In light of the rise in MERS CoV cases in the Middle East the Yale-Tulane ESF-8 Planning and Response Program has produced this special report. It was compiled entirely from open source materials. Please feel free to forward the report to anyone who might be interested.

1. BACKGROUND
SITUATION
26 APRIL 2014
RISK ASSESSMENTS
INFECTION CONTROL
MIDDLE EAST
SAUDI ARABIA
 MINISTRY OF HEALTH
 FACEBOOK | TWITTER
 NOVEL CORONAVIRUS
JORDAN
 MINISTRY OF HEALTH
QATAR
 SUPREME COUNCIL OF
HEALTH
UAE
 MINISTRY OF HEALTH
EGYPT
 MINSTRY OF HEALTH
EUROPE
FRANCE
 MINISTRY OF HEALTH
GREECE
 HELLENIC CENTRE FOR
DISEASECONTROL AND
PREVENTION
GERMANY
 MINISTRY OF HEALTH
ENGLAND
 MINISTRY OF HEALTH
ITALY
 MINISTRY OF HEALTH
NORTH AFRICA
TUNISIA
 MINISTRY OF HEALTH
ASIA
MALAYSIA
 MINISTRY OF HEALTH
PHILIPIINES
 DEPARTMENT OF HEALTH
YALE- TULANE ESF-8 SPECIAL REPORT
MIDDLE EAST RESPIRATORY SYNDROME (MERS-CoV)
DEAD
345 107
LABORATORY
CONFIRMED CASES*
WHAT IS MERS-CoV?
INTERNATIONAL ORGANIZATIONS
WHO
 WORLD HEALTH ORGANIZATION – EASTERN MEDITERRANEAN
 DISEASEOUTBREAK NEWS
 GLOBAL ALERT RESPONSE – CORONAVIRUS INFECTIONS
 WHO – MERS-COV
US GOVERNMENT
 CDC – MERS
US EMBASSY SAUDI ARABIA
EUROPEANUNION
 ECDC _MERS
CANADA
 PUBLIC HEALTH AGENCY OF CANADA The World Health Organization (WHO) is
concerned about the rising number of
cases of Middle East respiratory
syndrome coronavirus (MERS-CoV) in
recent weeks, especially in the Kingdom
of Saudi Arabia and the United Arab
Emirates (UAE) and in particular that two
significant outbreaks occurred in health
facilities.
HEALTHCARE WORKER
INFECTED
72
*Numbers reported by the European Centre for
Disease Prevention and Control (ECDC) as of 23 APR 14
Graphic: Mallory Brangan
NEW SOURCES
 ALERTNET
 CNN
 Washington Post
 Wall Street Journal
 ARAB NEWS
PORTALS, BLOGS, AND RESOURCES
CIDRAP
HEALTH MAP
PROMED MAIL
VIROLOGY DOWN UNDER BLOG
FLUTRACKERS

2. BACKGROUND
Middle East Respiratory Syndrome (MERS) is viral respiratory illness first
reported in Saudi Arabia in 2012. It is caused by a coronavirus called MERS-CoV.
Most people who have been confirmed to have MERS-CoV infection developed
severe acute respiratory illness. They had fever, cough, and shortness of breath.
Since MERS was discovered in 2012, there has been a steady stream of cases
with the majority coming out of Saudi Arabia. In March 2014 the World Health
Organization (WHO) had reported that there had been 199 cases worldwide,
including 84 deaths and all of the cases had been linked to the Middle East.
In April 2014 the numbers out of Saudi Arabia (KSA) and the United Arab
Emirates (UAE) had soared (47% in past month). Most of the new cases coming
from two healthcare‐associated outbreaks, one in a hospital in Jeddah, KSA and
the second among paramedics in UAE.
The European Centre for Disease Prevention and Control now says the total
is 345 cases, including 107 deaths. (AS OF 23 APR 14)
The cause of the rapid increase in cases is unknown. Possible scenarios that
might explain this are
• More sensitive case detection through more active case finding and contact
tracing or changes in testing algorithms,
• Increased zoonotic transmission with subsequent transmission in healthcare
settings
• Breakdown in infection control measures or otherwise increased transmission
in the local healthcare setting,
• Change in the virus resulting in more effective human-to-human
transmission, resulting in both nosocomial clusters, and increased numbers of
asymptomatic community acquired cases, or
False positive lab results.
On Monday, 21 April 2014, the Saudi Arabia's Minister of Health was replaced.
His replacement, the Acting Minister of Health Adel bin Mohammed
Fakeih, promised ”transparency and to promptly provide the media and society
with the information needed. “He has appointed Dr. Tarek Madani as a medical
advisor for the Ministry of Health (MOH).
Stars highlight difference in scale at left-hand side, (x-axis) numbers. Seasons
based on info. Source: Ian Mackay, an epidemiologist at the Australian
Infectious Diseases Research Centre at the University of Queensland
On 24 April 2014, WHO encourages all Member States to continue their
surveillance for severe acute respiratory infections (SARI) and to carefully review
any unusual patterns

