Imported cases of Middle East respiratory syndrome: An update

Abstract

Dear Editor, In a recent paper published in Travel Medicine and Infectious Disease, Al-Tawfiq and colleagues state with reason that despite a great concern regarding the potential for the Hajj to cause a global epidemic of Middle East Syndrome Coronavirus (MERS-CoV); only a limited number of travel-associated cases were reported with no major event related to the Hajj [1]. Screening for MERS-CoV carriage was conducted among cohorts of Hajj pilgrims in 2012 and 2013 and resulted negative [2], [3], [4]. Up to 1 November 2014, 21 cases of travel-associated MERS have been reported from various sources including ProMED (http://www.promedmail.org/), WHO (http://www.who.int/csr/outbreaknetwork/en/), ECDC (http://www.ecdc.europa.eu/en/Pages/home.aspx) and USCDC (http://www.cdc.gov/) updates, some of which were also reported in the medical literature as summarized recently by Pavli and colleagues [5]. In Table 1 , we are describing the MERS cases identified out of the Middle Eastern countries among individuals who traveled to and/or from the Middle Eastern countries. All cases but two were confirmed by polymerase chain reaction on at least two specific genomic targets. The majority of cases were in Europe (10 cases), North Africa (5 cases) and Asia (4). Two cases were imported to the US. Likely place of exposure was in the Kingdom of Saudi Arabia (KSA) in the majority of cases. Three patients were Middle East nationals transferred to European hospitals for medical care. Seven cases were among expatriates living in the Middle East and traveling back to their country of origin, including one patient living in Qatar who participated to the Umrah in KSA (a shorter pilgrimage to Mecca that can be undergone at any time). Ten cases were among short-term travelers with a mean time of stay in the Middle East of 18 days (range 3 h–40 days). Among short-travelers, 7 participated to the Umrah, one traveled for holidays, one was in transit in Abu Dhabi airport and the information is missing in one case. Nine patients died, nine recovered, one was asymptomatic and the information missing in two cases. Possible source of infection was identified in some patients including exposure to camels or their products (four cases) or bats (one case), exposure to MERS patients (six cases of which three were health care workers) and visit to Saudi hospitals (two cases). Table 1 Characteristics of travel-associated cases of Middle East coronavirus syndrome (2012–2014)a. Country of diagnostic Country of current residence Year Age (years)/gender Likely place of exposure Travel duration (days) Reason for travel Outcome Possible source of infection PCR target genes Referencesa UK Qatar 2012 49/M Qatar and KSA NA Medical transfert Died Visited a camel farm UpE and ORF1 [1,2] Germany (Essen) Qatar 2012 45/M Qatar NA Medical transfert Recovered Contacts with camels UpE and ORF1 [3,4] Germany (Munich) UAE 2013 73/M UAE NA Medical transfert Died Contacts with camels UpE and ORF1 [5,6] France France 2013 64/M UAE 8 ND Died ND UpE and ORF1 [7,8] Italy Italy 2013 45/M Jordan 40 Holiday Recovered ND UpE [9] Tunisia Tunisia 2013 66/M Qatar and KSA 31 in Qatar and 8 in KSA Visit family + Umrah Died None identified ORF1 and N2 [10] Tunisia Qatar (expatriate) 2013 30/F Qatar and KSA NA Umrah + attended funerals in Tunisia Recovered Exposure to MERS patient UpE and ORF1 [10] UK UK 2013 55/M Pakistan and KSA 35 in Pakistan, 8 in KSA Visit family + Umrah Died None identified UpE and two other genes [11] Netherlands Netherlands 2014 70/M KSA 16 Umrah Recovered Hospitalization in Saudi Arabia UpE, N and ORF1 [12,13] Netherlands Netherlands 2014 73/F KSA 16 Umrah Recovered Exposure to MERS patient UpE, N and ORF1 [12,13] Algeria Algeria 2014 66/M KSA 14 Umrah Recovered ND UpE, N and ORF1 [14-16] Algeria Algeria 2014 59/M KSA 24 Umrah Died ND UpE, N and ORF1 [14-16] Greece KSA (expatriate) 2014 69/M KSA NA Visit to citizenship country Died Visited hospitals in Saudi Arabia and had indirect contacts with bats UpE, N and ORF1 [17,18] US (Indiana) KSA (expatriate) 2014 65/M KSA NA Visit to citizenship country Recovered Exposure to MERS patients (HCW) ORF1 and N2 [19,20] US (Florida) KSA (expatriate) 2014 44/M KSA NA Visit to citizenship country Recovered Exposure to MERS patients (HCW) ORF1 and N2 [20] Malaysia Malaysia 2014 55/M KSA 13 Umrah Died Drank raw camel milk UpE, N and ORF1 [21] Egypt KSA (expatriate) 2014 27/M KSA NA Visit to citizenship country Recovered Exposure to MERS patients Confirmed according to ECDC report [22,23] Philippines UAE (expatriate) 2014 ND/M UAE NA Visit to citizenship country Asymptomatic Exposure to MERS patients (HCW) Confirmed according to ECDC report [24] Bangladesh US 2014 53/M UAE 3 h transit in Abu Dhabi airport Visit to citizenship country ND ND ND [16] Turkey KSA (expatriate) 2014 ND/M KSA NA Visit to citizenship country Death ND ND [25,26] Austria KSA 2014 29/F KSA NA ND ND ND Confirmed according to ECDC report [27,28] a See online appendix. From this figure, it is notable that 8 out of 21 travel-associated cases were in patients who participated to the Umrah (38%), a proportion which culminate to 70% among short-term travelers. Among the 8 patients participating to the Umrah, two were exposed to MERS patients, one was hospitalized in Saudi Arabia prior contracting MERS and one drank camel milk in KSA. No risk factor was identified in two patients and the information was missing in two cases. These 8 Umrah-associated MERS cases over an estimated 20 million pilgrims who visited Mecca from 2012 through 2014 are not significant in terms of public health. The high prevalence of participation to Umrah among the few travel-associated MERS cases in short-term travelers likely reflects the fact that tourism in the region is significantly dependent on religious tourism. According to the Saudi Tourism and Antiquities Committee (SCTA) data, of the 17 million international tourists who visited Saudi Arabia in 2013, 6.9 million (40.6%) did so for religious reasons. From a clinical perspective, physicians should have a high degree of suspicion for MERS in patients with severe respiratory symptoms following pilgrimage to Mecca; however, surveillance data in England and France showed that a diagnostic of influenza was most likely in such travelers [3], [6], [7]. Conflict of interest None.