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PostPosted: Wed Apr 23, 2014 6:29 am 

Joined: Wed Aug 19, 2009 10:42 am
Posts: 56044
Location: Pittsburgh, PA USA
Onward transmission by HCW:

The following details were provided to WHO on 18 April by the Ministry of Health UAE:
A 63 year-old woman from Abu Dhabi who had close contact with a previously laboratory-confirmed case reported on 14 April. She was screened on 13 April and became ill on 15 April. She is reported to have an underlying medical condition. She is reported to have no exposure to animals or a recent travel history.
A 73 year-old woman from Abu Dhabi who has been an in-patient at the hospital since 26 February due to other illnesses. She has underlying medical conditions. The patient was admitted to the intensive care unit (ICU) on 14 April. She is reported to have no exposure to animals or a recent travel history.


PostPosted: Wed Apr 23, 2014 9:03 am 

Joined: Wed Aug 19, 2009 10:42 am
Posts: 56044
Location: Pittsburgh, PA USA

http://www.recombinomics.com/News/04231 ... er_22.html


PostPosted: Wed Apr 23, 2014 8:17 pm 

Joined: Wed Aug 19, 2009 10:42 am
Posts: 56044
Location: Pittsburgh, PA USA
WHO office sounds alarm as MERS cases push higher

Lisa Schnirring | Staff Writer | CIDRAP News | Apr 23, 2014

Against the backdrop of 33 more Middle East respiratory syndrome coronavirus (MERS-CoV) cases reported by Saudi Arabia—some in Mecca—and the United Arab Emirates (UAE), the World Health Organization (WHO) today raised concerns about the ongoing spike in cases, especially in healthcare settings, and offered to help the countries pull together a global team to help investigate and assess the risks.

The WHO aired the issues in a press release that its Eastern Mediterranean office (EMRO) in Cairo e-mailed to journalists. The statement came amid two separate announcements of cases from Saudi Arabia's health ministry—one reporting 11 new cases and the other reporting 13 new illnesses, two of them fatal, along with two other deaths. In addition, WHO headquarters in Geneva announced details about nine MERS-CoV cases that it received from the UAE on April 16, 18, and 21.

The statements from Saudi Arabia included details about the first cases reported in the holy city of Mecca, including one in a Turkish pilgrim.

WHO offers assistance
Ala Alwan, MD, EMRO's director, said in the statement that 75% of recently reported infections are secondary cases, considered to have been spread from other people. "The majority of these secondary cases have been infected within the healthcare setting and are mainly healthcare workers, although several patients are also considered to have been infected with MERS-CoV while in hospital for other reasons," he added.

Underscoring WHO EMRO's concerns about illness links to health settings, three of Saudi Arabia's MERS-CoV case-patients reported today are healthcare workers, two from Jeddah and one from Riyadh. Also, two of the UAE patients had hospital exposure: one while visiting a facility and the other a patient who had been hospitalized since late February for another medical condition.

Among other common threads in today's cases, 17 had underlying medical conditions, and 10 are listed as contacts of other confirmed cases. Most of the patients who had known contact with a lab-confirmed case-patient have no symptoms or only mild symptoms.

WHO EMRO said that though most of the cases involve asymptomatic or mild infections and don't spread the virus to others, key information gaps remain about the transmission of the virus and the route of infection. One of the unanswered questions is the type of exposure in healthcare settings that transmit the virus.

Therefore, the WHO is offering to gather international expertise to help the two countries probe the recent outbreaks to identify the transmission chain in the clusters and if the pattern signals any new risks.

The WHO also raised concerns about a fresh round of MERS-CoV infections in people who visited Saudi Arabia or the UAE, as recent cases were reported in Greece, Jordan, Malaysia, and the Philippines. It said that though no further spread of the virus has been linked to those cases, earlier imported cases in France and the United Kingdom resulted in limited human-to-human spread.

It urged nations to stay vigilant and enhance surveillance to detect any sign that the virus has changed in a way that makes it more transmissible among humans.

Saudi Arabia reports 24 cases
Saudi Arabia said today in its first statement (posted in English on the health ministry's web site) that four of the 11 case-patients reported today are from Riyadh, six are from Jeddah, and one is from Mecca. All 11 of the cases are residents of Saudi Arabia. Ten are adults, ranging in age from 24 to 81 years old. One is a 13-year-old Jeddah resident, a contact of a previous case, who is asymptomatic.

Of the 11 patients, eight are being treated in intensive care units (ICUs), two are listed in stable condition, and one is asymptomatic. Three of the patients are healthcare workers.

Later today the health ministry announced 13 more cases, according to a machine translation of a statement posted in Arabic. Five cases are reported from Riyadh, two from Jeddah, four from Mecca, one from Medina, and one from Jordan, which appears to be an imported case from Saudi Arabia.

The statement contained several details about the cases that haven't typically been included in past ministry statements, such as hospitalization locations and dates, which underlying medical conditions they have, and if they have pneumonia and are on respirators. It's not clear if the added details in the latest statement are the result of the country's recent change in health ministers. Earlier in the week Saudi Arabia reassigned its health minister and appointed labor minister Adel bin Mohammad Faqih as acting health minister.

