RECOMBINOMICS

[dothedd]

H7N9 In Shaoxing Zhejiang Has PB2 D87N
Recombinomics Commentary 21:00
October 18, 2013

State Key Laboratory of Diagnosis and Treatment of Infectious Diseases at Zhejiang University and the Zhejiang CDC have released full sequences (at GISAID) from the recent case (35M) in Shaoxing (A/Zhejiang/DTID-ZJU05/2013 and A/Zheijiang/22/2013, respectively). Both labs used an October 14 collection, and the prompt release of sequences is commended.

The two sets of sequences confirmed that the lineages for all 8 gene segments matched the lineages for the consensus sequence for cases in Shanghai and adjacent provinces. The H7 sequence by both labs was identical and included Q226L, as expected. However, the sequences also contained Q222P, which is adjacent to the receptor binding domain.

However, the PB2 sequences differed. A/Zhejiang/22/2013 had an avian sequence which lacked mammalian adaptation markers. In contrast, A/Zhejiang/DTID-ZJU05/2013 had D60N and D87N. The latter is a mammalian adaption which produces an increased polymerase activity at lower temperatures (33 C), consistent with a higher viral load in a human nose in the winter. This temperature sensitive activity is also found in PB2 with E627K.

The CDC sequences suggests that isolates with higher levels of D87N will more efficiently transmit human to human.

[dothedd]

Another H7N9 Zhejiang Case Raises Concerns
Recombinomics Commentary 12:15

October 23, 2013

Patients Moumou, male, aged 67, farmer, now living in Xiuzhou. Incidence on October 16, Jiaxing now a hospital for treatment.

the patient was seriously ill, hospitals are in active treatment

The above translation describes the second confirmed H7N9 bird flu case (67M) in Zhejiang Province in a week. Like the earlier case (35M), the patient is in critical condition. These two cases cluster in time and space (see map) and raise concerns that the 2013/2014 flu season in northern China will lead to a dramatic increase in cases. In the spring, the vast majority of cases were concentrated in the greater Shanghai metropolitan area, with the most reported cases in Zhejiang province (see earlier map).

Sequences from the first case were promptly released by the Zhejiang University and Zhejiang CDC (A/Zhejiang/DTID-ZJU05/2013 and A/Zheijiang/22/2013, respectively). The H7 from the October 14 collection had Q226L and both sequences were identical. The H7, like the other 7 gene segments produced a constellation of sequences that matched the majority of cases in the spring.

However, the Zhejiang CDC PB2 sequence had no mammalian adaption markers, such as E627K, which was present in the vast majority of human PB2 sequences. However, the Zhejiang University PB2 sequence had two non-synonymous changes, including D87N.
D87N like E627K are associated with increased polymerase activity at lower temperatures (33 C) which is a strong selection marker associated with increased mammalian transmission.

The temporal and geographic clustering of the two recent H7N9 cases raises concerns that many additional H7N9 cases will be reported in the near term.

[dothedd]

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Commentary

Nosocomial MERS Cluster In Jubail KSA
Recombinomics Commentary 23:55
October 26, 2013
Ministry announces the registration of three cases infected with the virus in the Eastern Province.

First of citizenship at the age of 83 years, close contact with a confirmed case and has several chronic diseases and receive intensive care treatment and in stable condition.

Second resident working in the health sector at the age of 54 years old, and has a chronic illness and receiving treatment for intensive care and in a stable condition.

Third citizen at the age of 49 years, receiving intensive care treatment and his condition is stable.

The above translation from the Kingdom of Saudi Arabia Ministry of Health (KSA-MoH) website, describes three confirmed MERS cases in the Eastern Province, which follows an announcement of an Eastern Province case from Riyadh.

Local media reports indicate the index case (54M) was hospitalized in Jubail (see map) and died this week. An additional media reports describes a suspect case in his 80’s who has been hospitalized for a month in Jubail. Another media report describes another suspect case, who was a health care worker who was also hospitalized in Jubail.
Thus media reports indicate three of the four confirmed cases are in Jubail, which is the likely location of the fourth confirmed case.

These data support a nosocomial cluster in Jubail, raising concerns of further spread in the hospital.

[dothedd]

Nosocomial MERS Cluster In Jubail KSA Grows
Recombinomics Commentary 23:00

October 31, 2013

the Ministry of Health (MOH) has announced that a new case of the virus passed away in the Eastern Region.

The case was for a 56-year-old female citizen, who was in contact with a confirmed case of the virus, and she had been suffering from various chronic diseases

The above comments from the Kingdom of Saudi Arabia Ministry of Health (KSA-MoH) website describe the fifth recently confirmed MERS case in the eastern region. Media reports describe at least four cases (54M, 83F, 54M, 56F) in Jubal (see map), which includes at least three deaths (56M, 63F, 56F), including the index case (54M), who had been in Riyadh. The delayed reporting of the fatal cases (one, 83F, reported a day prior to reporting her death, while the above case was reported after her death), as well as the absence of the death of the index case (which was widely reported in local media last week prior to the reporting of the four most recent cases) raises concerns that the number of cases linked to the hospital in Jubail is significantly higher than the five confirmed cases.

The nosocomial cluster in Jubail has much in common with the nosocomial cluster in Al Hasa. The initial cases were reported after they died, and the location of the cluster was withheld. Like the current cluster, cases were cited as coming from the eastern province, which has multiple population centers.

The Jubail cluster represents the first reported confirmed cases in and around that city, which like the Al Hasa cluster includes at least one health care worker. The NEJM paper on the Al Hasa cluster cited two health care workers (including one case who subsequently died) which were among the 23 confirmed cases. 11 additional cases were defined as probable (hospitalized for pneumonia with a link to at least one confirmed case, but were not lab confirmed because of an absence of testing, or testing limited to one sample). The number of Al Hasa MERS infections was likely considerably higher than the 34 confirmed / probable cases, which is also true for the Jubail cluster.

More information on the relationship between confirmed cases as well as linkage to additional symptomatic cases in Jubail would be useful.

[dothedd]

Nosocomial MERS Cluster Deaths In Jubail Raise Concerns
Recombinomics Commentary 11:00
November 1, 2013
Saw the province of Jubail within ten days of the Declaration of the first case infected with Corona's death three cases were confirmed infected with the virus, while still one of the infected cases lying in intensive care at a hospital, and that there are cases awaiting laboratory results, and this number becomes the province of Jubail second highest mortality in the Kingdom After Al Ahsa.

