MERS-COV (73): SAUDI ARABIA, GUT AND TRANSMISSION

Posted on 21ST NOV 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, 3 new cases - MOH 14-20 Nov 2017
[2] Gastrointestinal tract transmission

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[1] Saudi Arabia, 3 new cases - MOH 14-20 Nov 2017
Date: 20 Nov 2017
Source: Saudi MOH [edited]
https://www.moh.gov.sa/en/CCC/PressReleases/Pages/default.aspx?PageIndex=1

As of Mon 20 Nov 2017, there have been a total of:
1743 laboratory-confirmed cases of MERS-CoV infection, including
705 deaths [reported case fatality rate 40.4 per cent],
1020 recoveries, and
19 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. - Mod.MPP]

Since the last ProMED-mail update, 13 Nov 2017, there have been a total of:
3 newly confirmed cases,
2 newly reported fatalities, and
4 newly reported recoveries.

Information on newly confirmed cases (3 cases)
Date: 20 Nov 2017 (1 case)
https://www.moh.gov.sa/en/CCC/PressReleases/Pages/statistics-2017-11-20-...?

1 - a 63 year old Saudi male, non-healthcare worker from Bisha [`Asīr region] noted to be in a stable condition. Classified as a primary case with a history of direct contact with camels in the 14 days preceding onset of illness.

Date: 18 Nov 2017 (1 case)
https://www.moh.gov.sa/en/CCC/PressReleases/Pages/statistics-2017-11-18-...?

2 - a 77 year old Saudi female, non-healthcare worker from Buraidah [Al Qaṣīm region] noted to be in a critical condition [note this individual reported as a fatality on 18 Nov 2017, see fatality no. 2 below.] Classified as a primary case with high risk exposure history still under investigation.

Date: 15 Nov 2017 (1 case)
https://www.moh.gov.sa/en/CCC/PressReleases/Pages/statistics-2017-11-15-...?

3 - a 59 year old expat male from Alzulfi [Riyadh region] noted to be in a stable condition. Classified as a primary case with high risk exposure history still under investigation.

Information on newly reported fatalities (2 fatalities)
Date: 18 Nov 2017 (2 fatalities)
https://www.moh.gov.sa/en/CCC/PressReleases/Pages/statistics-2017-11-18-...?

1 - a 75 year old Saudi female, non-healthcare worker from Unaizah [Al Qaṣīm region] with a history of pre-existing co-morbidities. [Reported as a newly confirmed case on 13 Nov 2017 at which time she was noted to be in a critical condition. Classified as a primary case with high risk exposure history still under investigation. - Mod.MPP]

2 - a 77 year old Saudi female, non-healthcare worker from Buraidah [Al Qaṣīm region] with a history of pre-existing co-morbidities. [Reported as a newly confirmed case on 18 Nov 2017 at which time she was noted to be in a critical condition. Classified as a primary case with high risk exposure history still under investigation (see newly confirmed case no. 2 above). - Mod.MPP].

Information on newly reported recoveries (4 recoveries)
Date: 17 Nov 2017 (1 recovery)
https://www.moh.gov.sa/en/CCC/PressReleases/Pages/statistics-2017-11-17-...?

1 - a 60 year old Saudi male, non-healthcare worker from Almajmaah [Riyadh region] with a history of pre-existing co-morbidities. [Reported as a newly confirmed case on 1 Nov 2017 at which time he was noted to be in a critical condition. Classified as a primary case with a history of direct exposure to camels in the 14 days preceding onset of illness. - Mod.MPP]

Date: 15 Nov 2017 (2 recoveries)
https://www.moh.gov.sa/en/CCC/PressReleases/Pages/statistics-2017-11-15-...?

2 - a 36 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 27 Oct 2017 at which time he was noted to be in a stable condition. Classified as a primary case with high risk exposure history still under investigation. - Mod.MPP]

3 - a 65 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 5 Nov 2017 at which time he was noted to be in a stable condition. Classified as a primary case with high risk exposure history still under investigation. - Mod.MPP]

Date: 14 Nov 2017 (2 recoveries)
https://www.moh.gov.sa/en/CCC/PressReleases/Pages/statistics-2017-11-14-...?

4 - a 59 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 29 Oct 2017 at which time he was noted to be in a critical condition. Classified as a primary case with a history of direct contact with camels in the 14 days preceding onset of illness. - Mod.MPP]

--
communicated by:
ProMED-mail

[Since the beginning of November 2017, there have been a total of 11 newly confirmed cases of MERS-CoV infection reported by Saudi Arabia, compared with a total of 11 newly confirmed cases reported each month during September and October 2017. All 11 cases reported this month (November 2017) were classified as primary cases with 4 reported to have had direct contact with camels in the 14 days preceding onset of illness. Since 1 Sep 2017, a total of 33 newly confirmed cases/infections have been reported by Saudi Arabia, 32 of whom were classified as primary cases (19 with history of direct or indirect contact with camels in the 14 days preceding onset of illness) and 1 an asymptomatic household contact of a known MERS-CoV case (reported on 1 Sep 2017).