One of the patients is a 65-year-old pilgrim from Turkey who is hospitalized in stable condition in Mecca.

Two deaths were reported among the 13 new cases: an 80-year-old man with several underlying medical conditions who died at a Riyadh hospital on Apr 22 and a 52-year-old who was hospitalized in Mecca and also died on Apr 22. Saudi Arabian officials also reported two other deaths in presumably previously confirmed cases, which include a 45-year-old health worker from Al-Kharj governorate who died on Apr 21 and a 29-year-old who died at King Fahd Hospital in Jeddah on Apr 22.

Five of the patients are hospitalized at a military hospital in Riyadh, one is at King Faisal Specialist Hospital in Jeddah, one is hospitalized in Medina, one at a security force hospital in Mecca, and three apparently at another hospital in Mecca.

Of the 13 cases, two patients died, three are on respirators, three are being treated in ICUs, four are stable, and one is asymptomatic. Hospitalization dates, listed for 10 of the patients, range from Mar 27 through Apr 21.

Patient ages range from 13 to 88, though most are middle-aged and older adults.

MERS sickens nine more in UAE
Details about the nine cases in the UAE were included in a statement today from the WHO. All of the patients are adults from Abu Dhabi, ranging in age from 28 to 73 years old. One is a 52-year-old woman who got sick after traveling to Jeddah in Saudi Arabia from Apr 5 through Apr 16, where she visited the hospital three times. One of the others is a 73-year-old woman who had been hospitalized since Feb 26 for another medical condition and was admitted to the ICU on Apr 14.

Six of the UAE cases, all reported to the WHO on Apr 16, had close contact with a lab-confirmed case that was reported on Apr 10. Three are women and three are men. Four had mild illnesses and two were asymptomatic. Only one of them had an underlying medical condition.

With the flurry of recent new cases and lack of clarity in some of the recent health ministry statements, the outbreak total is unclear. FluTrackers, an infectious disease news message board, maintains a running list of lab-confirmed MERS-CoV cases, along with an updated overall case count. However, it said today that some of the cases appear to have already been reported, such as that of a 52-year-old UAE woman reported today, and that as of today it will no longer track the overall count, though it will continue to provide daily case totals.

The WHO said today in the EMRO statement that it has received reports of 253 lab-confirmed cases, including 93 deaths. FluTrackers, in its last case count, said there were 364 cases reported by health ministries. Meanwhile, Saudi Arabia's health ministry said today that it has now recorded 285 infections from MERS-CoV, 83 of them fatal.

See also:

Apr 23 Saudi Arabian health ministry statement in English on 11 cases

Apr 23 WHO EMRO press release

Apr 23 Saudi Arabian health ministry statement in Arabic on 13 cases

Apr 23 WHO statement

Saudi Arabian health ministry main media page

Apr 21 CIDRAP News story "Saudi Arabia sacks health chief as MERS cases surge"

http://www.cidrap.umn.edu/news-perspect ... ush-higher


PostPosted: Wed Apr 23, 2014 9:52 pm 

Joined: Wed Aug 19, 2009 10:42 am
Posts: 56044
Location: Pittsburgh, PA USA
Gush of MERS cases sparks speculation about causes
Robert Roos | News Editor | CIDRAP News | Apr 23, 2014

Some experts speculate that MERS-CoV may spread more readily in the spring.

With few data available, experts are at a loss to explain the rising tide of MERS-CoV (Middle East respiratory syndrome coronavirus) cases in Saudi Arabia and the United Arab Emirates (UAE). But when it comes to speculation, two leading possibilities mentioned are a change in the virus and a seasonal pattern to its transmission.

Saudi Arabia has reported more than 100 cases since the beginning of April, many of them in a healthcare-related outbreak in the Red Sea port of Jeddah. The number of recent cases in the UAE, meanwhile, is unclear but seems to be well above 25, including 14 that, according to the World Health Organization (WHO), stemmed from one healthcare worker (HCW).

In a statement today, the WHO noted that about 75% of the recent cases are secondary ones resulting from human-to-human transmission, with the majority occurring in healthcare settings, often in HCWs. Acknowledging "critical information gaps," the agency said it is unaware of what specific kinds of exposures have sparked the cases in healthcare facilities.

Experts are quick to emphasize that very little is known so far about the outbreaks in Saudi Arabia and the UAE, making it impossible to reach any conclusions about their cause as yet.

"These cases are just being reported and information regarding them is trickling in to WHO," said David Swerdlow, MD, leader of MERS activities at the US Centers for Disease Control and Prevention (CDC). "As we learn more, we can get a sense of the nature of these newly reported cases. For example, is this just seasonality, an increase in cases because of a hospital outbreak or a change in the efficiency of how the virus is transmitted?

"At this time, there is no conclusive indication the virus has adapted enough to sustain human-to-human transmission, something CDC is monitoring closely," he added.