Mohammed: The cousin is coming from the city of Riyadh, and at the age of 54 years old, and was visiting his family in Al Khobar, then moved to the city of Jubail before Eid al-Adha, and added he did not know that he has the virus , where raided some of the symptoms I think she entered several flu clinics in Riyadh and Khobar before coming to Jubail, but he was prejudiced against himself, even intensified by the disease, where it was introduced intensive care and died five days later

The above translation confirms that additional cases in Jubail (see map) are awaiting lab confirmation of a MERS infection and provides detail on the index (54M), who died last week. Although the Kingdom of Saudi Arabia Ministry of Health (KSA-MoH) and WHO have confirmed MERS in this case (as well as his travel from Riyadh to the eastern province, neither have acknowledged his death, which has been widely reported in local media last week, prior to the announcement of four additional confirmed MERS case in the eastern province, including the death of two (83F and 54F).

One death (83F) was announced one day after the confirmation of MERS was cited by the KSA-MoH, while the other was announced after the patient (54F) died.

The withholding of the death of the index case raises serious transparency concerns, as does the above translation which cites additional hospitalized patients which have not been lab confirmed.
The report also noted that one of the fatal cases (83F) had been hospitalized for deep vein thrombosis well in advance of developing MERS symptoms, further supporting the nosocomial nature of the outbreak.

More detail on the fatal, confirmed, and suspect cases would be useful.

[dothedd]

Another MERS Super Spreader In Eastern Region KSA?
Recombinomics Commentary 14:30
November 1, 2013

"Al- Watan" sources of responsible health East , that the hospital , who scored the deaths of the three disease governorate of Al Jubail reservations as well as currently 3 other cases in the isolation of intensive care two days ago , including a girl of 15 years old , while Taatjaozat cases other two sixth decade of age , stressed sources also that the detention of the three cases does not mean a record sure to HIV infection , but they are suspected cases just yet, which raised analyzes three cases to the central laboratory in Dammam was not sure yet of the final result ,

The above translation suggests 2 or 3 additional symptomatic cases in Jubail are being MERS tested, raising concerns that the index case (54M) is another eastern region super spreader (see map). Although neither the Kingdom of Saudi Arabia Ministry of Health (KSA-MoH) nor WHO has confirmed his death (which was widely reported in local media last week), his origin from Riyadh was acknowledged, raising concerns that he is linked to the Riyadh case (73M) announce within a day of his announcement. Media reports indicate the index case visited clinics in Riyadh and Al Kobar prior to his arrival in Jubail.

One (49M) of the three cases announced earlier by KSA-MoH has not been cited in media reports describing the cases in Jubail, raising the possibility that the case was in the eastern province, but not in Jubail. Similarly, the health care worker (56M) who was Jubail may have been transferred there, and thus may have been infected in Al Kobar also.
The first announced death (83F) by the KSA-MoH is a case who was hospitalized in Jubal for deep vein thrombosis a month prior to developing MERS symptoms, suggesting she was infected in the hospital by the index case. Similarly, the second death (56F) acknowledged by KSA-MoH also had contact with a confirmed case, suggesting she was infected directly or indirectly by the index case.

It is also likely that the three ICU cases cited in the above translation were also infected directly or indirectly by the index case, raising concerns that he was a super spreader.

More detail on contact between the index case and the most recent case from Riyadh, the other four confirmed cases in the eastern region, and the three cases cited in the translation above (and additional cases under investigation in Riyadh or Al Kobar) would be useful.

[dothedd]

MERS Cluster In Jubail Royal Commission Hospital
Recombinomics Commentary 18:00

November 1, 2013

died on Thursday in the province of Al Jubail lady in the sixth decade due to hit epidemic disease during Tnoimha in Corona Hospital Royal Commission for Jubail Industrial, according to a relative of the deceased briefing The disease Coruna moved to in the intensive care unit, which was lying where due to hit crisis acute in the chest has long been a result of hypnosis, one injured and who died a few days ago in the same intensive care unit, also said he was conducting a full examination of the sons and daughters of the deceased to make sure there exposure to the same disease, where one of her daughters was isolated to the onset of some symptoms and send samples for screening of all the children to the lab to make sure the situation.

It is noteworthy that فاتين two cases were in the past week after injuries to the same disease in a hospital in the Royal Commission for Jubail Industrial and considers the latter case is the third with the presence of suspected cases have been isolated in the same hospital

The above translation has more detail on the MERS case (83F) whose confirmation and death were recently cited by the Kingdom of Saudi Arabia Ministry of Health. This case had been hospitalized for a month prior to developing MERS symptoms strongly suggesting she was infected by the index case (54M) who also died (based on multiple independent local media reports over the past week). The most recent confirmed case (56F) was reported after her death and as noted in the translation above, all were in the Royal Commission Hospital in Jubail (see map).

In addition to the fatal confirmed cases described above, media reports cite 3 more cases in the ICU in the same hospital. One is a teenager (15F), while the other two are in the sixth decade of life, indicating they are distinct from one confirmed case in the eastern region (49M) and may be distinct from the hospitalized health care worker (56M), who is also in Jubail.

The geographic and temporal relationship to the index case suggest he was a super spread and may be linked to all of the confirmed and suspect cases in the eastern region.

KSA-MoH and WHO have yet to acknowledge the death of the index case or to detail the linkage between the index case and the various confirmed and suspect cases including those at the Royal Commission Hospital.

[dothedd]

Oman Confirms First MERS Case
Recombinomics Commentary 23:55

November 1, 2013

The patient in Oman is a 68-year-old man from Al Dahkliya region who became ill on 26 October 2013 and was hospitalized on 28 October 2013. Preliminary epidemiological investigations revealed that he did not recently travel outside the country.

The above comments from the latest WHO MERS update describe the first reported confirmed case in Oman. Although some media reports cited development of symptoms while traveling outside of Oman, other reports, as noted in the WHO update, cite a lack of travel outside of the country.

The development of MERS inside Oman is consistent with the Kingdom of Saudi Arabia (KSA) comments noting that MERS is circulating in neighboring countries, but not reported because of limited surveillance. Recent surveillance has increased because of the Hajj, which may have contributed to the detection of the above case.

Increased surveillance due to Ramadan may have also contributed to the first case confirmed in Qatar. Although confirmation of MERS in Qatari citizens was reported in 2012, those cases were diagnosed in Europe (England and Germany). Similarly, cases linked to the UAE were diagnosed in Germany and Tunisia, again highlighting surveillance failures in countries neighboring KSA.

However, Qatar identified a resident returning from Medina after Ramadan, as well as contacts of the Qatari. Similarly, Qatar also recently reported the first confirmed asymptomatic case, which nwas made recently, after the Hajj ended.

Thus, it is likely that MERS is widespread in Oman and detection was linked to increased surveillance. Recent studies have also identified MERS antibodies in 100% of tested racing camels in Oman, supporting additional human cases.