It is noteworthy that the apparent baseline for newly confirmed MERS-CoV infections in Saudi Arabia in the absence of close contact with confirmed cases (either household contacts or healthcare related contacts) seems to be approximately 2-3 reported cases per week. It still begs the question of why it is Saudi Arabia and not other countries in the Arabian Peninsula where there are rare reported cases per year. Since 1 Jan 2017, UAE has reported 5 cases, Oman 2 cases, and Qatar 3 cases, an enigma that is yet to be resolved.

Maps of Saudi Arabia showing the locations of the newly confirmed cases, fatalities, and recoveries can be found at the source URL. The HealthMap/ProMED map of Saudi Arabia can be found at: http://healthmap.org/promed/p/131. - Mod.MPP]

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[2] Gastrointestinal tract transmission
Date: 16 Nov 2017
Source: ECNS [edited]
http://www.ecns.cn/2017/11-16/281222.shtml

The virus responsible for Middle East respiratory syndrome (MERS) may also infect humans through their intestinal tracts, a new study suggested on Wednesday [16 Nov 2017]. The findings, published in the US journal Science Advances, indicated that MERS infections can spread through fecal to oral transmission or fomite transmission when the virus persists in the environment for a prolonged period.

"The MERS epidemic has persisted for 5 years. Because MERS primarily manifests as a respiratory infection, airway exposure is intuitively assumed to be the only infection route," said Yuen Kwok-yung, a microbiologist of the University of Hong Kong, who led the study. "Our study suggested that the human intestinal tract may serve as an alternative infection route for MERS," Yuen wrote in an email to Xinhua.

The MERS virus was 1st identified as a novel one causing human respiratory infection in 2012. Since then, more than 2000 cases have been reported to the World Health Organization, including 710 deaths. While camel-to-human and human-to-human transmissions of the virus have been well-documented, many infections occurred in patients who have not been in direct contact with infected individuals or camels.

In the new study, Yuen's team studied how the MERS virus infected human intestinal cells and mouse models. They found human intestinal epithelial cells were highly susceptible to the MERS virus and supported viral replication. They verified these results in intestinal organoids and also found evidence of infection via the gastrointestinal tract in mouse models engineered with a human MERS virus receptor.

"Our findings may have important implications for MERS diagnosis and treatment as well as for halting the continuing MERS epidemic," Yuen said.

--
communicated by:
ProMED-mail

[The original article reference is: Zhou J, Li C, Zhao G, et al. Human intestinal tract serves as an alternative infection route for Middle East respiratory syndrome coronavirus. Science Advances 15 Nov 2017; 3(11): eaao4966. DOI: 10.1126/sciadv.aao4966 (full article available at http://advances.sciencemag.org/content/3/11/eaao4966.full.

Abstract:
"Middle East respiratory syndrome coronavirus (MERS-CoV) has caused human respiratory infections with a high case fatality rate since 2012. However, the mode of virus transmission is not well understood. The findings of epidemiological and virological studies prompted us to hypothesize that the human gastrointestinal tract could serve as an alternative route to acquire MERS-CoV infection. We demonstrated that human primary intestinal epithelial cells, small intestine explants, and intestinal organoids were highly susceptible to MERS-CoV and can sustain robust viral replication. We also identified the evidence of enteric MERS-CoV infection in the stool specimen of a clinical patient. MERS-CoV was considerably resistant to fed-state gastrointestinal fluids but less tolerant to highly acidic fasted-state gastric fluid. In polarized Caco-2 cells cultured in Transwell inserts, apical MERS-CoV inoculation was more effective in establishing infection than basolateral inoculation. Notably, direct intragastric inoculation of MERS-CoV caused a lethal infection in human DPP4 transgenic mice. Histological examination revealed MERS-CoV enteric infection in all inoculated mice, as shown by the presence of virus-positive cells, progressive inflammation, and epithelial degeneration in small intestines, which were exaggerated in the mice pretreated with the proton pump inhibitor pantoprazole. With the progression of the enteric infection, inflammation, virus-positive cells, and live viruses emerged in the lung tissues, indicating the development of sequential respiratory infection. Taken together, these data suggest that the human intestinal tract may serve as an alternative infection route for MERS-CoV."

Background information provided by the authors noted that gastrointestinal symptoms were seen in about a third of reported cases, and were the commonest extrapulmonary symptom observed. They also noted that in the Korean outbreak in 2015, most cases shared common healthcare environments with confirmed cases but did not have known direct contact with MERS cases, thereby postulating that fomite transmission might have played a larger role than previously suspected. Fomites are further suspected, as the MERS-CoV does remain stable at low temperatures and low humidity and can be recovered from environmental surfaces 48 hours after documented exposure.

The authors mentioned they had reported identifying MERS-CoV RNA in stool specimens of MERS-CoV infected individuals from 12 of 82 specimens tested (14.6 per cent). In this study, they showed that the virus was capable of replicating in cultured human intestinal epithelial cells. Another observation mentioned is the presence of high levels of the MERS-CoV receptor DPP4 in small intestinal tissue, favoring a possible gastrointestinal route of infection.

The 1st case of MERS-CoV infection reported by France involved an individual who 1st presented to the health sector with fever and severe gastroenteritis and only later developed pulmonary symptoms. His hospital roommate also developed severe disease, possibly due to fomite exposure in their room.

We await further studies addressing this issue. - Mod.MPP

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

See Also

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
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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