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Year : 2013  |  Volume : 1  |  Issue : 3  |  Page : 148-150

Status of the Middle East Respiratory Syndrome Coronavirus (MERS-CoV) in the Kingdom of Saudi Arabia

Department of Medicine, Infectious Diseases Section, King Faisal Specialist Hospital and Research Center, Riyadh, and Member in National Committee of Infectious Diseases, Ministry of Health, Riyadh, Saudi Arabia

Date of Web Publication30-Oct-2013

Correspondence Address:
Fahad Al Rabiah
Department of Medicine, Infectious Diseases Section, King Faisal Specialist Hospital and Research Center, MBC 46 PO Box 3354, Riyadh 11211
Saudi Arabia
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DOI: 10.4103/1658-600X.120856

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In September 2012, a case of novel coronavirus (CoV) infection was reported in Saudi Arabia. It is caused by a CoV called Middle East Respiratory Syndrome (MERS). Eight countries have reported the virus so far, with most of the reported cases from Saudi Arabia. Fatality rate is about 44% and most people who have been confirmed to have MERS-CoV developed severe acute respiratory illness. There is very limited information on transmission, severity and clinical impact with only small number of cases reported so far. However, the virus has not shown to spread in sustained way in communities. There is no available vaccine or proven treatment for this novel virus; however, there are several treatment protocols under trail. Healthcare is provided to infected individuals by alleviating symptoms and treating its complications; nevertheless the situation is still evolving.

Keywords: Coronavirus, Middle East Respiratory Syndrome Coronavirus, Saudi Arabia, severe acute respiratory syndrome

How to cite this article:
Al Rabiah F. Status of the Middle East Respiratory Syndrome Coronavirus (MERS-CoV) in the Kingdom of Saudi Arabia. J Health Spec 2013;1:148-50

How to cite this URL:
Al Rabiah F. Status of the Middle East Respiratory Syndrome Coronavirus (MERS-CoV) in the Kingdom of Saudi Arabia. J Health Spec [serial online] 2013 [cited 2020 Jun 6];1:148-50. Available from: http://www.thejhs.org/text.asp?2013/1/3/148/120856

In 2003, severe acute respiratory syndrome (SARS), a new disease caused by a previously unknown coronavirus caused major worldwide alarm and concern. Almost 10 years later in 2012, the discovery of another novel strain of SARS-like coronavirus is causing unusually severe pneumonia in a majority of infected patients. [1],[2]

In September 2012, a case of novel coronavirus infection was reported involving a man in Saudi Arabia who had been admitted to a hospital with pneumonia and acute kidney injury in June 2012. [2] This novel coronavirus has been named Middle East Respiratory Syndrome Coronavirus (MERS-CoV). Since then, MERS-CoV has been identified as the cause of pneumonia in patients in Saudi Arabia, Qatar, Jordan, the United Kingdom, Germany, France, Tunisia and Italy. [2],[3],[4],[5],[6],[7],[8]

Since the first reported Saudi case of MERS-CoV, the Saudi Ministry of Health mandated that all patients with respiratory illnesses needing admission to intensive care should be tested for the virus using any available clinical specimen.

Respiratory viruses are an emerging threat to global health security and have led to worldwide epidemics with substantial morbidity, mortality and economic consequences. MERS-CoV is a member of the coronavirus family, Coronaviridae family, a group of large, enveloped single-stranded RNA viruses that cause a range of infections in mammalian and avian hosts. Coronaviruses are responsible for one-third of all cases of the common cold. Human coronaviruses usually cause mild-to-moderate upper-respiratory tract illnesses of short duration. MERS-CoV is considered distinct from the coronavirus responsible for the SARS-CoV, which is a virulent, transmissible human pathogen that first emerged in southern China in the fall of 2002. [9]

There are currently no vaccines available to protect against human coronavirus infections.

The origin of MERS-CoV virus remains unidentified. Many of the important facts about this virus are still unknown, particularly where it comes from and how it spreads. However, although it has a worrying high mortality rate, most of those who have died already had pre-existing conditions. [5],[7]

Molecular investigation indicated that bats in Saudi Arabia are infected with several alpha and beta coronaviruses. Virus from one bat recently showed 100% nucleotide identity to the virus from the human index case patient from Saudi Arabia. [10] Bats might play a role in human infection. [10],[11]

Early scientific evidence suggests that the virus might already be widespread in animals but much about this virus remains to be understood. Animals might play role as intermediate host for MERS-CoV transmission to humans. Most important of all is whether infection can be sustained through human-to-human transmission. [12],[13]

All cases originated from, or had a history of travel to, the Middle East, except for two secondary cases in the UK, two in Tunisia and one in France. A large cluster (23) of cases has been documented in one hospital in Saudi Arabia, and another is suspected on the basis of a retrospective analysis of samples kept after an outbreak of respiratory disease in a Jordanian hospital in April 2012. [12]