3. BACKGROUND
Geographic distribution of confirmed MERS-CoV cases, worldwide, as of 23 April 2014 (n=345) SOURCE: ECDC RISK ASSESSMENT

4. • Common symptoms are acute, serious respiratory illness with fever,
cough, shortness of breath and breathing difficulties.
• Most patients have had pneumonia. Many have also had gastrointestinal
symptoms, including diarrhoea.
• Some patients have had kidney failure.
• About half of people infected with MERS-CoV have died.
• In people with immune deficiencies, the disease may have an atypical
presentation.
WHAT IS MERS CoV?
HOW IS IT TRANSMITTED
SIGNS AND SYMPTOMS
WHAT IS MERS-CoV?
• According to the limited available information it is likely to be
transmitted in a similar way to the other viruses from the corona virus
family. There are several theories including:
 Possible transmission through animal sources
 Direct spread through droplets from patients during cough or
sneezing.
 Indirect spread through contaminated surfaces and
instruments and then touching the mouth, nose or eyes.
 Direct close contact with affected individuals.
• MERS-CoV is a beta coronavirus.
• It was first reported in 2012 in Saudi Arabia. MERS-CoV used to be
called “novel coronavirus,” or “nCoV”.
• It is different from other coronaviruses that have been found in
people before.
WHERE ARE MERS-CoV INFECTIONS OCCURRING?
• Twelve countries have now reported cases of human infection with
MERS-CoV.
• Cases have been reported in France, Germany, Greece, Italy Jordan,
Malaysia , the Philippines, Qatar, Saudi Arabia, Tunisia, the United
Arab Emirates, and the United Kingdom.
• All cases have had some connection (whether direct or indirect) with
the Middle East.
• In France, Italy, Tunisia and the United Kingdom, limited local
transmission has occurred in people who had not been to the Middle
East but who had been in close contact with laboratory-confirmed or
probable cases.
SOURCE: CDC WHO
Distribution of confirmed cases of MERS-CoV by gender and age group, March
2012–23 April 2014 ECDC

5. DIAGNOSIS
TREATMENT
WHAT IS MERS-CoV?
Laboratory tests can be done to confirm whether the illness may be caused by
human coronaviruses. However, these tests are not used very often because
people usually have mild illness. Also, testing may be limited to a few
specialized laboratories.
Specific laboratory tests may include:
• Virus isolation in cell culture,
• Polymerase chain reaction (PCR) assays that are more practical
and available commercially, and
• Serological testing for antibodies to human coronaviruses.
Nose and throat swabs are the best specimens for detecting common human
coronaviruses. Serological testing requires collection of blood specimens.
• No vaccine is currently available.
• Treatment is largely supportive and should be based on the patient’s
clinical condition.
SOURCE: CDC WHO ECDC
INDIVIDUAL PROTECTION
• Wash your hands often with soap and water for 20 seconds, and help
young children do the same. If soap and water are not available, use
an alcohol-based hand sanitizer.
• Cover your nose and mouth with a tissue when you cough or sneeze
then throw the tissue in the trash.
• Avoid touching your eyes, nose, and mouth with unwashed hands.
• Avoid close contact, such as kissing, sharing cups, or sharing eating
utensils, with sick people.
• Clean and disinfect frequently touched surfaces, such as toys and
doorknobs.
VISITORS TO THE ARABIAN PENINSULA
Follow general travel health precautions that lower the risk of infection in
general, including illnesses such as influenza and traveller’s diarrhoea. This
includes:
• Wash hands often with soap and water. When hands are not visibly dirty, a
hand rub can be used.
• Adhere to good food-safety practices, such as avoiding undercooked meat
and unpasteurized milk (especially from camels) or food prepared under
unsanitary conditions, and properly washing fruits and vegetables before
eating them.
• Maintain good personal hygiene.
• Avoid unnecessary contact with farm, domestic, and wild animals,
especially camels.
• Use appropriate precautions when in close contact with case-persons
presenting with acute respiratory illness, diarrhoea or other potentially
infectious diseases.
• Consult their physician if suffering major medical conditions (e.g. chronic
diseases such as diabetes, chronic lung or renal disease,
immunodeficiency) that can increase the likelihood of illness including
MERS-CoV infection, or contact with healthcare facilities during travel.

