Friday, February 28, 2014

MERS Death Reported in Egypt; WHO Issues Update

Umrah pilgrim may be Egypt's first MERS death
UPDATE February 28:
Dr. Amr Kandil, Undersecretary of Egypt's Ministry of Health stated that a woman who passed away on February 28 in Aswan has not been confirmed as having MERS.

He called the report 'just a case of suspicion' and said samples were being sent to the central laboratories for testing.

The report said the woman was 56 years old and traveled to Saudi Arabia for Umrah two weeks ago. She is reported to have visited a hospital in Medina where she was diagnosed with pneumonia. Upon returning to Egypt, she was admitted to Assiut University Hospital where she died upon arrival.

An Egyptian woman has died from the Middle East Respiratory Syndrome (MERS), according to this report.

The woman was from Aswan in Upper Egypt and had recently returned from Saudi Arabia after performing the Umrah pilgrimage. She became ill and was taken to a local hospital where she passed away on February 28.

MERS has been confirmed in eleven countries so far, most in the Arabian Peninsula. The cases which have occurred outside the region have all had direct links to one of the effected countries.

MERS was suspected in the death of a woman from Mansoura, Egypt last October but tests later proved she died of the H1N1 virus.

A February 28 update by The World Health Organization (WHO) has confirmed two previously reported MERS cases in Saudi Arabia.  One was a 22 year old from the Eastern Region who passed away on February 12 and the other was a 67 year old who was hospitalized on January 25.

Both men suffered from underlying medical conditions and are considered 'sporadic' cases. That is, they reported no contact with animals or other confirmed MERS patients.

WHO currently recognizes 184 confirmed MERS cases and 80 deaths. A report released by the ECDC on February 23 reported 186 cases of MERS with 87 deaths.

Monday, February 24, 2014

MERS Case Definition and Confirmation Standards

When an ill person arrives at a hospital emergency room, how does staff determine if the patient could be carrying a dangerous new disease, like the Middle East Respiratory Syndrome (MERS), rather than a common form of influenza?

Public health agencies use 'Case Definitions' to establish a uniform set of criteria which can be applied consistently across international boundaries and in a variety of health care settings. These commonly applied standards allow public health agencies to reliably count and classify suspected cases.

The Center for Disease Control and Prevention (CDC) and The World Health Organization (WHO) have issued guidelines for the identification and reporting of suspected MERS infections. A suspected case or, 'Patient Under Investigation' (PIU) would include:
  • A fever of 38°C/100.4°F or higher with pneumonia or severe respiratory distress
    plus one of the following risk factors:
  • Residence or travel to the Arabian Peninsula or neighboring countries within 14 days before the onset of symptoms or close contact with someone who has recently traveled there.
  • Members of a suspected cluster of patients with severe and acute respiratory illness of unknown origin, especially for clusters involving health care providers. These patients should be evaluated for MERS and state or local health departments should be consulted. 
Testing for a variety of respiratory illnesses can be conducted simultaneously and positive results for a different illness should not preclude also testing for MERS.

Countries which are at risk for exposure to MERS include Bahrain, Iraq, Iran, Israel, Jordan, Kuwait, Lebanon, Oman, Palestinian territories, Qatar, Saudi Arabia, Syria, UAE and Yemen.

A Close Contact is defined by the CDC as a family member, health professional or anyone else who cared or worked closely with a suspected or confirmed MERS patient. It also includes other household members or visitors while the patient was sick.

WHO considers a wider group to be close contacts, including individuals who work together, students attending the same classroom or persons traveling together in any type of vehicle.

Detailed guidelines from WHO for investigating suspected MERS cases, including a patient questionnaire, testing procedures, infection control and reporting information is available here (pdf).

Laboratory Confirmation vs. Probable Cases
Polymerase Chain Reaction (PCR) and sequencing are used to genetically verify the presence of the MERS corona virus and produce a laboratory confirmation of the disease

These techniques allow small fragments of DNA to be replicated thousands of times, enabling researchers to target and study specific regions of the gene. PCR replicates both strands of DNA whereas Sanger sequencing duplicates only one.

This technique is extremely sensitive and highly useful in identifying the virus, but samples can be easily cross-contaminated with a minuscule amount of foreign material or the wrong DNA fragment may be amplified. Therefore, two positive tests are required for confirmation.

Laboratory Confirmation of MERS requires genetic testing of the virus and must produce two positive targets, either through a positive PCR on a minimum of two specific genomic targets or a single positive target with sequencing on a second.

Asymptomatic cases are held to a higher standard of proof and should be verified by re-extracting the RNA and testing for different target genes and, if possible, at an independent lab.

