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10 Jun 2013

Middle East respiratory syndrome- coronavirus (MERS CoV)–Multistate (ECDC/CDTR, June 10 2013, edited)

[Source: European Centre for Disease Prevention and Control (ECDC), full PDF document: (LINK). Edited.]


Week 23, 2-8 June 2013


Middle East respiratory syndrome- coronavirus (MERS CoV) – Multistate

Opening date: 24 September 2012 Latest update: 5 June 2013


Epidemiological summary

The first described case of MERS-CoV infection was a 60-year-old male resident of Saudi Arabia who died of severe pneumonia complicated by renal failure in June 2012. A previously unknown coronavirus isolated from this patient was identified.

As of 6 June 2013, 54 laboratory confirmed cases have been reported worldwide: Saudi Arabia (39), Jordan (two), Germany (two), United Kingdom (four), France (two), Italy (three) and Tunisia (two). Thirty of these cases have died. All cases remain associated with transmission in the geographic area of the Arabian Peninsula. There are several clusters among the reported cases both in health care and home settings, some with evidence of limited human-to human transmission and a few who had not been to the Middle East but had been in close contact with laboratory-confirmed or probable cases. The age-range of cases is from 14 to 94 years (age is unknown for four cases). Thirteen cases are female and 36 are male (gender is unknown for one case).

Since April 2013, all cases in Saudi Arabia were reported in the eastern provinces of the country with the majority linked to a healthcare facility in Al-Ahsa. Two patients are healthcare workers who were exposed to patients with confirmed MERS-CoV. The latest case was reported by WHO on 5 June, also from the eastern region of Saudi Arabia, but not part of the Al-Ahsa cluster. The patient is a 14 year old girl with multiple co-morbidities, presenting on 29 May with respiratory symptoms. She is in stable condition in the isolation ward.

On 1 June 2013, Italy reported an imported case, a 45-year-old man with recent travel to Jordan. This is the first time a patient has been diagnosed with MERS-CoV in Italy. He returned to Italy on 25 May 2013 and was hospitalised on 28 May 2013. Italy has reported two additional cases on 2 June, a two year old niece and a 42 year old female co-worker of the index case. All three patients are reported to be in stable condition. Ten further contacts of the index case tested positive for MERS-CoV initially, but subsequent confirmatory tests exluded MERS-CoV infection.



ECDC assessment

The additional recent novel coronavirus cases reported by the Saudi Arabian authorities indicate an ongoing source of infection present in the Arabian Peninsula.

The French index case who presented with diarrhoea is a reminder of the possibility that initial presentations may not necessarily include respiratory symptoms, especially in those with immunosuppression or underlying chronic conditions. This needs be taken into account when revising case-finding strategies. This case in France was the second nosocomial transmission in Europe following one reported in the UK in February 2013, highlighting the risk of onward transmission in Europe, in particular in healthcare settings. Both French patients had underlying conditions, and a degree of immunosuppression. One of the transmissions in the UK was also to an immunosuppressed person. These underlying conditions may be increasing the vulnerability and the risk of transmission. Specimens from the upper respiratory tract were negative taken from some patients who were later confirmed to be infected by MERS-CoV in samples from the lower respiratory tract. Therefore, specimens from patients’ lower respiratory tracts should be obtained for diagnosis where possible.

Information on many of the basic epidemiological indicators required for determining effective control measures are still missing for most cases that occurred in the Middle East, e.g. the reservoir of infection, risk groups, incubation period, period of infectivity and settings where infection has occurred.

The imported cases reported by Germany, France and Italy, following medical evacuation and travel, suggest that more imported cases may be expected in the EU in the future.

Due to the large number of guest workers in Saudi Arabia attention must also be drawn to the possible importation of MERS-CoV to the South East and Pacific Asia.



ECDC published an updated rapid risk assessment on 17 May 2013 and an updated epidemiological update on 3 June 2013. The results of an ECDC-coordinated survey on laboratory capacity for testing the novel coronavirus in Europe were published in

ECDC is closely monitoring the situation in collaboration with WHO and the European Union Member States.