The recent nosocomial cluster in Jubail as well as the prior clustering in Al Hasa also supports widespread MERS in eastern KSA as well as adjacent countries including Kuwait, Bahrain, UAE, and Oman.

[dothedd]

MERS Super Spreader In Eastern Region KSA Timeline
Recombinomics Commentary 18:00

 November 2, 2013

Official information on this currently reported outbreak in Jubail is difficult to find. ProMED-mail would greatly appreciate more information from official sources on the validity of these media reports on the transmission of MERS-CoV in Jubail.

The above ProMED RFI highlights the dearth of official information on the nosocomial MERS outbreak in Jubail at the Royal Commission Hospital (RCH) – see map. Moreover the index case (54M) for that outbreak may be linked to additional confirmed cases in Riyadh and the Eastern Region.

The cases in Jubail have been widely reported in local media, which have linked some of the confirmed cases to three deaths (54M, 83F, 54F) at RCH, including the index case. The index case was reported by the Kingdom of Saudi Arabia on October 18 and was included in the batch of cases reported by WHO on October 24. However, neither agency reported his death on October 22, which was widely reported in local media for the past two weeks.

The KSA-MoH reported noted that the case had traveled from Riyadh to the Eastern Region, but local media provided much more detail, indicating he was symptomatic while in Riyadh and traveled to Al Kobar, prior to his admission at RCH in Jubail. He visited clinics at both locations. He was admitted to RCH on October 17, so the confirmation made by KSA-MoH on October 18 was likely from a sample collected in Riyadh or Al Kobar.

KSA-MoH reported a confirmed Riyadh case (73M) on October 18, raising the possibility that the above index case for RCH was also linked to the Riyadh case. KSA-MoH also reported three confirmed cases on October 26 (83F, 56M, 49M) in the Eastern Region. Media reports indicated two of these cases were in Jubail. However, the absence of the 49M case from the Jubail media reports raises the possibility that the 49M case is linked to the index case via an Al Kobar clinic visit. Similarly, the health care worker (56M) may have been transferred to Jubail and also infected by the index case prior to his October 17 admission to RCH.

However, the index case is linked to the 83F, who had been admitted to RCH a month prior to her death (which was reported by the KSA-MoH on October 27) and developed symptoms just after the index case died.
Similarly, the death of another case (56F), which was reported by KSA-MoH on October 31, also had been admitted to RCH well in advance of symptoms (12 days) which also began shortly after the death of the index case. Media reports indicate the family of this case is considering suing RCH for negligence.

In addition to the above fove confirmed MERS cases, media reports cite 3 symptomaic cases in the RCH ICU. One (15F) does not match the age of any of the confirmed cases, which the other two (in the sixth decade of life) which match one or both of the confirmed cases.

Thus, the index case may be a super spreader linked to one confirmed case in Riyadh and four confirmed cases in the Eastern Region as well as multiple suspect cases in RCH.

Therefore, more information on the cases in RCH, as well as contacts with the additional recent confirmed cases would be useful.

[dothedd]

WHO Update Supports MERS Jubail Timeline
Recombinomics Commentary 22:45

November 4, 2013

The patient is a 56-year-old woman with underlying medical conditions from the Eastern Region. She became ill on 26 October 2013 and died on 30 October 2013. She had no contact with animals, but had contact with a previously laboratory confirmed case.

The above comments, from today’s WHO MERS update provide key dates (disease on set and death) for the most recent confirmed fatality in Jubail (see map). This detail supports the timeline based on local media reports, which note that the index case (54M) for the nosocomial outbreak at the Royal Commission Hospital (RCH) died on October 22, five days after he was admitted.

Media reports not that the latest fatality (56F) described above had been admitted 15 days prior to her death and developed symptoms 3 days prior to her death. She was in the ICU when the index was there, and therefore was infected in the hospital, which is the basis of a threaten law suit against the hospital.

Similarly, media reports indicated the other recent fatality (83F) was hospitalized 30 days prior to her death, and she as well as the aboive case developed symptoms shortly after the death of the index. Moreover, she was also in the same ICU as both of the above cases, and therefore was also infected by the index case.

Media reports also cite 3 additional patients in the ICU with similar symptoms. One (15F) does not match any of the confirmed cases from the eastern region cited by the Kingdom of Saudi Arabia Ministry of Health (KSA-MoH). However, the other two patients, who are said to be in the sixth decade of life, have ages similar to the other two confirmed cases, a health care worker (56M) and a slightly younger patient (49M).

More detail on these confirmed cases, as well as the additional patients in the RCH ICU, would be useful.

[dothedd]

Another H7N9 Dongguan Case Raises Concerns
Recombinomics Commentary 15:00

November 5, 2013

Patient is an approximately 3 years, 5 months boy, Sichuan Suining people living in Changping Town, Dongguan. Patients currently treated in isolation, Dongguan City People's Hospital, he had no fever, symptoms of mild, stable condition.

The above translation describes the most recent confirmed H7N9 case (3M) in China. He is the third confirmed H7N9 bird flu case this season, but he is near an August case, which was also in Dongguan City in Guangdong Province (see map). The two earlier cases this season were in Zhejiang province, near Shanghai in northern China (see map).

Full sequences have been released from patients in each geographic region. The earlier sequence from Dongguan, A/Guangdong/1/2013, had H7 and N9 sequences similar to the vast majority of cases from the spring (most of which were from northern China in and around Shanghai). However, the sequences for four of the internal gene segments (PB2, PB1, NP, NS) match H9N2 avian sequences from southern China (in and around Hong Kong), in contrast to the cases from northern China, which match H9N2 avian sequences from northern China (in and around Shanghai) as seen in A/Zhejiang/22/2013 and A/Zhejiang/DTID-ZJU10/2013 from the same case (35M).

Thus, the reporting of a second case in Dongguan since August, 2013 raises concerns that two distinct H7N9 lineages are circulating in China at the present time. Moreover, the detection (via routine surveillance) of the most recent case in a child who did not have a fever and had mild symptoms, raises concerns that the number of H7N9 cases, especially in children may be much higher than the reported cases. Moreover, initial reports have not cited a poultry link for the latest case.

More information on poultry exposure and the sequences from this case would be useful.

[dothedd]

Commentary
Third H7N9 Zhejiang Case Raises Concerns
Recombinomics Commentary 18:30
November 5, 2013

WHO ‏@who 1h
China has notified WHO of 2 new laboratory-confirmed #H7N9 cases in Guangdong and Zhejiang #influenza

Gregory Härtl‏@haertlg
Two #H7N9 cases in different parts of China on the same day. Winter is starting.

The above tweets from WHO and Gregory Hartl, WHO head of social media / public relations, indicate two new H7N9 bird flu infections have been reported today by China. The case from Guangdong Province (3M) has been widely reported in the media, but an update on a case in Zhejiang Province (see map) has been lacking.