6. CURRENT SITUATION
During April 2014 there has been an unprecedented increase in cases and
community transmission as well as transmission in hospital settings.
SAUDI ARABIA
• On 26 April the new action Health Minister, Adel Fakeih, announced the
country was reserving three medical centers to treat MERS. The main
referral center will be King Abdullah Medical Center In Jeddah. Prince
Mohammed bin Abdul Aziz in Riyadh, and Dammam Medical Center in the
eastern region. The plan is to equip these facilities with 146 ICU beds, and
the latest medical and laboratory equipment necessary.
• On Friday, 25 April 2014, Saudi Arabia discovered 14 more cases of the
potentially deadly Middle East Respiratory Syndrome (MERS) in the
kingdom. According to the Ministry of Health 94 people have died and
323 have contracted the virus in Saudi since September 2012.
• Approximately 75% of the recently reported cases are secondary cases,
meaning that they are considered to have acquired the infection from
another case through human-to-human transmission. There have not been
any tertiary cases.
• To date, more than half of all laboratory-confirmed secondary cases have
been associated with health care settings. These include health care
workers treating MERS-CoV patients, other patients receiving treatment for
conditions unrelated to MERS-CoV, and people visiting MERS-CoV patients.
• The specific types of exposure resulting in transmission in the health care
setting are currently unknown. (For additional information on infection
prevention and control measures, please refer to the infection control page
of this brief)
• Contact investigations in the Middle East around confirmed cases have
identified a number of asymptomatic and mild cases, younger cases, and an
increasing proportion of female cases.
DISTRIBUTION OF CONFIRMED CASES OF MERS-CoV REPORTED
BETWEEN 1 - 23 APRIL 2014 BY DAY AND PLACE OF REPORTING (N=151)
SOURC: ECDC
SOURCE: CDC WHO ECDC PHAC
• The mild and asymptomatic cases indicate a broader spectrum of disease
and raise concerns about the possibility of large numbers of milder cases
going undetected.
• Public concern over the spread of MERS mounted last week after the
resignation of at least four doctors at Jeddah’s King Fahd Hospital who
refused to treat patients for fear of infection.
• Several recent cases of people becoming infected in either Saudi Arabia
or United Arab Emirates and travelling to a third country have also been
reported. Greece, Jordan, Malaysia, and Philippines each reported one
such case. So far no further spread of the virus in those countries has
been detected. Imported cases already occurred in the past that resulted
in limited further human-to-human transmission in France and United
Kingdom.

7. CURRENT SITUATION
VIROLOGY DOWN UNDER BLOG
UNITED ARAB EMIRATES
On 11 APRIL the United Arab Emirates (UAE) announced a cluster of
Middle East Respiratory Syndrome Coronavirus (MERS-CoV) cases in six
Filipino paramedics, killing one of them (16 APR).
The paramedics worked for the same ambulance section in the city of Al
Ain, according to UAE’s interior ministry. It said the infections were
detected during periodic medical exams.
Subsequently there has been a total of 23 patients associated with this
cluster (17 APR)(23 APR)(APR 26) .
JORDAN
Jordan's health ministry notified the WHO of its latest case on 9 APR
which involves a 52-year-old man with underlying medical conditions who
visited Saudi Arabia between Mar 20 and Mar 29. He got sick on Mar 25
and visited a hospital in Jeddah, then returned to Jordan on Mar 29, where
he visited a hospital in Amman the same day and returned on Apr 2. He is
listed in stable condition. The patient is Jordan's fifth MERS case-patient
(11 APR).
GREECE
On 18 April 2014, the Hellenic Centre for Disease Control and Prevention
(KEELPNO)announced a laboratory confirmed case of MERS-CoV infection
in a 69 year old male patient. The individual is a Greek citizen,
permanently residing in Jeddah, Saudi Arabia, who arrived in Athens on 17
April on a flight via Amman, Jordan. Close contact tracing is ongoing; there
are no suspected or confirmed cases of MERS-CoV infection associated
with this individual to date.

