MERS-COV (26): SAUDI ARABIA, EMRO UPDATE, REQUEST FOR INFORMATION

Posted on 14TH MAY 2017
tagged MERS-CoV, Saudi Arabia

A ProMED-mail post
http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases
http://www.isid.org

In this update:
[1] Saudi Arabia, 8 newly confirmed cases, 4 deaths - 29 Apr-14 May 2017, RFI
[2] Global update - EMRO
[3] Mild cases may be missed

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[1] Saudi Arabia, 8 newly confirmed cases, 4 deaths - 29 Apr-14 May 2017, RFI
Date: 14 May 2017
Source: Saudi MOH [edited]
http://www.moh.gov.sa/en/CCC/PressReleases/Pages/default.aspx?PageIndex=1

As of 14:00 [2:00 PM] today [Fri 28 Apr 2017], there have been a total of:
1604 laboratory-confirmed cases of MERS-CoV infection, including
662 deaths [reported case fatality rate 41.3 percent],
932 recoveries, and
10 currently active cases

[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. - Mod.MPP]

Since the last ProMED-mail update [Fri 28 Apr 2017], there have been a total of:
8 newly confirmed cases, [1 is reported to be asymptomatic]
4 newly reported fatalities, and
6 newly reported recoveries.

Information on newly confirmed cases (8 cases)
Date: Sun 14 May 2017 (1 case)
http://www.moh.gov.sa/en/CCC/PressReleases/Pages/Statistics-2017-05-14-0...?

1 - A 55-year-old Saudi male, non-healthcare worker from Riyadh [Riyadh region] currently in critical condition. Classified as a primary case with high risk exposure history in the 14 days preceding onset of illness currently under investigation.

Date: Sat 13 May 2017 (1 case)
http://www.moh.gov.sa/en/CCC/PressReleases/Pages/Statistics-2017-05-13-0...?

2 - A 54-year-old Saudi male, non-healthcare worker from Bisha [Asir region] currently in critical condition. Classified as a secondary healthcare acquired case in a patient.

Date: Tue 9 May 2017 (1 case)
http://www.moh.gov.sa/en/CCC/PressReleases/Pages/Statistics-2017-05-09-0...?

3 - A 71-year-old Saudi male, non-healthcare worker from Bisha [Asir region] currently in critical condition. Classified as a primary case with high risk exposure history in the 14 days preceding onset of illness currently under investigation.

Date: Mon 8 May 2017 (2 cases)
http://www.moh.gov.sa/en/CCC/PressReleases/Pages/Statistics-2017-05-08-0...?

4 - A 75-year-old Saudi male, non-healthcare worker from Alnamas [Asir region], reported as having died at the time of initial confirmation report. Classified as a primary case with high risk exposure history in the 14 days preceding onset of illness currently under investigation.

5- A 40-year-old Saudi female, non-healthcare worker from Hufoof [Ash Sharqīyah region], currently in stable condition. Classified as a primary case with high risk exposure history in the 14 days preceding onset of illness currently under investigation.

Date: Sat 6 May 2017 (1 case)
http://www.moh.gov.sa/en/CCC/PressReleases/Pages/Statistics-2017-05-06-0...?

6- A 46-year-old Saudi male, non-healthcare worker from Riyadh [Riyadh region] reported as in stable condition at the time of initial confirmation. Classified as a primary case with high risk exposure history currently under investigation.

Date: Wed 3 May 2017 (1 case)
http://www.moh.gov.sa/en/CCC/PressReleases/Pages/Statistics-2017-05-03-0...?

7- A 74-year-old Saudi male, non-healthcare worker from Albukaria [Al Qaṣīm], reported to be in critical condition at the time of initial confirmation report. Classified as a primary case with a history of indirect contact with camels in the 14 days preceding onset of illness.

Date: Sat 29 Apr 2017 (1 case)
http://www.moh.gov.sa/en/CCC/PressReleases/Pages/Statistics-2017-04-29-0...??

8- A 69-year-old Saudi male, non-healthcare worker from Buraidah [Al Qaṣīm region], reported to be in stable condition at the time of initial confirmation report. Classified as a primary case with a history of direct camel contact in the 14 days preceding onset of illness.

Information on newly reported fatalities (4 fatalities)
Date: Sun 14 May 2017 (1 fatality)
http://www.moh.gov.sa/en/CCC/PressReleases/Pages/Statistics-2017-05-14-0...?