However, two earlier cases in Zhejiang Province were reported by WHO (67M on Oct 24 and 35M on Oct 16), which followed reports of a case in Guangdong province (51F on Aug 11). Sequences from each region indicated two distinct H7N9 sub-clades were circulating, with differences in four internal gene segments (PB2, PB1, NP, NS).

The latest report increases concerns that both sub-clades are emerging again and levels will likely be higher in the winter than the spring of 2013.

More information on the latest case in Zhejiang, as well as detail on poultry exposure for the case in Guangdong Province (which has not been cited thus far) would be useful.

[dothedd]

Spain Confirms MERS In Hajj Pilgrim
Recombinomics Commentary 22:45
November 6, 2013

Health officials in Spain have detected a case of MERS in a woman who recently returned to the country after attending last month’s Hajj pilgrimage in Saudi Arabia.

The above comments confirm that the MERS case in Spain (see map) was infected while on a Hajj pilgrimage, as suggested by statements in the Spain Ministry of Health press release, which noted that she (61F) flew to the Kingdom of Saudi Arabia (KSA) on October 1 and returned on November 1. Shortly thereafter MERS was confirmed.

However, media reports noted that she had been hospitalized in KSA on October 15 and diagnosed as having pneumonia. However, the etiological agent was not identified. Disease onset on or about October 15 raises the strong possibility that she contracted MERS somewhere along the Hajj route but KSA failed to identify MERS in the above case or the source of her infection.

Moreover, travel after the KSA hospitalization increased the potential for transmission to other travelers and significant spread.

KSA has maintained that no Hajj pilgrim was diagnosed with MERS, although cases in Riyadh and the Eastern Region (Jubail) were confirmed, with disease onset dates similar to the above case.

The confirmation of a Hajj pilgrim in Spain raises serious surveillance and transparency concerns.

[dothedd]

MERS In Hajj Pilgrim Raises Transparency Concerns
Recombinomics Commentary 23:30
November 6, 2013

According to the director explained how the Coordinating Center and Emergency Health Alerts, Fernando Simón, it is "a woman of 61 years who was in Saudi Arabia between October 2 and November 1" and "initiated a respiratory symptoms with fever and cough on 15 October. "

After that, "the 28 and October 20 began a process in which he was diagnosed with pneumonia in a hospital in Saudi Arabia." Later, Simon explained that she "traveled back to Spain on November 1 and was diagnosed back in Puerta de Hierro".

The above translation provides additional information on the Hajj pilgrim (61F) who was MERS confirmed in Spain (see map). She developed symptoms on October 15, during the Hajj. Although the hospital in the Kingdom of Saudi Arabia (KSA) diagnosed pneumonia, they failed to identify the etiological agent, which was done is Spain.

Consequently, the pilgrim returned to Spain, leading to significant exposure of other passengers as well as contacts in Spain, including health care workers. However, the vast majority of Hajj pilgrims did not come from Spain raising concerns that MERS was widely dispersed, although only Spain has reported a confirmed case and all recent confirmed cases in KSA were in Riyadh and the Eastern Region (primarily Jubail).

Many countries reported symptomatic returning pilgrims, but all reported cases were negative, including a fatality in Egypt who was H1N1pdm09 confirmed.

Detection of MERS is a challenge as seen by the failure of KSA to identify MERS in any of the millions of pilgrims participating in the Hajj. The Spain pilgrim was hospitalized with pneumonia, which is similar to the Al Hasa outbreak where 11 cases were classified as probably because they had pneumonia and contacts with a confirmed MERS case, but were either not tested or only tested once.

The current confirmed case in Spain raises concerns that MERS was widely dispersed from KSA and largely missed by receiving countries.

[dothedd]

MERS Hajj Medina Mecca Jeddah Madrid Journey
Recombinomics Commentary 19:30
November 7, 2013

Her symptoms began Oct 15 with cough and fever, and she was seen at a hospital emergency department of a Mecca hospital on Oct 28 and 29, where health workers diagnosed her as having pneumonia, based on chest x-ray findings.

According to the ECDC, the patient was sick during the flight and needed oxygen treatment while she was aboard.

The health ministry said she was in Medina from Oct 2 through Oct 10 and in Mecca from Oct 11 through Nov 1.

The above comments confirmed media reports which noted a disease onset date of October 15 for the above case (61F) as well as a Kingdom of Saudi Arabia (KSA) diagnosis of pneumonia. The peak of Hajj activity was between Oct 13-18, corresponding with the patient’s travel to Mecca.

The disease onset date of Oct 15 suggests she was infected in Medina, where KSA reported confirmed cases at the end of Ramadan, which was also linked to a Qatari who traveled from Medina to Qatar and developed symptoms on the day of his arrival, which was subsequently linked to onward transmission in Qatar. Although WHO noted that the Qatari did not perform Umrah or visit the Grand Mosque, his MERS infection became symptomatic after his attendance at a Medina clinic.

Thus, the presence of MERS in Medina after Ramadan raised concerns that Hajj pilgrims would be at risk and even though KSA cited the absence of any confirmed cases in Hajj or Ramadan pilgrims. MERS is widespread in KSA, including the Ramadan large cluster in Medina.

The recent MERS case was traveling and attending the Hajj in KSA while symptomatic and flew from Jeddah (see map) to Madrid after she was diagnosed with pneumonia in Mecca.

This extensive travel strongly suggest the number of MERS infections in Hajj pilgrims is high, KSA detection / reporting failures notwithstanding.

[dothedd]

MERS PCR Confirmed In Jeddah Camel
Recombinomics Commentary 18:15
November 11, 2013

The Saudi government said Monday that a camel has tested positive for MERS, in the first case of an animal infected with the coronavirus that has killed 64 people worldwide.

A camel owned by a person diagnosed with the disease had "tested positive in preliminary laboratory checks," the health ministry said in a statement carried by SPA state news agency.

The above comments support a recent Kingdom of Saudi Arabia Ministry of Health (KSA-MoH) announcement that a camel (see map) belonging to a recently confirmed Jeddah case (43M) has been PCR confirmed. This represents the first confirmation of an active MERS-CoV infection in a camel. Other than human, the only other mammal with an active MERS-CoV infection was a bat from Bisha, near the first confirmed MERS CoV case (60M) who died in Jeddah.

The current case was recently announced by the KSA-MoH and was a case who had not recently traveled outside of Jeddah, Other confirmed MERS cases have been linked to symptomatic camels (in the United Arab Emirates, UAE, and Batin in the Eastern Region of KSA), but MERS was not lab confirmed. MERS related antibodies (positive for MERS but negative for SARS and OC43) have been reported previously in racing camels in UAE and camels imported by Egypt from Sudan fro slaughter, but active MERS CoV was not confirmed in these or any other camels.

