MERS-COV (27): SAUDI ARABIA CLARIFICATION, OUTCOME UPDATE, WHO

Posted on 21ST AUG 2018
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] Clarification of points raised in MERS-CoV (26) - MOH
[2] Update on outcomes of cases - MOH
[3] July 2018 update - WHO/EMRO Situation Update July 2018

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[1] Clarification of points raised in MERS-CoV (26) - MOH
Date: 20 Aug 2018
From: Abdullah Assiri [edited]

Reference to: MERS-CoV (26): Saudi Arabia, abattoir workers (Nigeria), primary camel exposure
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In reference to PRO/AH/EDR> MERS-CoV (26): Saudi Arabia, abattoir workers (Nigeria), primary camel exposure, Archive Number: 20180818.5972601, we would like to highlight a few points:

You commented that it is difficult to discuss the case further in the absence of more details, other than to conclude it is classified as a primary case with community acquisition, in the absence of known direct (or indirect) camel contact. This is exactly the situation. In 2013, anti-MERS-CoV antibodies were confirmed in 0.15% of 10 009 people in 6 of the 13 provinces in Saudi Arabia. With more than one million camels in Saudi Arabia and extended families with strong social ties, even if not readily appreciated, ongoing indirect camel exposures are very likely https://www.ncbi.nlm.nih.gov/pubmed/25863564.

You commented that the newly revised website does not provide information on outcomes of reported cases. Actually, we did report the outcome for this case in the same post (deceased). In the updated website, if the outcome is not available on the day of reporting, the post is labeled as OPEN. Later, the same post will be updated with the final outcome.

[The moderator] posted: "As I have said before, why Saudi Arabia? Why are the overwhelming majority of cases reported from Saudi Arabia?"

We believe that surveillance and testing for MERS-CoV infection are extensive and widespread in Saudi Arabia with an average of greater than 5000 persons per month identified as being at high risk for infection due to clinical or epidemiologic criteria and were subsequently tested. The country implements robust surveillance practices (facilitated by the Health Electronic Surveillance Network (HESN)) and testing is readily available https://www.ncbi.nlm.nih.gov/pubmed/28322710.

Finally, we agree that further studies, including behavioral studies, are needed to address routes of transmission for the primary community-acquired cases. On the other hand, phenotypic studies are needed to examine the differences between virus strains in the Arabian Peninsula and Africa.

--
Abdullah Assiri
Assistant Deputy Minister for Preventive Health, Ministry of Health, Saudi Arabia

[Many thanks to Dr. Abdullah Assiri for clarification of points raised in the moderator comment of the prior posting MERS-CoV (26): Saudi Arabia, abattoir workers (Nigeria), primary camel exposure. Coincidentally, yesterday (19 Aug 2019) when checking the website for updates, I noticed that outcomes were available on the website (see section 2 below for outcome information on cases).

The observation that with over one million camels in Saudi Arabia "ongoing indirect camel exposures are very likely," is a highly probable occurrence in the country. I'm including the abstracts from the 2 references mentioned above, with an observation regarding the serosurvey; studies have shown that there are cases with waning immunity, especially following mild or sub-clinical infections, so that serosurveys may well be underestimating the background prevalence of MERS-CoV exposure in the country (see Choe PG, Perera RAPM, Park WB, Song KH, Bang JH, Kim ES, Kim HB, Ko LWR, Park SW, Kim NJ, Lau EHY, Poon LLM, Peiris M, Oh MD. MERS-CoV Antibody Responses Year after Symptom Onset, South Korea, 2015. Emerg Infect Dis. 2017 Jul;23(7):1079-1084. doi: 10.3201/eid2307.170310. Epub 2017 Jul 15. available 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."

Müller MA, Meyer B, Corman VM, Al-Masri M, Turkestani A, Ritz D, Sieberg A, Aldabbagh S, Bosch BJ, Lattwein E, Alhakeem RF, Assiri AM, Albarrak AM, Al-Shangiti AM, Al-Tawfiq JA, Wikramaratna P, Alrabeeah AA, Drosten C, Memish ZA. Presence of Middle East respiratory syndrome coronavirus antibodies in Saudi Arabia: a nationwide, cross-sectional, serological study. Lancet Infect Dis. 2015 May;15(5):559-64. doi: 10.1016/S1473-3099(15)70090-3. Epub 2015 Apr 8. Erratumin: Lancet Infect Dis. 2015 Jun;15(6):629.

"Background:
Scientific evidence suggests that dromedary camels are the intermediary host for the Middle East respiratory syndrome coronavirus (MERS-CoV). However, the actual number of infections in people who have had contact with camels is unknown and most index patients cannot recall any such contact. We aimed to do a nationwide serosurvey in Saudi Arabia to establish the prevalence of MERS-CoV antibodies, both in the general population and in populations of individuals who have maximum exposure to camels.