Probable cases of MERS are also defined by a specific set of factors, involving clinical, epidemiological and laboratory criteria. The probable MERS patient will fit one of the following scenarios:
  • A patient with symptoms of pneumonia or acute respiratory distress with a direct epidemiological link to a confirmed MERS patient. MERS testing must be unavailable or produces a negative result when using a single and inadequate sample.
  • A patient with symptoms of pneumonia or acute respiratory distress who is a resident or visitor to a region where the disease is known to be present. In addition, there must have been an inconclusive laboratory test, such as a positive initial screening without confirmation.
  • Finally, a patient with respiratory illness of any severity who also is a close contact of a confirmed MERS case, combined with an inconclusive laboratory test, such as a positive initial screening without confirmation. 
WHO recommends re-testing inconclusive patients to definitively determine if MERS is present.

Public Health Agencies have developed a detailed Case Definition for identifying and reporting suspected MERS cases. These standards, though imperfect, provide researchers and health professionals with a set of common standards for reliably identifying and tracking the disease through a wide variety of health care facilities around the world.

Sunday, February 23, 2014

ECDC Issues MERS Update: 186 Cases; 87 Deaths

The European Centre for Disease Prevention and Control has released an update on the MERS virus in it's February 22 Communicable Disease Threats Report.

The report breaks down the numbers of MERS cases confirmed since April, 2012 by country and mortality:

MERS regional map

MERS has been confirmed in five countries outside the Middle East, accounting for twelve confirmed infections and six deaths. All of these victims had some link to the region, either through recent travel to one of the effected countries or had been in close contact with a confirmed or probable case.

MERS cases / deaths by country
Twenty-two cases in Saudi Arabia and three in the United Arab Emirates are considered asymptomatic, or without symptoms.

Although the virus can be spread through close contact or in health care facilities, as in a hospital cluster in Al-Ahsa, Saudi Arabia, researchers concluded it was not capable of sustained human to human transmission.

Detail of non-Saudi states
In order to better understand risk factors and epidemiology, the authors recommend, "investigative studies, including international case-control, serological, environmental, and animal-human interface studies."

The report emphasized the need for, "further review and strengthening of tools, such as standardised case definitions and surveillance, and further emphasis on infection control and prevention."

Since April, 2012, the ECDC has reported 186 laboratory confirmed cases of MERS, including 87 deaths.

Thursday, February 20, 2014

Saudi MERS Totals Rise; Researchers Call for Transparency

Cough and Sneeze Etiquette (from Saudi MOH)
In a brief statement, the Ministry of Health reported two new cases of MERS in the Saudi Kingdom today.

A 58 year old man from Al-Ahsa, who suffers from underlying medical conditions, is currently 'receiving the proper treatment', according to the announcement.

An 81 year old woman has passed away in Riyadh from MERS. She also suffered from chronic medical conditions.

No other details about these cases, including travel history or exposure to other MERS patients or animals, was released. Scarcity of information continues to frustrate researchers, who have yet to identify the source of the virus or method of transmission.

According to this study by the Annals of Internal Medicine, published January 27, 2014:
"The severity of symptoms, high fatality rate, and ease of transmission resemble the infection caused by severe acute respiratory syndrome coronavirus (SARS-CoV) but data on MERS-CoV-infected critically ill patients are limited."
The scientific community's need for reliable and timely information is frustrated by a Saudi legal and cultural emphasis on personal privacy.

The custom of protecting personal information is fundamental and permeates the culture. It is based on a local interpretation of Sharia (Islamic) Law and is codified in the Saudi Constitution. Legal action can be taken against someone who wrongfully discloses another's personal data.

Despite the tension between local law and scientific need, the study concludes:
"The authors suggest an urgent collaborative study to examine therapeutic options to treat MERS-CoV, as the disease has the potential to become a worldwide public health threat. The authors of an accompanying editorial cite lessons learned from SARS-CoV and agree that scientific transparency and collaboration is needed to effectively protect populations from MERS-CoV."
CIDRAP reports there have been 186 cases of MERS worldwide with 81 deaths to date. The Saudi Ministry of Health website officially recognizes 147 MERS cases in KSA, including 61 fatalities.

Sunday, February 16, 2014

Saudi Man Dies of MERS; Two Test Negative in Hong Kong

KSA reports 145 MERS cases and 60 deaths
The Saudi Minister of Health has reported the death of a 22 year old man from the Middle East Respiratory Syndrome (MERS). The young man, who was from the 'eastern region' of the country reportedly suffered from cancer.

No other information was released regarding contact with suspected cases or exposure to animals. The Health Ministry website currently reports 145 cases in the Kingdom, including 60 fatalities.

A World Health Organization report issued on February 7 recognized 182 laboratory confirmed cases of MERS worldwide with 79 deaths since September, 2012.