Possibility of viral evolution

Allison McGeer, MD, a microbiologist and infectious diseases consultant at Mt. Sinai Hospital in Toronto, agrees that there is too little information to do more than speculate for now, but she sees some signs that suggest the possibility that the virus is changing. She was part of a team that traveled to Saudi Arabia last year and advised the government about its response to MERS-CoV.

In an interview, McGeer, who led efforts to stop the SARS (severe acute respiratory syndrome) coronavirus outbreak in Toronto in 2003, compared the Jeddah outbreak with the outbreak in Al-Ahsa (also written Al-Hasa) in eastern Saudi Arabia a year ago. That one involved 23 confirmed and 11 probable cases in several hospitals, according to a June 2013 report in the New England Journal of Medicine (NEJM).

McGeer said that although information is lacking, the Jeddah outbreak "seems like a multi-institutional, really complicated outbreak. . . . It's clear that there are a substantial number of healthcare workers involved."

But the two outbreaks, she said, seem to differ in at least one way: "Compared to last year, the attack rate in healthcare workers appears to be higher, and I don't think that that is related to more testing. One of the striking things about the Al-Hasa outbreak was that the attack rate in healthcare workers was relatively low compared to the rate in patients.

"This ratio of healthcare workers to patients looks different now, and that raises the issue of whether the virus is changing," she added. "To me that's the critical issue that needs to be answered."

A spring thing?

Connie Savor Price, MD, chief of infectious diseases at Denver Health and Hospital, speculates that there may be something about MERS-CoV that makes it spread more readily in spring.

She noted that the first known outbreak of MERS-CoV occurred in a Jordan hospital in the spring of 2012. (The virus had not yet been discovered at the time, but months later, analysis of stored clinical samples revealed that MERS-CoV was the cause.)

"Of course I'm going on a really, really limited number of outbreaks, but, among the larger healthcare outbreaks: Jordan hospital outbreak peaked in April, as did Al-Hasa outbreak, and now we have this recent activity in Jeddah," Price told CIDRAP News.

Further, she observed that SARS, another coronavirus, peaked in March and April of 2003 and was largely gone by summer.

"[I'm] still perplexed why no one got sick at Hajj last fall," she added. "Perhaps spring is special for MERS. We do know that other coronaviruses have a marked winter/spring seasonality."

"That's just one very theoretical idea," Price cautioned. "Without detailed information on the recent Saudi cases, it's really hard to do anything but guess. One could imagine it's a combination of factors—in addition to the theory above, sheer lack of data on transmission to guide best practice, infection control lapses, super-spreaders, evolving virus becoming more fit to spread human-to-human. We could guess endlessly."

McGeer also mentioned the possibility of a seasonal pattern to MERS-CoV transmission. She speculated about one possible contributing factor. Recent studies have indicated that MERS-CoV is fairly widespread in camels on the Arabian Peninsula, and it seems to be more common in young camels than adults. She noted that camels usually give birth in spring, which means a higher population of young camels at that time of year, perhaps raising the risk of human MERS outbreaks.

German virologist Christian Drosten of the University of Bonn hinted at the same possibility in a news story in the Mar 28 issue of Science. He said young camels may contract MERS shortly after birth and be in their most infectious condition in the spring.

Infection control issues

But even if there were a known seasonal aspect to MERS transmission, it wouldn't explain why the current outbreak in Jeddah is so much larger than the Al-Ahsa one a year ago, said McGeer.

"The Kingdom of Saudi Arabia has perfectly good infection control practices, they know how to do that well, they did a great job with Al-Hasa last year, yet this outbreak appears to be substantially larger than Al-Hasa was," she said.

"So how this virus got past what I think generally are competent infection control people and caused a larger outbreak than was seen last year, I think really raises an issue about whether the virus has changed," McGeer added.

Another possibility that some have mentioned is the emergence of "super spreaders," meaning infected people who spread the virus to many others. The UAE MERS patient who infected 14 others appears to be in that category, and one patient in the Al-Hasa outbreak was believed to have infected seven others.

McGeer said it's theoretically possible that a super spreader is a factor in the Jeddah outbreak, but she thinks it unlikely that that would explain all the cases, because that would seem to require several super spreaders, not just one.

Research badly needed

One way to help figure out if the virus is changing is to get a MERS-CoV sample, sequence its genome, and compare it with earlier isolates. But McGeer said, "Nobody's seen any 2014 isolates."

Noting that cases were identified last week in Greece and Malaysia, she expressed a hope that isolates from those patients will be sequenced.

The CDC's Swerdlow said in response to a question, "We are working with our partners to obtain [MERS-CoV] samples for sequencing."

Price voiced what is probably the view of many observers of the MERS-CoV landscape: "We need to stop guessing, get all hands on deck (ie, international collaboration), and do a detailed outbreak investigation with case-control study, complemented by genetic sequencing data to understand what is happening. This should be doable right now."

See also:

Apr 23 WHO statement

Jun 19, 2013, CIDRAP News story on NEJM study of Al-Ahsa outbreak

http://www.cidrap.umn.edu/news-perspect ... out-causes


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