Middle East respiratory syndrome coronavirus (MERS-CoV): situation update and cases reported in the Netherlands

Global situation

Since April 2012, and as of 16 May 2014, 614 laboratory‐confirmed cases of human infection with Middle East respiratory syndrome coronavirus (MERS‐CoV) have been reported to WHO, including 181 deaths. Overall, 65.6% of cases are male and the median age is 49 years (range 9 months–94 years). The affected countries include:

• Middle East: Jordan, Kuwait, Oman, Qatar, Saudi Arabia, the United Arab Emirates and Yemen;
• Europe: France, Germany, Greece, Italy, the Netherlands and the United Kingdom;
• Africa: Egypt and Tunisia;
• Asia: Malaysia and the Philippines;
• North America: the United States of America (USA).

All of the cases recently reported outside the Middle East (Egypt, Greece, Malaysia, the Netherlands, the Philippines and the USA) travelled from Saudi Arabia or the United Arab Emirates.

It is not yet understood exactly how people become infected with MERS‐CoV, but there is currently no evidence of the virus readily passing from person to person or of sustained community transmission. Studies in animals support the premise that camels are a likely source of infection in humans, and some cases report exposure to camels. In some cases, human-to-human transmission appears to occur, with the virus passing from an infected person to another person in close contact with them. This has been seen among family members, patients, and health‐care workers. Recently, the number of reports of health-care‐associated infections has increased, with two important health-care-associated outbreaks in Saudi Arabia and the United Arab Emirates accounting for the majority of these cases. In some communities, however, people have become ill but no known source of infection has been found. It is possible that these people were infected by exposure to an animal or perhaps to another source or person. Investigations to determine the ways in which people become infected as well as effective measures to prevent infection are continuing.

Situation in the European Region

In the European Region, since April 2012, in total 12 laboratory-confirmed cases have been reported by France, Germany, Greece, Italy, the Netherlands and the United Kingdom. With the exception of three cases who were close contacts of laboratory-confirmed cases in France and the United Kingdom, all the other cases have been returning travellers or residents of countries of the Middle East. The most recent cases were reported by Greece (1 case reported to WHO on 18 April 2014) and by the Netherlands (2 cases reported to WHO on 14 and 15 May 2014). The Greek case is a Greek citizen living in Saudi Arabia who came to Greece on holiday and was diagnosed in Athens on arrival. The two cases in the Netherlands were returning travellers from countries of the Middle East. Extensive tracing of contacts of these cases has been conducted or is under way to ensure that any new cases are detected in a timely fashion.

Risk assessment

WHO constantly monitors the situation and adjusts its risk assessment according to new information. WHO/Europe coordinates its efforts with the European Centre for Disease Prevention and Control (ECDC). WHO expects that additional cases of MERS‐CoV infection will be reported from the Middle East, and that cases will continue to be exported to other countries by tourists, travellers, guest workers or pilgrims who may acquire infection following exposure to an animal (for example, while visiting farms or markets) or human source (possibly in a health care setting). Until more is understood about the exposures and the implementation of preventive measures, cases will continue to be reported.

Conditions for a Public Health Emergency of International Concern not yet met

Concern about the recent sharp rise in cases, the weaknesses in infection prevention and control, as well as the gaps in critical information was expressed during the fifth meeting of the Emergency Committee. Convened under the International Health Regulations (2005) on 13 May 2014 by the WHO Director-General, the Committee met to review the risk assessment and provide advice. Based on current information, the Committee indicated that the seriousness of the situation had increased in terms of public health impact, but that there is no evidence of sustained human-to-human transmission. It concluded that the conditions for a Public Health Emergency of International Concern (PHEIC) have not yet been met.

Advice of the Emergency Committee

The Emergency Committee recommended all countries to:

• improve and implement national policies for infection prevention and control in health care facilities;
• initiate and accelerate critical investigations to better understand the epidemiology and risk factors and assess the effectiveness of control measures;
• strengthen case identification and management, and contact tracing;
• enhance awareness and effective risk communication about MERS-CoV among the general public, health professionals, at-risk groups and policy-makers;
• strengthen intersectoral collaboration across ministries and internationally;
• continue sharing information with WHO in a timely manner, in accordance with the International Health Regulations (2005).

Implications for Europe

Cases will probably continue to be exported from countries of the Middle East, including to European countries. Member States should be prepared to detect, investigate and manage cases of MERS-CoV in a timely way by implementing the advice of the Emergency Committee and following WHO guidance. As many European Member States have significant capacities to detect and respond to emerging disease events, they are well positioned to provide crucial information to WHO to help control this outbreak.

The risk of the spread of MERS-CoV in European countries is currently low, as there is no evidence of sustained, ongoing human-to-human spread. Diligent adherence to infection prevention and control measures is critical to prevent the spread of MERS‐CoV in health care facilities.

Preventive measures to protect the population

As it is still unclear to date how humans have become infected with this virus, people travelling to areas in the Middle East where there have previously been cases should adopt some general measures that would help prevent the acquisition of any respiratory illness, such as: avoid close contact, when possible, with anyone who shows symptoms of illness (coughing and sneezing); avoid direct contact with animals; and maintain good hand hygiene.

The chances of people contracting the virus are small as the virus does not seem to spread easily in the community.  Nevertheless, if people have recently travelled to the Middle East and develop breathing difficulties that are not explained by any other illness or virus, and if their immunity is in any way compromised, they should see a health specialist as soon as possible and be sure to give him/her a complete medical and travel history.

As health care workers come into contact with patients with many different infectious illnesses more often than the general public, they should apply appropriate measures to prevent infections. National health authorities should alert all health care facilities about this new virus so that they can be prepared to deal with a suspected case.