Methods:
In the cross-sectional serosurvey, we tested human serum samples obtained from healthy individuals older than 15 years who attended primary health-care centres or participated in a national burden-of-disease study in all 13 provinces of Saudi Arabia. Additionally, we tested serum samples from shepherds and abattoir workers with occupational exposure to camels. Samples were screened by recombinant ELISA and MERS-CoV seropositivity was confirmed by recombinant immunofluorescence and plaque reduction neutralisation tests. We used two-tailed Mann Whitney U exact tests, χ(2), and Fisher's exact tests to analyse the data.

Findings:
Between [1 Dec 2012, and 1 Dec 2013], we obtained individual serum samples from 10 009 individuals. Anti-MERS-CoV antibodies were confirmed in 15 (0·15%; 95% CI 0·09-0·24) of 10 009 people in 6 of the 13 provinces. The mean age of seropositive individuals was significantly younger than that of patients with reported, laboratory-confirmed, primary Middle Eastern respiratory syndrome (43·5 years [SD 17·3] vs 53·8 years [17·5]; p=0·008). Men had a higher antibody prevalence than did women (11 [0·25%] of 4341 vs 2 [0·05%] of 4378; p=0·028) and antibody prevalence was significantly higher in central versus coastal provinces (14 [0·26%] of 5479 vs one [0·02%] of 4529; p=0·003). Compared with the general population, seroprevalence of MERS-CoV antibodies was significantly increased by 15 times in shepherds (2 [2·3%] of 87, p=0·0004) and by 23 times in slaughterhouse workers (5 [3·6%] of 140; p<0·0001).

Interpretation:
Seroprevalence of MERS-CoV antibodies was significantly higher in camel-exposed individuals than in the general population. By simple multiplication, a projected 44 951 (95% CI 26,971-71,922) individuals older than 15 years might be seropositive for MERS-CoV in Saudi Arabia. These individuals might be the source of infection for patients with confirmed MERS who had no previous exposure to camels."

Saeed AA, Abedi GR, Alzahrani AG, Salameh I, Abdirizak F, Alhakeem R, Algarni H, El Nil OA, Mohammed M, Assiri AM, Alabdely HM, Watson JT, Gerber SI. Surveillance and Testing for Middle East Respiratory Syndrome Coronavirus, Saudi Arabia, April 2015-February 2016. Emerg Infect Dis. 2017 Apr;23(4):682-685. doi: 10.3201/eid2304.161793.

"Saudi Arabia has reported greater than 80% of the Middle East respiratory syndrome coronavirus (MERS-CoV) cases worldwide. During April 2015-February 2016, Saudi Arabia identified and tested 57 363 persons (18.4/10,000 residents) with suspected MERS-CoV infection; 384 (0.7%) tested positive. Robust, extensive, and timely surveillance is critical for limiting virus transmission."

For the HealthMap/ProMED map of Saudi Arabia, see http://healthmap/promed/p/131. - Mod.MPP]

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[2] Update on outcomes of cases - MOH
Date: 20 Aug 2018
Source: Saudi MOH Events website [edited]
https://www.moh.gov.sa/en/CCC/events/national/Pages/2018.aspx