1 - A 46-year-old Saudi male, non-healthcare worker from Riyadh [Riyadh region] with a history of pre-existing co-morbidities. [reported as a newly confirmed case on 6 May 2016 (see newly confirmed case no. 6 above) at which time he was noted to be in stable condition. Classified as a primary case with high risk exposure history still under investigation. - Mod.MPP]

Date: Mon 8 May 2017 (2 fatalities)
http://www.moh.gov.sa/en/CCC/PressReleases/Pages/Statistics-2017-05-08-0...?

2- A 75-year-old Saudi male, non-healthcare worker from Alnamas [Asir region] with a history of pre-existing co-morbidities. [reported as a newly confirmed case on 8 May 2017 (see newly confirmed case no. 4 above] who had died at the time of initial confirmation report. Classified as a primary case with high risk exposure history still under investigation. - Mod.MPP]

3- An 86-year-old Saudi male, non-healthcare worker from Taif [Makkah region] with a history of pre-existing co-morbidities. [reported as a newly confirmed case on 14 Apr 2017 at which time he was noted to be in stable condition. Classified as a primary case with a history of direct contact with camels in the 14 days preceding onset of illness. - Mod.MPP]

Date: Thu 4 May 2017 (1 fatality)
http://www.moh.gov.sa/en/CCC/PressReleases/Pages/Statistics-2017-05-04-0...?

4- An 81-year-old Saudi male, non-healthcare worker from Hufoof [Ash Sharqīyah region] with a history of pre-existing co-morbidities. [reported as a newly confirmed case on 28 Apr 2017 at which time he was noted to be in critical condition. Classified as a primary case with high risk exposure history still under investigation. - Mod.MPP]

Information on newly reported recoveries (6 recoveries)
Date: Fri 12 May 2017 (2 recoveries)
http://www.moh.gov.sa/en/CCC/PressReleases/Pages/Statistics-2017-05-12-0...?

1- A 74-year-old Saudi male, non-healthcare worker from Buraidah [Al Qaṣīm region] with a history of pre-existing co-morbidities. [most likely the 74-year-old Saudi male from Albukaria who was reported as a newly confirmed case on 3 May 2017 (see case no. 7 above) at which time he was noted to be in critical condition. Classified as a primary case with a history of indirect exposure to camels in the 14 days preceding onset of illness. - Mod.MPP]

2- A 26-year-old Expat male, non-healthcare worker from Wadi Aldwasir [Riyadh region] with no history of co-morbidities. [reported as a newly confirmed case on 26 Apr 2017 at which time he was noted to be in stable condition, detected as part of asymptomatic contact tracing. Classified as a secondary case in a household contact. - Mod.MPP]

Date: Thu 11 May 2017 (1 recovery)
http://www.moh.gov.sa/en/CCC/PressReleases/Pages/Statistics-2017-05-11-0...?

3- A 69-year-old Saudi male, non-healthcare worker from Buraidah [Al Qaṣīm region] with a history of pre-existing co-morbidities. [reported as a newly confirmed case on 29 Apr 2017 (see case no. 8 above) at which time he was noted to be in stable condition. Classified as a primary case with a history of direct contact with camels in the 14 days preceding onset of illness. - Mod.MPP]

Date: Tue 9 May 2017 (1 recovery)
http://www.moh.gov.sa/en/CCC/PressReleases/Pages/Statistics-2017-05-09-0...?

4- A 58-year-old expat male, non-healthcare worker from Wadi Aldwasir [Riyadh region] with a history of pre-existing co-morbidities. [reported as a newly confirmed case on 21 Apr 2017 at which time he was noted to be in stable condition, detected as part of asymptomatic contact tracing. Classified as a secondary case in a household contact. - Mod.MPP]

Date: Tue 2 May 2017 (1 recovery)
http://www.moh.gov.sa/en/CCC/PressReleases/Pages/Statistics-2017-05-02-0...?

5- A 65-year-old Saudi male, non-healthcare worker from Alhaso (Hasu) [Al Madinah region] with a history of pre-existing co-morbidities. [reported as a newly confirmed case on 28 Apr 2017 at which time he was noted to be in stable condition. Classified as a primary case with a history of direct contact with camels in the 14 days preceding onset of illness. - Mod.MPP]

Date: Sun 30 Apr 2017 (1 recovery)
http://www.moh.gov.sa/en/CCC/PressReleases/Pages/Statistics-2017-04-30-0...?

