NOVEL CORONAVIRUS - EASTERN MEDITERRANEAN (06): UK, FATALITY
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A ProMED-mail post
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International Society for Infectious Diseases
http://www.isid.org
Date: 19 Feb 2013
Source: HPA press release [edited]
http://www.hpa.org.uk/NewsCentre/Nation ... ronavirus/
Update on family cluster of novel coronavirus infection in the UK - [19 Feb 2013]:
The Health Protection Agency (HPA) continues its investigations into a family cluster of novel coronavirus infections in the UK. Three members of the same family have all tested positive for novel coronavirus. Two of these had no history of recent travel, suggesting that transmission has occurred in the UK.
One person has sadly died. This patient had an underlying condition that may have made them more susceptible to respiratory infections. The 1st patient in this cluster, who had recent travel history to Saudi Arabia and Pakistan, is still receiving treatment. The 3rd case, who had a mild illness, has recovered.
Since September 2012, when an earlier case was diagnosed in the UK, there have been a total of 12 confirmed cases of novel coronavirus reported globally, with 6 deaths. Intensive work has been carried out in the UK to identify contacts of the UK cases. In total, the HPA has identified and followed up on more than 100 people who had close contact with the cases in this recent family cluster. Besides the identified secondary cases, all tests carried out on contacts to date have been negative for the novel coronavirus infection.
Professor John Watson, head of the respiratory diseases department at the HPA, said: "The routes of transmission to humans of the novel coronavirus have not yet been fully determined, but the recent UK experience provides strong evidence of human-to-human transmission in at least some circumstances. The 3 recent cases in the UK represent an important opportunity to obtain more information about the characteristics of this infection in humans and risk factors for its acquisition, particularly in the light of the 1st ever recorded instance of apparently lower severity of illness in one of the cases. The risk of infection in contacts in most circumstances is still considered to be low, and the risk associated with novel coronavirus to the general UK population remains very low. The HPA will continue to work closely with national and international health authorities and will share any further advice with health professionals and the public if and when more information becomes available."
Notes to editors:
Laboratory confirmed cases to date: 12 (6 deaths)
Saudi Arabia: 5 (3 deaths)
Jordan: 2 (2 deaths)
UK: 4 (1 patient from Qatar - receiving treatment, 3 patients from UK; 1 receiving treatment, 1 recovered, 1 death)
Germany: 1 (patient from Qatar - discharged)
Coronaviruses are causes of the common cold but can also include more severe illness, such as SARS (severe acute respiratory syndrome). This new coronavirus was 1st identified in September 2012 in a patient who died from a severe respiratory infection in June 2012. The virus has so far only been identified in a small number of cases of acute, serious respiratory illness who presented with fever, cough, shortness of breath, and breathing difficulties.
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Communicated by:
ProMED-mail
<promed@promedmail.org>
[The above press release by HPA (Health Protection Agency) UK summarizes the global situation on confirmed cases of respiratory illness associated with infection with this novel coronavirus (nCoV). As mentioned above, this is the 1st time infection with the nCoV has been confirmed in a case with mild illness. In prior clusters, only cases with severe disease were confirmed to have an infection with the nCoV, whereas milder respiratory illnesses were found to be negative for infection with the nCoV using currently available testing methods (see prior ProMED-mail posts: Novel coronavirus - Eastern Mediterranean: WHO, Jordan, conf., RFI 20121130.1432498 and Novel coronavirus - Saudi Arabia (18): WHO, new cases, cluster 20121123.1421664).
For the interactive HealthMap/ProMED map of the UK, see http://healthmap.org/r/1lNY. For the interactive HealthMap/ProMED map of the Middle East, see http://healthmap.org/r/1HAJ. - Mod.MPP]
Neuartiger Corona-Virus - WHO warnt vor Lungenkrankheit
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Neuartiger Corona-Virus - SA, UK, DE
NOVEL CORONAVIRUS - EASTERN MEDITERRANEAN (07): SAUDI ARABIA, UK, GERMANY
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A ProMED-mail post
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In this report:
[1] Saudi Arabia, UK - WHO update
[2] UK - 4th case in cluster suspected
[3] UK - CIDRAP report
[4] Case investigation, Germany, 2nd Qatari case - Eurosurveillance
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[1] Saudi Arabia, UK - WHO update
Date: Thu 21 Feb 2013
Source: WHO GAR [Global Alert and Response] [edited]
http://www.who.int/csr/don/2013_02_21/en/index.html
Novel coronavirus infection - update -- 21 Feb 2013
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The Ministry of Health in Saudi Arabia has informed WHO of another confirmed case of infection with the novel coronavirus (NCoV).
