Hospital outbreak of middle east respiratory syndrome coronavirus

• Authors: Abdullah Assiri, Ministry of Health Saudi Arabia; Allison McGeer, University of Toronto; Trish M. Perl, Johns Hopkins University; Connie S. Price, University of Colorado at Denver; Abdullah A. Al Rabeeah, Ministry of Health Saudi Arabia; Derek A. T. Cummings, Johns Hopkins University; Zaki N. Alabdullatif, Ministry of Health Saudi Arabia; Maher Assad, Ministry of Health Saudi Arabia; Abdulmohsen Almulhim, Ministry of Health Saudi Arabia; Hatem Makhdoom, Ministry of Health Saudi Arabia; Hossam Madani, Ministry of Health Saudi Arabia; Rafat Alhakeem, Ministry of Health Saudi Arabia; Jaffar A. Al-Tawfiq, Johns Hopkins Aramco Healthcare; Matthew Cotten, Wellcome Sanger Institute; Simon J. Watson, Wellcome Sanger Institute; Paul Kellam, Wellcome Sanger Institute; Alimuddin I. Zumla, Ministry of Health Saudi Arabia; Ziad Memish, Emory University
• Journal Title: New England Journal of Medicine
• Volume: Volume 369, Number 5
• Publisher: Massachusetts Medical Society | 2013-01-01, Pages 407-416
• Type of Work: Article | Final Publisher PDF
• Publisher DOI: http://doi.org/10.1056/NEJMoa1306742
• Subjects: Biology, Virology
• Keywords: Coronavirus; respiratory viruses; MERS-CoV; Middle East; person-to-person transmission

Abstract

BACKGROUND: In September 2012, the World Health Organization reported the first cases of pneumonia caused by the novel Middle East respiratory syndrome coronavirus (MERSCoV). We describe a cluster of health care-acquired MERS-CoV infections. METHODS: Medical records were reviewed for clinical and demographic information and determination of potential contacts and exposures. Case patients and contacts were interviewed. The incubation period and serial interval (the time between the successive onset of symptoms in a chain of transmission) were estimated. Viral RNA was sequenced. RESULTS: Between April 1 and May 23, 2013, a total of 23 cases of MERS-CoV infection were reported in the eastern province of Saudi Arabia. Symptoms included fever in 20 patients (87%), cough in 20 (87%), shortness of breath in 11 (48%), and gastrointestinal symptoms in 8 (35%); 20 patients (87%) presented with abnormal chest radiographs. As of June 12, a total of 15 patients (65%) had died, 6 (26%) had recovered, and 2 (9%) remained hospitalized. The median incubation period was 5.2 days (95% confidence interval [CI], 1.9 to 14.7), and the serial interval was 7.6 days (95% CI, 2.5 to 23.1). A total of 21 of the 23 cases were acquired by person-to-person transmission in hemodialysis units, intensive care units, or in-patient units in three different health care facilities. Sequencing data from four isolates revealed a single monophyletic clade. Among 217 household contacts and more than 200 health care worker contacts whom we identified, MERS-CoV infection developed in 5 family members (3 with laboratory-confirmed cases) and in 2 health care workers (both with laboratory-confirmed cases). CONCLUSIONS: Person-to-person transmission of MERS-CoV can occur in health care settings and may be associated with considerable morbidity. Surveillance and infection-control measures are critical to a global public health response.