Confirmation of MERS-CoV in a camel own by the latest case in Jeddah would demonstrate inter-species transmission and would likely be from camel to human although the timing of the illness in the two host would help determine the direction.

MERS in camels suggests human cases are more common and widespread than indicated by the current confirmed cases, which have been largely reported in KSA. Other countries with significant camel populations would likely have significant human cases.

Thus, the confirmation of MERS-CoV sequences in the above camel would lead to more aggressive testing (via antibody and PCR) and help determine the geographic reach of MERS-CoV.
Media Link

[dothedd]

MERS Jeddah Camel and Case Sequence Match
Recombinomics Commentary 22:00
November 11, 2013

Statement of the Ministry of Health, the former regarding the status register infected Coruna in Jeddah, a citizen at the age of 43 years, which is still receiving treatment at a hospital in the province, and within the work of Investigation epidemiological played by the ministry in a scientific and systematic, the ministry has examined contacts of infected according to scientific standards followed, as the ministry within the quest for knowledge and finding the source of infection to take samples from the environment surrounding the patient including a set of (beauty) in a barn belonging to the patient, has been shown a positive one (beauty) for the initial laboratory tests for the virus.

The above translation describes the PCR confirmation of MERS in a camel in a barn owned by the recent case (43M) from Jeddah (see map). PCR confirmation of MERS involves testing using primers representing two disnct regions of human MERS-CoV. This approach has led to the generation of full sequences which are >99.5% identical to the consensus sequence. This high level of identity is distinctly different from most of the closely related bat beta 2c sequences, which are, 92.5% identical. The only except was a bat sequence from Bisha which was an exact match with one of the human sequences (EMC/12) isolated from the first confirmed case, who lived in Bisha but was confirmed and died in Jeddah. This identity was for a short segment (203 BP). The size was limited due to the disruption of the cold chain during shipment of the sample from the Kingdom of Saudi Arabia (KSA) to Columbia University in New York.

However, since the above camel and case are alive a full sequence (over 30,000 BP) from each host is expected, and the detection by PCR strongly suggests the two sequences will be virtually identical (based on the specificity of the PCR test as well as temporal and geographic parameters associated with the two hosts.

The identity between these two samples will increase the confidence in the antibody results obtained from racing camels in Oman and camels in Egypt which were imported from Sudan for slaughter. The antibody testing showed that the antibodies recognized MERS-CoV, but not SARS-CoV or OC43. This specificity could have been due to other beta 2c virus similar to those found in bats in Asia, Europe, and Africa. However, the likely match between the two collections in Jeddah suggests that the camel antibodies are due to a MERS-CoV infection.

The presence of MERS in camels in Oman, Sudan, and Egypt as well as symptomatic camels linked to cases in the UAE and Batin indicates that MERS-CoV is present throughout the Middle East and the number of unreported cases in countries such as Sudan and Egypt is high (neither country has reported a human case).

The PCR match in Jeddah will also lead to more aggressive antibody and PCR testing in camels throughout the Middle East, which will help determine the geographic range and concentration of the virus, which is likely to be widespread and common.

These high levels will create considerable concern.

[dothedd]

MERS Jeddah Camel and Case Match Concerns
Recombinomics Commentary 14:00
November 12, 2013

Meanwhile, within the framework of MOH’s efforts to recognize and monitor the source of infection, it has tested some samples of the patient’s surroundings, including a group of camels in his own stockyard, whose initial laboratory tests proved positive for one of these camels.

The above comments from the Kingdom of Saudi Arabia Ministry of Health (KSA-MoH) website strongly suggest that the PCR positive on a sample from a camel belonging to a MERS confirmed case (43M) was based on the same assay used to detect MERS-CoV in humans. These probes are based on human MERS sequences and designed to be specific for the beta 2c coronavirus linked to human cases. Sequences from these cases are >99.5% identical to the consensus sequence, and higher for clade B sequences which are present in all human cases due to infections following the first confirmed case, 60M in July, 2012.

In contrast, beta 2c sequences from bats come from a research protocol which uses a universal probe designed to detect all coronavirus. Thus, most bat coronavirus sequences are not beta 2c, and for those that are, the identity with the human sequences is < 92.5%, with the exception of a sequence from an Egyptian Tomb bat in Bisha, which was 100% identical to one of the sequences (EMC/12) from the first confirmed case, who was from Bisha (but was treated and died in Jeddah). Thus, the other bat beta 2c sequences are decades or centuries away from the human sequences. However, be one bat sequence which matches the human case in Bisha is found in Egyptian tomb bats, which are localized to the area around Bisha and therefore would not be linked to the vast majority of human cases in KSA. Moreover, the bat sequence matches the clade A sequence which has not been detected in humans since July, 2012.

Moreover, recent sequence data indicate the infection in July 2012 involved at least two distinct MERS-CoVs. The second sequence (Bisha-1) was clade B and had a 17 BP deletion, which was also detected in the first confirmed case (45M gym teacher) in Riyadh. Moreover Riyadh_1 was almost identical to Bisha_1 even though it was from an infection in Riyadh which had a disease onset date that was four months after the Bisha case.

These data discount to role of Egyptian tomb bats in cases in KSA, although this species is much more common in Egypt, Sudan, and India, raising the possibility that these species acts as an animal reservoir in those countries.

However, camels are more likely to be a source for human infections, base on MERS-like antibodies found at high titers and frequencies in racing camels in Oman as well as camels imported from Sudan for slaughter in Egypt. The PCR positive camel in Jeddah strongly suggests the sequence will be virtually identical to the recent Jeddah case (43M), who owns the camel and this identity will greatly increase the likelihood that the MERS-like antibodies in the above camels are due to a MERS-CoV infection (and not due to beta 2c sequences similar to other bat beta 2c sequences).

Thus, a sequence match in the Jeddah camel with accelerate research into the distribution of MERS-CoV in camels as well as viral concentrations in various samples collected from infected camels throughout the Middle East. These camel studies will also be used to determine the direction of the inter-species transmission (C2H or H2C or both), which will shed light on the role of camels in the frequency of MERS cases.

[dothedd]

MERS Jeddah Camel and Case Sequences
Recombinomics Commentary 19:00
November 12, 2013

To complete the investigation extensive environmental/animal contact sources were pursued. Camels owned by the patient which were symptomatic with fever and rhinorrhea were tested for MERS-CoV and tested positive.