Whereas as yet, an unidentified animal reservoir might have caused the initial outbreaks by introducing the virus into the human population, the occurrence of clusters, whether in the community or in hospitals, is a worrying development, because it might result from adaptation of the virus to inter-human transmission. [14],[15]

Most patients with MERS-CoV infection have been severely ill with pneumonia and acute respiratory distress syndrome, and some have had acute kidney injury. Other clinical manifestations that have been reported are gastrointestinal symptoms (anorexia, abdominal pain, diarrhoea), pericarditis and disseminated intra-vascular coagulation. [5],[12],[13]

In review of 47 cases of MERS-CoV in Saudi Arabia, the case fatality rate rose with increasing age. Most patients (96%) had comorbid medical conditions including diabetes mellitus, cardiac and renal diseases. [5]

As of 30 September 2013, a total of 136 cases of human MERS-CoV infection with 60 deaths have been reported to the World Health Organisation (WHO). Of those, 114 cases had been reported from Saudi Arabia with 49 deaths. [16]

Routine MERS-CoV testing of all patients with severe pneumonia is now on-going in Saudi Arabia. Serologic testing of close contacts of patients with this disease will help to define local transmission and risk factors. Laboratory testing for MERS-CoV remains a challenge. Validated serologic assays are not yet commercially available, and this may have limited the identification of cases. WHO and Centers for Disease Control and Prevention recommend that lower respiratory tract specimens should be the first priority for collection and real time reverse-transcriptase polymerase chain reaction (rRT-PCR). [17],[18],[19] It seems prudent to conclude that one cannot reliably rule out MERS-CoV disease on the basis of a single negative test when a patient presents with the appropriate clinical syndrome and epidemiologic exposure. There is evidence that repeat testing of sputum or bronchoalveolar-lavage fluid is of value in improving diagnostic accuracy. [20],[21]

The WHO does not recommend either special screening for MERS-CoV at points of entry or the application of any travel or trade restrictions. [22] The Saudi Ministry of Health recommends that elderly (aged above 65 years) and those with chronic diseases (e.g. heart disease, kidney disease, respiratory disease, diabetes) and pilgrims with immune deficiency (congenital and acquired), malignancy and terminal illnesses, pregnant women and children (under 12) coming for Hajj and Umrah this year, to postpone the performance of the Hajj and Umrah for their own safety. [23]

Although current data on MERS-CoV infections are biased by high case fatality in admitted patients with medical co-morbidities, since 15 June 2013, the Saudi Ministry of Health has further reported MERS-CoV infections in at least 16 asymptomatic individuals after screening contacts of confirmed MERS-CoV cases. [24]

Population-based antibody testing will help to establish the extent of MERS-CoV infection, instead of only seeing the tip of the iceberg represented by cases admitted. As of today, data indicate that MERS-CoV does not appear to be as readily transmissible among humans; however, continued risk assessment, surveillance and vigilance by all countries are required. The public health communities in all countries must be aware of the public health risk associated with this MERS-CoV virus. It is not clear yet how far this virus might spread and nobody knows what impact it may have on global health.