Information on the outcomes of cases reported since:
Case identifier: Date of report / Region / City / Age / Sex / status at time of report / Animal exposure / Household exposure
18-1710: 22-May-18 / Makkah / Taif / 71 / M / Critical / Yes / died (24 May 2018)
18-1711: 23-May-18 / Najran / Najran / 45 / M / Critical / Yes / recovered
18-1712: 27-May-18 / Najran / Najran / 39 / M / Stable / No / Yes / recovered
18-1713: 28-May-18 / Najran / Najran / 46 / M / Stable / No / Yes / recovered
18-1714: 28-May-18 / Najran / Najran / 19 / M / Stable / No / Yes / recovered
18-1715: 29-May-18 / Najran / Najran / 28 / M / Stable / No / Yes / recovered
18-1716: 29-May-18 / Najran / Najran / 31 / M / Stable / No / Yes / recovered
18-1717: 30-May-18 / Najran / Najran / 52 / M / Stable / No / Yes / recovered
18-1718: 31-May-18 / Najran / Najran / 33 / M / Stable / No / Yes / recovered
18-1719: 31-May-18 / Najran / Najran / 56 / M / Stable / No / No / recovered
18-1720: 1-Jun-18 / Najran / Najran / 49 / M / Stable / No / Yes / recovered
18-1721: 2-Jun-18 / Najran / Najran / 50 / M / Stable / No / Yes / recovered
18-1722: 2-Jun-18 / Najran / Najran / 33 / M / Stable/ No / Yes / recovered
18-1723: 3-Jun-18 / Najran / Najran / 76 / M / N/A / Yes / No / recovered
18-1724: 8-Jun-18 / Najran / Najran / 40 / M / Stable / No / Yes / recovered
18-1725: 9-Jun-18 / Makkah / Jeddah / 57 / M / Dead / Yes / No / died (9-Jun-18)
18-1726: 11-Jun-18 / Riyadh / Riyadh / 76 / M / stable / No / No / recovered
18-1727: 14-Jun-18 / Najran / Najran / 54 / F / stable / No / No / recovered
18-1728: 19-Jun-18 / Riyadh / Riyadh / 84 / M / stable / Yes / No / recovered
18- 1729: 30-Jun-18 / Riyadh / Almuzahmia / 70 / M / stable / Yes / No / N/A
18 -1730: 7-Jul-18 / Al Ḥudūd ash Shamāliyah / Arar / 55 / M / Critical / Yes / No / recovered
18- 1731: 9-Jul-18 / Riyadh / Afeef / 35 / M / Critical / Yes / No / died
18- 1732: 10-Jul-18 / Riyadh / Riyadh / 74 / M / Stable / No / No / died
18- 1733: 13-Jul-18 / Najran / Najran / 29 / M / Stable / Yes / No / recovered
18- 1734: 14-Jul-18 / Riyadh / Afeef / 45 / M / Stable / Yes / No / recovered
18- 1735: 19-Jul-18 / Al Ḥudūd ash Shamāliyah / Arar / 68 / M / Dead / No / No / died (hospital acquired)
18- 1736: 29-Jul-18 / Al Qaṣīm / Al Asiah / 73 / M / Critical / Yes / No / recovered
18- 1737: 1-Aug-18 / Ash Sharqīyah - Eastern / Hufoof / 55 / M / stable / Yes / No / pending
18- 1738: 4-Aug-18 / Tabūk / Tabuk / 82 / F / Stable / No / No / pending
18- 1739: 5-Aug-18 / Ash Sharqīyah - Eastern / Dammam / 41 / M / Stable / Yes / recovered
18- 1740: 17-Aug-18 / Al Bāhah / Buljorshy / 80 / M / Hospitalized / No / died (19-Aug-18)

--
Communicated by:
ProMED-mail

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[3] July 2018 update - WHO/EMRO Situation Update July 2018
Date: 20 Aug 2018
Source: WHO/EMRO Situation Update July 2018 [edited]
http://www.emro.who.int/pandemic-epidemic-diseases/mers-cov/mers-situati...

At the end of July 2018, a total of 2237 laboratory-confirmed cases of Middle East respiratory syndrome (MERS), including 793 associated deaths (case-fatality rate: 35.5%) were reported globally; the majority of these cases were reported from Saudi Arabia (1861 cases, including 719 related deaths with a case-fatality rate of 38.6%).

During the month of July 2018, a total of 6 laboratory-confirmed cases of MERS were reported in Saudi Arabia including one associated death (case-fatality rate: 16.7%).

These cases include one symptomatic household contact; no healthcare associated transmission or hospital outbreak was reported during this month [July 2018].

The demographic and epidemiological characteristics of reported cases, when compared during the same corresponding period of 2013 to 2018, do not show any significant difference or change. Owing to improved infection prevention and control practices in hospitals, the number of hospital-acquired cases of MERS has dropped significantly since 2015.

The age group 50-59 years continues to be at highest risk for acquiring infection of primary cases. The age group 30-39 years is most at risk for secondary cases. The number of deaths is higher in the age group 50-59 years for primary cases and 70-79 years for secondary cases.

--
Communicated by:
ProMED-mail

[Note that with the recent MOH updates during the month of August (2018), information on the reported cases of MERS-CoV infection during the month of July 2018 is different than presented in the EMRO situation update. During the month of July 2018, there were a total of 7 newly confirmed cases of MERS-CoV infection of whom one was classified as a healthcare acquired case, and the remainder were classified as primary community acquired cases, 5 of whom had a history of contact with camels. Outcome information includes 3 who died, and the other 4 were listed as having recovered.

For those interested in more detailed epidemiological data, graphics and tables are available at the source URL. - Mod.MPP]

See Also
MERS-CoV (26): Saudi Arabia, abattoir workers (Nigeria), primary camel exposure 20180818.5972601
MERS-CoV (25): risk assessment, WHO 20180808.5954813
MERS-CoV (24): Saudi Arabia, MoH reports 20180807.5950858
MERS-CoV (23): Saudi Arabia, WHO, RFI 20180711.5899938
MERS-CoV (22): Saudi Arabia, WHO 20180629.5862285
MERS-CoV (21): EMRO/WHO update May 2018 20180612.5852927
MERS-CoV (20): Saudi Arabia (NJ) susp. family cluster 20180602.5835120
MERS-CoV (10): Oman, Saudi Arabia, WHO 20180315.5690014
MERS-CoV (01): Malaysia (ex KSA), Saudi Arabia, UAE (ex Oman) 20180102.5532148
2017
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MERS-CoV (77): Saudi Arabia, camels, human, epidemiology, assessment 20171222.5520561
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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