The patient was hospitalized on [29 Jan 2013] and died on [10 Feb 2013]. The case was laboratory-confirmed on [18 Feb 2013]. Further investigation into this case is ongoing.
In the United Kingdom, the Health Protection Agency continues to investigate the family cluster where 3 members of the family tested positive for NCoV infection. One member of this family, who had an underlying health condition, has died.
To date, WHO has been informed of a total of 13 confirmed cases of human infection with NCoV, including 7 deaths.
Based on the current situation and available information, WHO encourages all Member States (MS) to continue their surveillance for severe acute respiratory infections (SARI) and to carefully review any unusual patterns. Testing for the NCoV should be considered in patients with unexplained pneumonias, or in patients with unexplained, severe, progressive or complicated respiratory illness not responding to treatment, particularly in persons traveling from or resident in areas of the world known to be affected.
Any clusters of SARI or SARI in healthcare workers should be thoroughly investigated, regardless of where in the world they occur.
All MS are reminded to promptly assess and notify WHO of any new case or clusters of cases with NCoV infection.
WHO does not advise special screening at points of entry with regard to this event nor does it recommend that any travel or trade restrictions be applied.
WHO continues to closely monitor the situation.
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Communicated by:
ProMED-mail Rapporteur Marianne Hopp
[The above report from WHO confirms another fatal case of severe acute respiratory illness (SARI) attributable to infection with the novel coronavirus (nCoV) in a Saudi Arabian resident, bringing the total number of confirmed cases to 13 including 7 fatalities. The breakdown of cases (and deaths) by country of report is:
Saudi Arabia: 6 (4 deaths)
Jordan: 2 (2 deaths)
UK: 4 (1 patient from Qatar - under treatment, 3 patients from UK (one with history of travel to Saudi Arabia and Pakistan prior to illness); 1 under treatment, 1 recovered, 1 death)
Germany: 1 (patient from Qatar - discharged).
For the interactive HealthMap/ProMED map of the Middle East, see http://healthmap.org/r/1HAJ.
For the interactive HealthMap/ProMED map of the UK, see http://healthmap.org/r/1lNY. - Mod.MPP]
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[2] UK - 4th case in cluster suspected
Date: Thu 21 Feb 2013
Source: The Canadian Press via The Province [edited]
http://www.theprovince.com/health/There ... story.html
There may have been a 4th case in UK coronavirus family cluster: WHO
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British authorities announced Tuesday [19 Feb 2013] that another person has died from infection with the new coronavirus as European scientists revealed the new virus easily infects the cells of the airways of the human lung.
The current cluster of novel coronavirus cases in Britain may have included another infection, a World Health Organization official says.
To date, 3 members of an extended family have tested positive for the new virus, which is a cousin of the SARS coronavirus. One of the 3 died earlier this week [see prior ProMED-mail post Novel coronavirus - Eastern Mediterranean (06): UK, fatality
20130220.1552014].
But officials investigating how the virus moved from one member of the family to the next suspect another relative may have contracted the virus and may even have spread it to the 3rd confirmed case in the cluster. This 4th family member had a respiratory illness but was not tested until after she recovered, at which point the test came back negative.
Dr. Anthony Mounts, the WHO's point person for the new coronavirus outbreak, says the U.K. cluster adds slightly to the WHO's concern over the virus, but in the main serves to confirm some things the organization has already strongly suspected.
Those are: In some circumstances, person-to-person spread can occur, though so far, it appears those chains of infection has been short. And while the 1st few cases spotted all involved severe illness, some infections can produce mild symptoms only.
The WHO revised its new coronavirus case definition this week to remind doctors not to automatically rule out people with mild symptoms when they look for possible cases. And Mounts says the organization's recommendations on how to do surveillance for cases will also be updated.