Gregory Härtl ‏@haertlg 33m
.@hniman @ecdc_Flu @fla_Medic @who #MERS #nCov #coronavirus yes, + for 2 pts. And yes, as I understand it, same primers as for humans. @who

The above comments (in blue) are from today's Ziad Memish post at ProMED describing symptoms of camels and a positive result for MERS CoV (although it is unclear if more than one camel was positive). The comments in red are from a Gregory Hartl tweet stating that it was his understanding that the PCR test used two sets of primers which matched the primers used in testing of human cases.

These comments strongly suggest that the camel and case sequences will be virtually identical (>99.9%) because the set of primers used for MERS testing in humans is very specific and all human sequences to date have been >99.5% identical to the MERS-CoV consensus sequence (and even higher for clade B sequences, which has been the clade identified in all human cases since July 2012.)

Since the case (43M) and camel(s) are still alive, a source of viral RNA should not pose a problem and full sequences from the camel(s) and case are expected. However, initial partial sequences should already be generated and such sequences would confirm that the match between case and camel are likely to be >99% for the full sequences.

Thus, although full sequences will remove all doubt about inter-species transmission between camels and people, partial sequences should be released to demonstrate the significance of PCR positives for the case and camel(s).

[dothedd]

Media Myth On Jeddah Camel MERS Sequence
Recombinomics Commentary 21:00
November 12, 2013

Marion Koopmans, a Dutch virologist who led the first study that found MERS antibodies in camels, said the Saudi finding is an interesting development. But she said it will be important to see the sequence of the virus the PCR test detected.

For one thing, there are other known camel coronaviruses, which at least in theory might have generated a positive hit on the MERS test.

“I would want to know for sure that the MERS corona[virus] PCR assay does not pick up those viruses,” said Koopmans, chief of virology at the National Institute of Public Health for the Netherlands.

“PCR positive, that tells that there is most likely a coronavirus. But the sequencing will tell whether it is MERS corona. But it’s of course a strong signal if they used the MERS coronavirus assays.”

The above comments suggest that the PCR positive on the Jeddah camel may be due to a related beta2c coronavirus that is not >99% identical to the consensus sequence for the published human cases. However, comments by Ziad Memish and Gregory Hartl strongly suggest that the MERS PCR test was used to declare the camel positive.

The MERS PCR test is very different than the PCR test used to identify coronavirus sequences in bats, which date back to questions raised by the SARS outbreak in 2003. In that outbreak SARS-CoV sequences were identified in multiple species found in Hong Kong markets (such as civet cats and raccoon dogs). These sequences were almost identical to human sequences suggesting the interspecies jumps were linked to the proximity of the market animals and humans and did not represent the natural reservoir for SARS-CoV.

Consequently, a universal coronavirus probe was created to detect all know coronavirus sequences. This probe was directed against a conserved region of the RNA dependent RNA polymerase and therefore positives samples required sequencing to determine if the coronavirus was alpha, beta, or gamma, as well further divisions. This approach showed that many different types of coronavirus viruses were in bats, including a SARS-related series. The bat testing led to the dividion of betacornaviruses into four groups, including 2a for sequences similar to the human cold virus, OC43, and 2b for sequences closely related to SARS-CoV. Additional bat beta coronaviruses were classified as 2c and 2d.

The first confirmed MERS-CoV case (60M) had symptoms similar to SARS-CoV, but tested negative for all know human coronaviruses. However, PCR testing using the universal probe generated a positive, and sequencing identified a novel betacornavirus that was most closely related to bat coronavirus 2c sequences. The universal probe was also used to PCR confirm the second case (49M from Qatar who was diagnosed in England). Sequencing showed that it was 99.5% identical to the first case, confirming the discovery of a new human coronavirus. The full sequences were only 82% identical to bat beta 2c sequences from China. More closely related bat beta 2c sequences were subsequently identified in Europe and Africa, but the most closely related sequence had a 92.5% identity until the Bisha bat sequence was released, which was an exact match with the EMC/12 sequence from the Bisha case. However, only 203 BP were generated for the bat sequence (full sequences are over 30,000 BP).

The sequences from the first two human cases were used to create a new set of primers that are specific for MERS. PCR confirmation requires a positive result for two regions, and all MERS PCR positive human cases have yielded sequences that were >99.5 identical to the consensus sequence.

Thus, the comments by Ziad Memish and Gregory Hartl indicate the camel was MERS PCR positive, which was based on the same probes used to identify human cases and therefore signal MERS-CoV. The sequences from the camel and case will determine if the sequences are more than 99.9% identical, signaling interspecies transmission, but the use of the human MERS CoV test insures that the camel sample has MERS-CoV sequences.

[dothedd]

MERS In Two Kuwait Travelers Raises Concerns
Recombinomics Commentary 23:30
November 13, 2013

Ministry of Health announced the Kuwaiti state registration of infecting a second "Corona" to a Kuwaiti citizen reach the 52-year-old newly feet of travel abroad and said his health is now reassuring.

The above translation describes the second confirmed MERS case (52 years old), which follows the announcement this morning of the first case (47M) who is in critical condition in Adan (see map). Media reports noted that the first case had traveled in the Kingdom of Saudi Arabia (KSA), while the above case recently returned from “travel abroad”. These are the first two reported confirmed cases in Kuwait, but they are not related. The reporting of two cases who were independently infected and reported after return from travel abroad indicates each are linked directly or indirectly to the end of the Hajj.

These two cases follow reports of the first case (68M) reported in Oman (see map). Media reports indicate that case had not traveled, but two relatives had just returned from a Hajj pilgrimage. Moreover, United Arab Emirates (UAE) reported a confirmed case (75M) in another Omani who had recently traveled to Abu Dabi. His prior travel history was unclear, but the reporting of MERS in unrelated Omani’s shortly after the end of Hajj, raises concerns that these cases were linked directly or indirectly to the Hajj, through contact with Hajj attendees, travelers infected by Hajj attendees, or cases identified due to enhanced surveillance due to movement of Hajj pilgrims.

In addition, Qatar reported a confirmed case, who travel history was not described, which is also true for a case in Riyadh (72M). Another KSA case (43M) was in Jeddah, which was linked to the detection of MERS in at least one of his camels.

These seven cases follow the report of a case (61F) from Madrid who traveled to KSA for the Hajj. She developed symptoms shortly after her arrival in Mecca from Medina. She sought medical treatment in Mecca and was diagnosed with pneumonia via x-ray. She refused admission and traveled to Jeddah to her flight to Madrid. She had breathing difficulties in flight, which required oxygen. MERS was confirmed when she was hospitalized in Madrid.

Thus, the above 8 confirmed cases in Spain, Qatar, KSA, UAE, Oman, and Kuwait, which developed symptoms during or shortly after the end of the Hajj raises serious questions about the KSA Hajj surveillance which failed to confirm MERS in any pilgrim performing Umrah during Ramadan or traveling to Mecca and Medina for the Hajj.