Two Test Negative for MERS in Hong Kong
The Hong Kong Minister of Health reports two suspected cases of MERS have tested negative in preliminary tests for the virus.

The first involved a 20 year old man who had traveled with his wife to Guangzhou (formally Canton) in China and then Dubai, UAE on February 3. He became ill with cough and fever on February 7 and was admitted to Tuen Mun Hospital on February 12. He did not have contact with poultry or other confirmed MERS patients during his visit. It is unknown if he had contact with other types of animals.

The man is isolated and in stable condition. His mother and brother, who were also sick with a respiratory illness, have recovered.

The second case involves a 73 year old man who has been in isolation at Princess Margaret Hospital since February 11 and had become ill while traveling in Iran.

Hong Kong Department of Health Officials reassured the public that  "No human infection with this virus has been identified so far in Hong Kong,"

image from

Wednesday, February 12, 2014

Hong Kong Reports Suspected MERS Case

The Centre for Health Protection in Hong Kong is reporting a suspected case of Middle East Respiratory Syndrome, according to The Standard. If confirmed, it would mark the first case of MERS in Hong Kong.

The 73 year old man had traveled in Iran with his family from February 2 through February 8. He became ill on February 3 with shortness of breath, fever and cough.

He is in isolation and in stable condition at Princess Margaret Hospital and has been diagnosed with pneumonia. Family members and traveling contacts are being monitored and have not shown any symptoms of MERS to date.

Saturday, February 8, 2014

Third MERS Death in Jordan

MERS virus
Jordan's Ministry of Health announced a state of emergency and raised monitoring levels after the death of a Jordanian man from the MERS virus, according to Alrai News.

The man, who was reported to be in his eighties and suffered from Leukemia, makes the second death in Jordan from MERS in the last two weeks.

Dr. Bassam Hijjawi, Health Care chief at the Ministry of Health said they have been screening contacts of the man and samples have so far been negative.

It is unknown how he contracted the virus, but Hijjawi speculated he may have been exposed when out of the country two months before he became ill.

The World Health Organization recently confirmed MERS was responsible for the death of a 46 year old Jordanian man on January 26. He had recently returned from the UK where he had traveled for treatment of an unrelated illness.

Dr. Hijjawi said that courses and workshops have been organized to train doctors and nurses on how to recognize and treat the virus.

Friday, February 7, 2014

UAE Man Hospitalized With MERS

MERS virus
The World Health Organization announced another laboratory confirmed MERS case in the UAE. He is a resident of Abu Dhabi and suffers from chronic medical conditions.

The 66 year old man became ill on January 20 and was admitted to the hospital on January 24 with pneumonia and renal failure.

He is currently in the intensive care unit and in stable condition. Health officials are testing close contacts and conducting epidemiological studies.

The man is known to keep camels in the UAE and had recently traveled to Oman where he also had contact with camels.

The United Arab Emirates ranks second only to Saudi Arabia in MERS infections. From September, 2012, WHO reports a global total of 182 confirmed cases of MERS with 79 fatalities.

Thursday, February 6, 2014

WHO Confirms Two More MERS Deaths

More than half of MERS infections originate in health care facilities
The World Health Organization (WHO) announced an additional laboratory confirmed case of MERS (Middle East Respiratory Syndrome) in Riyadh, Saudi Arabia and the confirmation of a previously reported case in the UAE.

The most recent confirmed case in KSA involves a 60 year old man who became ill on January 19, was hospitalized on the 24th and passed away on January 28.

He had a history of chronic medical conditions and is not known to have contact with any other confirmed MERS patients.

On February 3, Saudi health officials announced they were treating a 67 year old man for MERS in Riyadh who suffered from chronic diseases in an intensive care unit. No other details were given.

The Saudi Ministry of Health website currently reports 144 confirmed cases of MERS, including 59 deaths in the Kingdom.

WHO has also confirmed that MERS caused the death of a 33 year old health care worker in Dubai, UAE. The man, who suffered from asthma and chronic kidney disease, had contact with an infected patient and developed symptoms on December 27.

He was admitted to the hospital the following day with bilateral pneumonia, acute renal failure and thrombocytopenia (low blood platelet count which can cause uncontrolled bleeding). He died on January 16.

WHO now confirms 181 MERS infections and 79 deaths since September, 2012.  Hospitals which treat MERS patients are urged to "take appropriate measures to decrease the risk of transmission of the virus to other patients, health-care workers and visitors." Exposures in health care facilities have accounted for more than half the confirmed cases so far, according to a WHO update issued last month.

WHO stressed the need to take appropriate caution with any acute respiratory illness, whether MERS is suspected or not. And in suspected cases, the patient should be treated as infected, even if initial screening tests prove negative.