6- A 62-year-old Saudi male, non-healthcare worker from Riaydh [Riyadh region] with a history of pre-existing co-morbidities. [reported as a newly confirmed case on 6 Apr 2017 at which time he was noted to be in critical condition. Classified as a primary case with a history of indirect contact with camels in the 14 days preceding onset of illness. - Mod.MPP]

--
Communicated by:
ProMED-mail

[From the above information, it appears as though there is a new focus of nosocomial transmission, this time in Bisha (Asir region), with a newly confirmed case reported on 13 May 2017 (yesterday) that is classified as a secondary healthcare acquired case in a patient (see newly confirmed case no. 2 above). Four days earlier on 9 May 2017, there was another case reported from Bisha, classified as a primary case, but high risk exposures were still under investigation. Presumably, more information will be available in the ensuing days or when the next WHO update on MERS-CoV is published. If this follows other recent nosocomial clusters, we may expect to see a few more newly confirmed cases, some asymptomatic individuals found to be positive during "active" case finding and contact screening, with hopefully few additional clinical cases. If any of our subscribers have more information on this nosocomial incident, we'd greatly appreciate receiving updated information.

As of today, 14 May 2016, Saudi Arabia has confirmed 1604 cases of MERS-CoV infection including 662 deaths (reported case fatality rate of 41.3 percent) since reporting the 1st case on 15 Sep 2012. In the 16 days since the last update, there have been 8 newly confirmed cases, 4 deaths, and 6 recoveries reported. Of note is that the 8 cases come from 4 different regions in Saudi Arabia, and only one case was classified as a secondary case, while 7 were classified as primary cases with 5 of the 7 still under investigation for possible high risk exposures. Maps of Saudi Arabia showing the locations of these cases can be found at the source URLs. - Mod.MPP]

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[2] Global update: EMRO
Date: 11 May 2017
Source: EMRO (Eastern Mediterranean Regional Office), WHO [edited]
http://www.emro.who.int/health-topics/mers-cov/news.html

Highlights, April 2017
- At the end of April 2017, a total of 1950 laboratory-confirmed cases of Middle East respiratory syndrome coronavirus (MERS-CoV), including 714 deaths (case-fatality rate: 36.6%) were reported globally; the majority of these cases were reported from Saudi Arabia (1586 laboratory-confirmed cases, including 640 deaths with a case-fatality rate of 40.4%).

- Owing to improved infection prevention and control practices in the hospitals, the number of hospital-acquired cases of MERS has dropped significantly in 2015 and in 2016 compared to previous years. The demographic and epidemiological characteristics of the cases reported between January and April 2017 do not show any significant difference when compared with cases reported during the same period from 2013 to 2016. The percentage of secondary cases from MERS reported during the 1st quarter of 2017 was 19% compared to 26% during the same period in 2016, and 33% in 2015 and 39% in 2014.

- The age group of those aged 50-59 years continues to be the group at highest risk for acquiring infection as primary cases. For secondary cases, it is the age group of 30-39 years who are mostly at risk. The deaths are higher in the age group of 50-59 years for primary cases and 70-79 years for secondary cases.

--
Communicated by:
ProMED-mail Rapporteur Mary Marshall

[Graphics accompanying this report can be found at http://applications.emro.who.int/docs/EMROPub_2017_EN_19671.pdf?ua=1 and provide updating of previously presented data. - Mod.MPP]

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[3] Mild cases may be missed
Date: 9 May 2017
Source: CIDRAP [edited]
http://www.cidrap.umn.edu/news-perspective/2017/05/mers-study-indicates-...

A new analysis of blood samples from people sickened in South Korea's MERS-CoV outbreak showed variable antibody response, including undetectable antibodies in mild cases, which might complicate seroprevalence studies and convalescent serum treatment.

Four patients had undetectable antibodies:
In the MERS-CoV study, researchers from South Korea and Hong Kong followed antibody titers of 11 patients with lab-confirmed infections over one year after treatment at a hospital in Seoul. The team published its findings yesterday [8 May 2017] in an early online edition of Emerging Infectious Diseases.

Robust antibody responses were seen in people who had severe disease, with titers that waned over the 1st 6 months then held steady over the following 6 months. Duration of RNA detection in sputum correlated with the magnitude of antibody response.

In 4 of 6 people who had mild disease, however, antibodies were undetectable, though most had pneumonia during their illnesses.

Researchers said their findings support other antibody findings from survivors in Saudi Arabia and Jordan and in patients with SARS (severe acute respiratory syndrome).

The results suggest that MERS-CoV antibody tests can identify only some patients who had infections and that seroprevalence studies might underestimate the extent of mild illnesses in a population, the team reported.