[dothedd]

Spain MERS Hajj Cluster Raises Concerns
Recombinomics Commentary 23:30
November 18, 2013

During the investigation of contacts of the case mentioned, a woman who belonged to the same group tour, with whom he shared the hotel room in Saudi Arabia , has been successful in one of the laboratory tests for the new coronavirus

The above translation, from a November 14 alert from the Department of Public Health in Spain describes a second lab confirmed MERS case in Spain in a Hajj pilgrim. A media report indicated both cases have recovered and have been discharged, but the disease onset date for the second case is still unclear.

The first case (61M) had traveled to the Kingdom of Saudi Arabia from Spain on October 1. She developed symptoms on October 15 shortly after she arrived in Mecca from Medina, suggesting she was infected in Medina and was symptomatic during the Hajj. On October 28 she sought medical attention at a hospital in Mecca and was diagnosed as have pneumonia because on a clinical x-ray. However, she refused admission and flew from Jeddah to Madrid (see map), where she developed breathing difficulties and was administered oxygen in flight.

She was MERS lab confirmed in Madrid and contacts were investigated. The above alert indicated testing was still ongoing on additional contacts raising concerns that more cases will be confirmed.
Release of disease onset dates for the above case would be useful.

[dothedd]

Delayed Spain MERS Hajj Cluster Testing Raises Concerns
Recombinomics Commentary 02:30
November 19, 2013

Study conducted close contacts have been obtained so far laboratory results 65% of these being negative.

Gregory Härtl ‏@haertlg 8h
.@helenbranswell @who 1 #Kuwait #MERS case had travel history to #KSA. Still waiting for #Spain confirmation.

The above translation (in red) is from the November 14 alert from the Spain Ministry of Health citing lab confirmation of a second MERS case (who traveled with the first MERS case, who developed symptoms on October 15). Thus, one month after the index case developed symptoms, WHO has not confirmed the index case (as indicated by today's Gregory Hartl tweet , in blue) and more than 1/3 of her contacts has not generated a lab result.

These testing delays raise serious concerns. The index case was hospital tested for pneumonia and her x-ray was positive on October 28. She declined admission and flew back to Madrid from Jeddah on November 1. Breathing difficulties led to treatment with oxygen in flight, which would have exposed the flight crew, passengers, and contacts.

Thus, the number of contacts who traveled with the two lab confirmed cases, either as a group attending the Hajj or passengers exposed to the two confirmed cases would be high, but one month after the index case developed symptoms, test results on more than 1/3 of her contacts had not been generated.

Similarly, more than a month after she became symptomatic and more than two weeks after she returned to Spain, WHO has not confirmed the local lab confirmation announced by the Spain MoH on November 6.

These testing delays suggest that many infected contacts will be reported as negatives due to testing delays.

[dothedd]

WHO Confusion On Spain MERS Hajj Cluster Raises Concerns
Recombinomics Commentary 16:00
November 19, 2013

The onset was on October 15, 2013

In fact, Mounts said it is possible that she contracted the virus after the pilgrimage was over, which would assuage fears that the event might seed MERS outbreaks in other countries too.

"The concern we had was that the Hajj would accelerate spread, that there would be transmission in the Hajj, during the Hajj itself," he said.

But if investigation of the woman's case leads to the conclusion she became infected after the pilgrimage, her participation in the Hajj will turn out to be coincidental. "And if that's the case, I think it's a little less concerning," Mounts said.

The above translation (in blue) is from the Spain Ministry of Health (MoH) alert issued on November 6, which also cited lab confirmation of the case (61F). That report generated a large series of local reports which cited the above disease onset date.

However, an English language report, following the Spain MoH and local reports, detailed WHO speculation (in red above) on an onset after the Hajj (which was from October 13-18). Since Mounts was the WHO point person, he should have been well aware of the disease onset, since the Spain MoH had already published the date, which they clearly knew well in advance of the October 6 alert. Additional reports noted that the index case had traveled to Kingdom of Saudi Arabia (KSA) on October 1 and had been in Medina prior to developing symptoms in Mecca. Mounts was also aware of the fact that she sought medical treatment in Mecca on October 28, so the basis for the speculation (and its publication) was far from clear. His comments on the index case were more appropriate for the travel companion, who was not cited prior to the Spain MoH alert on October 14, which noted the MERS lab confirmation for the companion.

The delayed testing and confusing media reports is similar to the cluster in England in early 2013, which was also linked to a return from KSA (after performing Umrah in association with the medical condition of his son, who was undergoing treatment for a brain tumor. The index case had traveled to KSA with a daughter, but her condition was not described in initial media reports. The son and sister of the index case were subsequently MERS confirmed, and both cases were also co-infected with para-influenza type 2 (HPIV-2) in contrast to the index case who was co-infected with H1N1pdm09. The daughter of the index case was tested after she recovered, and consequently tested negative.

The delay in testing contacts of the Spain cases raises similar concerns regarding MERS false negatives.

[dothedd]

H1N1pdm09 Louisiana Tamiflu Resistance Cluster
Recombinomics Commentary 21:45
November 19, 2013

The CDC has released a series of H1N1pdm09 sequences from the current season, which included two sets of sequences from Louisiana, which had H274Y, signaling Tamiflu (oseltamivir) resistance. A sample from one case (25F), A/Louisiana/07/2013, was collected on October 7, which was followed by another case (56F), A/Louisiana/08/2013, which was collected on October 9. The relationship between these two cases is unknown, but the virtual identity for all 8 gene segments indicates this sub-clade is spreading via clonal expansion.

In the week 43 FluView, the CDC reported testing on 28 H1N1pdm09 during the 2013/2014 and none were Tamiflu resistant. However, in week 44 nine additional samples were tested, and two were resistant, strongly suggesting that the two examples were the two cases described above. In week 45 the CDC reported one more case of resistance, but those sequences have not been released, so the relationship to the above two cases is unknown.

The sequence similarity between the first two cases signals evolutionary fitness for this sub-clade. More information on the status and relationship of these two cases to each other and the third case, reported in week 45, would be useful.

[dothedd]

Jeddah MERS Camel and Case Sequence Update
Recombinomics Commentary 15:30
November 20, 2013

Saudi officials have said the MERS-CoV isolates from the camel and its owner are being sequenced to determine if they match. Ziad A. Memish, MD, the country's deputy minister for public health, told CIDRAP News today that he hopes the sequencing will be completed next week.

The above comments suggest that full MERS sequences from a Jeddah case (43M) and one of his camels will be completed next week. These sequences will almost certainly be virtually identical (well over 99%) due to positive results on the MERS PCR test. This test targets two regions of the MERS sequence which are designed to be specific for the sequences identified in human cases. All human sequences reported to date are >99.5% identical with the consensus sequences and for sequences from a common source such as the nosocomial transmission in Al Hasa, many sequences were greater than 99.99% identical to each other.