  References Top

1.Alwan A, Mahjour J, Memish ZA. Novel coronavirus infection: Time to stay ahead of the curve. East Mediterr Health J 2013;19:S3-4.  Back to cited text no. 1
2.Zaki AM, van Boheemen S, Besterbroer TM, Osterhaus AD, Fouchier RA. Isolation of a novel coronavirus from a man with pneumonia in Saudi Arabia. N Engl J Med 2012;367:1814-20.  Back to cited text no. 2
3.AlBarrak AM, Stephens GM, Hewson R, Memish ZA. Recovery from severe novel coronavirus infection. Saudi Med J 2012;33:1265-9.  Back to cited text no. 3
4.Wise J. Patient with new strain of coronavirus is treated in intensive care at London hospital. BMJ 2012;345:e6455.  Back to cited text no. 4
5.Assiri A, Al-Tawfiq JA, Al-Rabeeah AA, Al-Rabiah FA, Al-Hajjar S, Al-Barrak A, et al. Epidemiological, demographic, and clinical characteristics of 47 cases of Middle East respiratory syndrome coronavirus disease from Saudi Arabia: A descriptive study. Lancet Infect Dis 2013;13:752-61.  Back to cited text no. 5
6.Centers for Disease Control and Prevention (CDC). Update: Severe respiratory illness associated with Middle East Respiratory Syndrome Coronavirus (MERS-CoV) - Worldwide, 2012-2013. MMWR Morb Mortal Wkly Rep 2013;62:480-3.  Back to cited text no. 6
7.World Health Organization. Global alert and response. Middle East respiratory syndrome coronavirus (MERS-CoV) - update. Available from: http://www.who.int/csr/don/2013_07_13/en/index.html [Last accessed on 2013 Jul 13].  Back to cited text no. 7
8.Gulland A. Two cases of novel coronavirus are confirmed in France. BMJ 2013;346:f3114.  Back to cited text no. 8
9.Cotton M, Lam TT, Watson SJ, Palser AL, Petrova V, Grant P, et al. Full-genome deep sequencing and phylogenetic analysis of novel human betacoronavirus. Emerg Infect Dis 2013;19:736-42.  Back to cited text no. 9
10.Memish ZA, Mishra N, Olival KJ, Fagbo SF, Kapoor V, Epstein JH, et al. Middle east respiratory syndrome coronavirus in bats, Saudi Arabia. Emerg Infect Dis 2013;19.  Back to cited text no. 10
11.Annan A, Baldwin HJ, Corman VM, Klose SM, Owusu M, Nkrumah EE, et al. Human betacoronavirus 2c EMC/2012-related viruses in bats, Ghana and Europe. Emerg Infect Dis 2013;19:456-9.  Back to cited text no. 11
12.Assiri A, McGeer A, Perl TM, Price CS, Al Rabeeah AA, Cummings DA, et al. Hospital outbreak of middle east respiratory syndrome coronavirus. N Engl J Med 2013;369:407-16.  Back to cited text no. 12
13.Memish ZA, Zumla AI, Al-Hakeem RF, Al-Rabeeah AA, Stephens GM. Family cluster of Middle East respiratory syndrome coronavirus infections. N Engl J Med 2013;368:2487-94.  Back to cited text no. 13
14.Guery B, Poissy J, el Mansouf L, Séjourné C, Ettahar N, Lemaire X, et al. MERS-CoV study group. Clinical features and viral diagnosis of two cases of infection with Middle East Respiratory Syndrome coronavirus: A report of nosocomial transmission. Lancet 2013;381:2265-72.  Back to cited text no. 14
15.Müller MA, Raj VS, Muth D, Meyer B, Kallies S, Smits SL, et al. Human coronavirus EMC does not require the SARS-coronavirus receptor and maintains broad replicative capability in mammalian cell lines. MBio 2012;3.  Back to cited text no. 15
16.Centers for Disease Control and Prevention (CDC), Update Middle East Respiratory Syndrome (MERS). Available from: http://www.cdc.gov/coronavirus/mers/ [Last accessed on 2013 Oct 21].  Back to cited text no. 16
17.World Health Organization. Global alert and response. Novel coronavirus summary and literature update. Available from: http://www.who.int/chr/disease/coronavirus infections/update 20130517/en/index.html. [Last accessed on 2013 May 8].  Back to cited text no. 17
18.Centers for Disease Control and Prevention (CDC). Interim guidelines for collection, processing and transport of clinical specimens from patients under investigation for Middle East Respiratory Syndrome (MERS). Available from: http://www.cdc.gov/coronavirus/mers/downloads/Interim-Guidelines-MERS-Collection-Processing-Transport.pdf. [Last accessed on 2013 Jun 7].  Back to cited text no. 18
19.Corman VM, Eckerle I, Bleicker T, Zaki A, Landt O, Eschbach-Bludau M, et al. Detection of a novel human coronavirus by real-time reverse-transcription polymerase chain reaction. Euro Surveill 2012;17.  Back to cited text no. 19
20.Drosten C, Seilmaier M, Corman VM, Hartmann W, Scheible G, Sack S, et al. Clinical features and virological analysis of a case of Middle East respiratory syndrome coronavirus infection. Lancet Infect Dis 2013;13:745-51.  Back to cited text no. 20
21.World Health Organization. Laboratory testing for novel coronavirus. Interim recommendations - 21 December 2012. Available from: http://www.who.int/csr/disease/coronavirus_infections/LaboratoryTestingNovelCoronavirus_21Dec12.pdf [Last accessed on 2012 Dec 21].  Back to cited text no. 21
22.World Health Organization. International health and travel. Middle East respiratory syndrome - coronavirus (MERS-CoV) - update. Available from: http://www.who.int/ith/updates/20130605/en/index.html [Last accessed on 2013 Jun 5].  Back to cited text no. 22
23.Ministry of Health, Saudi Arabia, Hajj and Umrah e-portal. Available from: www.moh.gov.sa/en/hajj/pages/healthregulations.aspx   Back to cited text no. 23
24.Memish ZA, Zumla AI, Assiri A. Middle East respiratory syndrome coronavirus infections in health care workers. N Engl J Med 2013;369:884-6.  Back to cited text no. 24


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