Also, they said plasma with the highest antibody titers will probably be available only from people who had severe illness within 6 months of their infections.

"To use convalescent-phase patient plasma for treatment, it will be necessary to assess the antibody titer of potential donors before collection to ensure good antibody titer," the group wrote. The authors added that, while the neutralization test might be ideal for assessing plasma for therapy, their finding that ELISA testing results correlated well with neutralization titers demonstrates that it might also be a useful screening test.

[Byline: Lisa Schnirring]

--
Communicated by:
ProMED-mail Rapporteur Mary Marshall

[The article referred to in the above report from CIDRAP is: Choe PG, Perera RAPM, Park WB, Song K-H, Bang JH, Kim ES, et al. MERS-CoV antibody responses 1 year after symptom onset, South Korea, 2015. Emerg Infect Dis. July 2017, and can be found at: https://wwwnc.cdc.gov/eid/article/23/7/17-0310_article.

"Abstract:
We investigated the kinetics of the Middle East respiratory syndrome coronavirus (MERS-CoV) neutralizing and spike protein antibody titers over the course of 1 year in 11 patients who were confirmed by reverse transcription PCR to have been infected during the outbreak in South Korea in 2015. Robust antibody responses were detected in all survivors who had severe disease; responses remained detectable, albeit with some waning, for [less than] 1 year. The duration of viral RNA detection (but not viral load) in sputum significantly correlated with the antibody response magnitude. The MERS S1 ELISA antibody titers correlated well with the neutralizing antibody response. Antibody titers in 4 of 6 patients who had mild illness were undetectable even though most had evidence of pneumonia. This finding implies that MERS-CoV seroepidemiologic studies markedly underestimate the extent of mild and asymptomatic infection. Obtaining convalescent-phase plasma with high antibody titers to treat MERS will be challenging."

These findings are in agreement with those reported from Saudi Arabia in Alshukairi AN, Khalid I, Ahmed WA, Dada AM, Bayumi DT, Malic LS, et al. Antibody response and disease severity in healthcare worker MERS survivors. Emerg Infect Dis. 2016;22:1113-5 [available at https://wwwnc.cdc.gov/eid/article/22/6/16-0010_article].

The implication of these findings, which is clearly highlighted in both reports, is the caution needed to be taken in interpreting results of MERS-CoV retrospective serosurveys and in drawing conclusions from them about the burden of disease in an area. - Mod.MPP

A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/promed/p/131.]

See Also

MERS-CoV (25): Saudi Arabia, Qatar, WHO 20170428.5002073
MERS-CoV (24): UAE (AZ), Saudi Arabia (RI), WHO 20170425.4993929
MERS-CoV (23): Saudi Arabia (AS) animal reservoir, human contact, OIE, RFI 20170421.4986081
MERS-CoV (22): UAE (AZ), Saudi Arabia (RI,MK) Qatar, RFI 20170415.4971825
MERS-CoV (21): Egypt, animal reservoir, camel, ex Sudan, control, RFI 20170405.4948727
MERS-CoV (20): Qatar, Saudi Arabia, WHO 20170404.4947466
MERS-CoV (10): Saudi Arabia (SH, MK) 20170202.4811346
MERS-CoV (09): Saudi Arabia (MK) WHO 20170127.4797694
MERS-CoV (08): Saudi Arabia (MK, RI) 20170125.4792072
MERS-CoV (06): Saudi Arabia, WHO 20170119.4775249
MERS-CoV (05): Saudi Arabia (NJ, SH, RI), RFI 20170114.4766221
MERS-CoV (04): Saudi Arabia (MK, QS), nosocomial outbreak, RFI 20170110.4754928
MERS-CoV (03): Saudi Arabia (SH) & clarification 20170108.4750515
MERS-CoV (02): Saudi Arabia (QS) nosocomial transmission 20170107.4748974
MERS-CoV (01): Saudi Arabia (QS,RI,MD), RFI 20170105.4744802
2016
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MERS-CoV (123): Saudi Arabia (MK, AS) new cases 20161231.4734758
MERS-COV (01): Oman, Saudi Arabia 20160105.3911188
2015
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MERS-COV (167): acute management and long-term survival 20151231.3904300
MERS-CoV (01): Saudi Arabia, new cases, new death 20150104.3069383
2014
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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 (01): Saudi Arabia, UAE, Oman, WHO 20140103.2150717
2013
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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
2012
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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
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