The case and his contacts have been provided information about further management and evaluation. Contacts were identified and all have tested negative for MERS-CoV.

Globally, 2122 laboratory-confirmed cases of infection with MERS-CoV including at least 740 related deaths have been reported to WHO.

WHO risk assessment
Infection with MERS-CoV can cause severe disease resulting in high mortality. Humans are infected with MERS-CoV from direct or indirect contact with dromedary camels. MERS-CoV has demonstrated the ability to transmit between humans. So far, the observed non-sustained human-to-human transmission has occurred mainly in healthcare settings.

The notification of additional cases does not change WHO's overall risk assessment. WHO expects that additional cases of MERS-CoV infection will be reported from the Middle East, and that cases will continue to be exported to other countries by individuals who might acquire the infection after exposure to animals or animal products (for example, following contact with dromedaries) or human source (for example, in a healthcare setting). WHO continues to monitor the epidemiological situation and conducts the risk assessment based on the latest available information.

communicated by:

[According to the report above, an individual transporting camels from Oman to the UAE was found to have an asymptomatic infection with the MERS-CoV after 5 out of 10 of the camels he was transporting were found to be MERS-CoV positive as part of routine screening of camels crossing into the UAE. This is the 3rd case of MERS-CoV infection associated with an Omani citizen during 2017 and the 7th case reported by the UAE during 2017. In earlier studies, 50/50 camels from Oman were found to have serologic evidence of prior MERS-CoV infection (Reusken CB, Haagmans BL, Müller MA, et al. Middle East respiratory syndrome coronavirus neutralising serum antibodies in dromedary camels: a comparative serological study. Lancet Infect Dis. 2013; 13(10): 859-66. doi: 10.1016/S1473-3099(13)70164-6; In the event detailed in the WHO report above, 50 per cent of the camels being transported to the UAE were found to be positive for MERS-CoV infection, (there is no mention of the type of testing performed to know if it is serologic evidence of prior infection of the camels or PCR testing for presence of the virus). Clearly the MERS-CoV continues to circulate among camels on the Arabian peninsula.

As stated in the report above, with the addition of this current asymptomatic infection, there have been a total of 2122 laboratory-confirmed cases of infection with MERS-CoV, including at least 740 deaths reported to WHO. This tally includes reports from Saudi Arabia through 8 Dec 2017 and does not as yet include the returning pilgrim reported by Malaysia. The addition of the cases reported in Saudi Arabia since 8 Dec 2017 (6 cases and 1 death) and the case reported in Malaysia will raise the total to 2129 cases and 741 deaths. - Mod.MPP

HealthMap/ProMED maps
United Arab Emirates:

See Also
MERS-CoV (77): Saudi Arabia, camels, human, epidemiology, assessment 20171222.5520561
MERS-CoV (76): Saudi Arabia (MK) WHO 20171222.5518476
MERS-CoV (75): Saudi Arabia (RI, JF, QS) 20171211.5496478
MERS-CoV (74): Saudi Arabia (AS, RI, QS) 20171129.5472838
MERS-CoV (73): Saudi Arabia, gut and transmission 20171121.5455769
MERS-CoV (72): Saudi Arabia (RI, QS) 20171113.5441815
MERS-CoV (71): Oman, Saudi Arabia (QS), WHO 20171110.5437063
MERS-CoV (70): Oman (SN), Saudi Arabia (RI) 20171106.5427278
MERS-CoV (60): UAE, Saudi Arabia, WHO 20170922.5334852
MERS-CoV (59): Oman, Saudi Arabia, WHO 20170913.5313874
MERS-CoV (50): Saudi Arabia 20170806.5232071
MERS-CoV (40): animal reservoir, camels, review, FAO 20170619.5115999
MERS-CoV (30): Saudi Arabia (RI,MD,MK) 20170602.5077920
MERS-CoV (20): Qatar, Saudi Arabia, WHO 20170404.4947466
MERS-CoV (10): Saudi Arabia (SH, MK) 20170202.4811346
MERS-CoV (01): Saudi Arabia (QS,RI,MD), RFI 20170105.4744802
MERS-CoV (123): Saudi Arabia (MK, AS) new cases 20161231.4734758
MERS-COV (01): Oman, Saudi Arabia 20160105.3911188
MERS-COV (167): acute management and long-term survival 20151231.3904300
MERS-CoV (01): Saudi Arabia, new cases, new death 20150104.3069383
MERS-CoV (69): Saudi Arabia, new case, RFI 20141230.306305
MERS-CoV (01): Bangladesh, KSA, Algeria, UAE, Iran, WHO, RFI 20140616.2541707
MERS-CoV - Eastern Mediterranean (82): anim res, camel, seroepidemiology 20140613.2537848
MERS-CoV - Eastern Mediterranean (32): Saudi Arabia, UAE, Malaysia, WHO, RFI 20140417.2411430
MERS-CoV - Eastern Mediterranean (31): Saudi Arabia, Malaysia, UAE, Philippines 20140416.2406647
MERS-CoV - Eastern Mediterranean (01): Saudi Arabia, UAE, Oman, WHO 20140103.2150717
MERS-CoV - Eastern Mediterranean (106): animal reservoir, camel, Qatar, OIE 20131231.2145606
MERS-CoV - Eastern Mediterranean: Saudi Arabia, new case, RFI 20130518.1721601
Novel coronavirus - Eastern Mediterranean (29): MERS-CoV, ICTV nomenclature 20130516.1717833
Novel coronavirus - Eastern Mediterranean: bat reservoir 20130122.1508656
Novel coronavirus - Eastern Mediterranean (06): comments 20121225.1468821
Novel coronavirus - Eastern Mediterranean: WHO, Jordan, conf., RFI 20121130.1432498
Novel coronavirus - Saudi Arabia (18): WHO, new cases, cluster 20121123.1421664
Novel coronavirus - Saudi Arabia: human isolate 20120920.1302733