8. REPORTING COUNTRY CASES DEATHS
Saudi Arabia 272 81
United Arab Emirates 42 9
Qatar 7 4
Jordan 4 3
Oman 2 2
Kuwait 3 1
United Kingdom 4 3
Germany 2 1
France 2 1
Italy 1 0
Tunisia 3 1
Malaysia 1 1
Philippines 1 0
Greece 1 0
TOTALS 335 107
CURRENT SITUATION
MALAYSIA
The patient is a 54 year-old man with underlying health conditions. He
travelled to Jeddah, Saudi Arabia with a pilgrimage group of 18 people from
15 to 28 March 2014 and became ill on 4 April. He sought treatment in a
private clinic in Johor, Malaysia on 7 April and went to a hospital on 9 April.
The patient died on 13 April. The patient visited a camel farm on 26 March,
during which he consumed camel milk.
PHILIPINES
A male nurse was tested MERS, by authorities in the United Arab Emirates
after he came into close contact with a Filipino paramedic who died of the
virus. The results of his test were only released after he had departed for
Manila on an aircraft. Philippine health officials immediately quarantined the
nurse as well as several family members who came into close contact with
him following his arrival. A second test on the nurse came back negative.
EGYPT
A 27-year-old civil engineer was diagnosed Saturday, 26 April 14 after
returning from Saudi Arabia, where the Middle East respiratory syndrome, or
MERS, has been centered. The man was quarantined upon his arrival at Cairo
airport Friday and transported to a nearby hospital. This would be Egypt first
case.
SOUCE : ECDC AS OF 23 APRIL 2014
Eng. Faqih during his visit to King Fahad Hospital in Jeddah SOURCE: MOH

9. RISK OF INTERNATIONAL SPREAD
• Countries should be on the lookout for cases of MERS in
people returning from Middle Eastern countries affected by
the virus.
• It is very likely that cases will continue to be exported to other
countries, through tourists, travelers, guest workers or
pilgrims, who might have acquired the infection following an
exposure to the animal or environmental source, or to other
cases, in a hospital for instance.
RISK ASSESSMENT
ECDC RISK ASSESSMENT
GENERAL INFORMATION
A marked and sudden increase in the number of Middle East
respiratory syndrome coronavirus (MERS-CoV) cases have been
reported in April 2014. The majority of cases continue to be in Saudi
Arabia and the Arabian Peninsula but earlier this month a confirmed
case in Greece brought the total number of EU affected countries to
five (France, Germany, Italy and the UK the other four). Given the
current epidemiology, it is likely that more cases will be imported to
the EU.
RISK OF FURTHER CASES
• It is very likely that more primary cases will occur, and
consequently further transmission will occur.
• Diagnosing cases rapidly may be a challenge because some
have mild or atypical symptoms.
• Given the potential to initially miss MERS cases, health-care
workers should apply infection control precautions consistently
with all patients, all the time, regardless of their diagnosis.
Distribution of confirmed cases of MERS-CoV by month of onset and
symptom status, March 2012–23 April 2014 (n=345*) ECDC
WHO RISK ASSESSMENT

10. INFECTION CONTROL
• Enhancing infection prevention and control awareness and measures is
critical to prevent the possible spread of MERS CoV in -health care
facilities.
• Health care facilities that provide care for patients suspected or confirmed
to be infected with MERS CoV infection should take - appropriate
measures to decrease the risk of transmission of the virus from an
infected patient to other patients, health care workers and visitors.
• It is not always possible to identify patients with MERS CoV early because
some - have mild or unusual symptoms.
• For this reason, it is important that health care workers apply standard
precautions consistently with all patients – regardless of their diagnosis
– in all work practices all the time.
• Droplet precautions should be added to the standard precautions when
providing care to all patients with symptoms of acute respiratory
infection.
• Contact precautions and eye protection should be added when caring for
probable or confirmed cases of MERS-CoV infection. Airborne precautions
should be applied when performing aerosol generating procedures.
SOURCE: OUTFOX PREVENTION
FOR DETAILED INFORMATION VISIT THE FOLLOWING SITES:
• Interim Infection Prevention and Control Recommendations for
Hospitalized Patients with Middle East Respiratory Syndrome
Coronavirus (MERS-CoV) (CDC)
• 2007 Guideline for Isolation Precautions: Preventing Transmission of
Infectious Agents in Healthcare Settings (CDC)
• 2013 Infection prevention and control during health care for probable
or confirmed cases of novel coronavirus (nCoV) infection (WHO)