However, the virtual identity between the above case and camel will only indicate an interspecies transmission has occurred, which could be from camel to case, but also could be from case to camel. Media reports have noted that the above case had 8 camels in the barn adjacent to his residence (see map), but only one male camel was symptomatic. The asymptomatic camels may indicate MERS-CoV can be present in asymptomatic camels, or may mean that transmission among the camels may be limited.

Prior studies identified MERS-related antibodies, which were not detected in OC43 (beta2a) or SARS (beta2b) targets. However, the camel antibodies may have been directed against a beta2c CoV that was related to various beta2c isolates detected in bats. Only one bat beta2c sequence (from Bisha) was closely related to MERS. However, the MERS PCR data for the Jeddah camel suggests that the antibody results for camels on Oman and Egypt were due to prior MERS infection(s), but the antibodies may have been due to multiple exposures in the past and therefore may not predict active infections under circumstances reflected by the 8 camels described above.

In addition to the camel and case sequences cited above, more information on the detectability of MERS in various collections from different camel sites and times would be useful.

[dothedd]

US H1N1pdm09 Tamiflu Resistance Increases
Recombinomics Commentary 17:30
November 22, 2013
Week 46 ILI


MAP: www.recombinomics.com/News/11221301/H1N1_H274Y_Wk46.html

The above figure from the CDC week 46 FluView shows the highest US ILI in states flanking Louisiana. In addition, the week 46 report indicates H1N1pdm09 is clearly the dominant influenza currently in circulation in the US. For week 46 280/312 (89.7%) of typed samples were influenza A, and of the sub-typed influenza A samples 118/132 (89.4%) were H1N1pdm09.

Recently the CDC released the initial sequences from the 2013/2014 season, which included two sequences from Louisiana. Both sequences contained H274Y, which led to the release of full sequences for both samples - the vast majority of CDC seasonal flu sequences include only three gene segments (HA, NA, and MP). The 8 gene segments from A/Louisiana/07/2013 and A/Louisiana/08/2013 were virtually identical, signaling clonal expansion (samples were collected 2 days apart). In week 44 the CDC cited the first 2 Tamiflu resistant sequences for the 2013/2014 season, which were almost certainly from the above two case (25F and 56F, respectively).

The week 45 FluView cited a third case, and in week 46 the number increased to four. Although sequences from week 45 and 46 cases have not been released, it is likely that one or both of the newer cases are also from Louisiana due to concerns generated by the above matching sequences.

More information about the relationship between the first two sequences, as well as the locations for the two most recent examples of oseltamivir resistance would be useful, as well as the number of H1N1pdm09 cases in Louisiana being tested for H274Y.

[dothedd]

CDC Investigates H1N1pdm09 Louisiana H274Y Cluster
Recombinomics Commentary 19:30
November 25, 2013

The CDC has recently released H1N1pdm09 sequences which included two isolates (A/Louisiana/07/2013 and A/Louisiana/08/2013) from Louisiana that had H274Y, which are likely the first two reported cases (25F and 56F, respectively) in the 2013/2014, as reported in week 44. A third case was reported in week 45, and the Louisiana Department of Health (DoH) has confirmed to Recombinomics that the CDC has requested additional samples, which led to the identification of a third Louisiana case with H274Y.

Louisiana DoH has indicated that the three cases were not linked and were identified through routine surveillance. These cases were not unusually severe.

The CDC has not released the sequences from the case reported in week 45 or the fourth case (reported in week 46). Release of sequences from the recently reported cases would be useful.

[dothedd]

MERS Asymptomatic Camel Cluster In Qatar
Recombinomics Commentary 09:30
November 28, 2013

“We can confirm that the 3 camels were investigated among a herd of 14 camels, and the samples were collected as part of the epidemiological investigation in coordination between the Public Health Department and the Department of Animal Resources.

It is to be noted that none of the 14 camels showed any sign of disease when the samples were collected. As a precautionary measure, the 14 camels were put in quarantine since the initial sampling and after 40 days as of now, none have shown any symptom or sign of the disease.”

The above comments from the Qatar Supreme Council of Health (SCH) describe the lab confirmation of MERS in 3 asymptomatic camels (see map) linked to two recently confirmed cases (the 61M owner of the barn, as well as an ex-patriot (23M) who worked for the owner. Both cases have recovered and the younger case was mild.

The detection of MERS in asymptomatic camels follows a report from the Kingdom of Saudi Ministry of Health (KSA-MoH) of lab confirmation in a symptomatic camel linked to a confirmed case (43M) who was in critical condition. 7 additional asymptomatic camels were quarantined and are under investigation.

The detection of MERS in the four camels cited above raises serious concerns, since there camels were linked to confirmed cases and the camels reported by the SCH were asymptomatic. These PCR confirmed cases increases the likelihood that the MERS-related antibodies detected in racing Camels on Oman and camels imported from Sudan for slaughter in Egypt were also due in MERS-CoV infections.

[dothedd]

MERS Asymptomatic Camels In Qatar Sequence Confirmed
Recombinomics Commentary 15:30
November 28, 2013

Ab Osterhaus, a professor of virology at the Erasmus Medical Centre in The Netherlands that worked on the camel study, told Reuters the results were confirmed by a range of tests including sequencing and antibody testing.

The above comments indicate that the asymptomatic MERS positives camels in Qatar (see map) have been sequence confirmed, which was expected. Earlier the Kingdom of Saudi Arabia Ministry of Health (KSA-MoH) had announced PCR confirmation of MERS in a critical case (43M) and one of his eight camels (which was symptomatic). Media reports suggested that sequence data from the camel and case may be announced or released this week. That sequence data was expected to show the the camel had an active MERS infection, with a match to its owner of >99.9%.

The Qatar result indicates 3 of 14 asymptomatic camels were PCR confirmed and partial sequence data confirmed that the PCR (and antibody) results signaled an active MERS infection. Prior antibody results on racing camels in Oman and animals imported by Egypt from Sudan (for slaughter) signaled a high frequency of infections, and the latest PCR data strongly suggests that the antibody data for the camels signaled prior MERS infections.

The report that active MERS infections were present in asymptomatic camels (which were linked to two MERS confirmed cases, 61M and 23M, raises concerns that MERS is widespread in camels throughout the Middle East (including Oman and Egypt).

Although the direction of the interspecies transmission is unclear, the finding of MERS in 3 asymptomatic camels in Qatar increases the likelihood that camels represent a reservoir that leads to human infections. Although most confirmed human cases do not have a direct camel link, independent introductions, followed by transmission by milder human cases, has raised serious concerns.