Mild infections are a mixed blessing. Obviously everyone would hope the virus didn't always cause severe disease. But people suffering only mild infections may be more likely to spread the virus, if the virus transmits easily.
That's because people sick enough to be in hospital ICUs mainly encounter health-care workers protected by masks, but people with mild respiratory infections generally go about their daily life. And mild infections are much harder to spot, especially when they occur during cold and flu season.
The 3rd confirmed case in this cluster had only mild symptoms and has since recovered. "The fact that she had such a mild illness really does raise our concerns about what we might be missing," Mounts admits.
Others share the WHO's concern. In fact, several of the researchers who were key players in the response to the 2002-2003 SARS epidemic admit the patterns they are seeing bring back memories.
"It is certainly beginning to look concerning, given the obvious fact that there can be onward transmission," says Malik Peiris, chair of the department of microbiology at the University of Hong Kong.
"It is somewhat reminiscent of the emergence of SARS in 2002."
Ron Fouchier, a virologist at Erasmus Medical Centre in Rotterdam, the Netherlands, also sees those similarities.
And Fouchier is concerned about how many infections may be going unnoticed, untested or unreported. He notes that several of the 12 confirmed cases were diagnosed in European hospitals.
In addition to the current family cluster in Britain, one case from Qatar was diagnosed in Britain in September [2012] [see prior ProMED-mail post: Novel coronavirus - Saudi Arabia (03): UK HPA, WHO, Qatar 20120923.1305982] and a 2nd from Qatar was diagnosed in Germany in October [2012] [see prior ProMED-mail post: Novel coronavirus - Saudi Arabia (18): WHO, new cases, cluster 20121123.1421664]. Both men got sick in Qatar but left the country for treatment - a practice that is not uncommon for wealthy residents of Middle Eastern countries.
"The fact that we are finding these cases in Europe and not anywhere else, that has to raise suspicion," Fouchier says. "What we're seeing in Europe is just the tip of the iceberg and we really have no clue how big the iceberg is."
Saudi Arabia has reported 5 cases, the most recent in late November [2012] [see above WHO report in section [1] -- there are now 6 confirmed cases in Saudi Arabia, most recent date of onset 29 Jan 2013 - Mod.MPP]. Qatar has had the 2 confirmed cases. And Jordan has reported 2 cases, but the confirmations came months after the 2 individuals died [see prior ProMED-mail posts below].
Samples taken during an unexplained respiratory outbreak at a Jordanian hospital last April [2012] were tested for the virus late last year [see prior ProMED-mail post from 30 Nov 2012: Novel coronavirus - Eastern Mediterranean: WHO, Jordan, conf., RFI 20121130.1432498 - Mod.MPP]. At the time of the outbreak, the existence of the virus was not yet known.
Fouchier feels not enough is being done to find cases or to track down the source of the virus.
The virus's genetic sequence indicates it likely comes from bats, but it still isn't clear how people are becoming infected. "We know that humans don't come into contact with bats a whole lot," Fouchier says.
He and other experts suspect there may be some intermediate host -- a domestic animal, perhaps -- that is being infected and is passing on the virus to people.
Mounts says the WHO is trying to get countries to look harder for the virus. "We're concerned and really watching it very closely and trying to push people to do more investigation."
He also says the organization is putting together networks of experts to help it with the coronavirus situation -- an approach the WHO used with much success during the SARS outbreak.
A laboratory network and a network of expert epidemiologists -- sometimes called disease detectives -- are being set up. As well, a group of clinical experts who have advised the WHO over the past decade on possible treatments for H5N1 -- bird flu -- and during the 2009 H1N1 pandemic is being reactivated to help with this situation, Mounts says.
[Byline: Helen Branswell]
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Communicated by:
ProMED-mail Rapporteur Mary Marshall
[The information of a 4th family member with a history of a mild respiratory illness but negative on laboratory testing for infection with the novel coronavirus (nCoV) is a recurrent theme thus far in the history of laboratory confirmation of cases in suspected clusters -- mild respiratory illnesses have been observed in contacts of confirmed cases, but on laboratory testing (often retrospective testing) these individuals are found to be negative by current tests available. Of note was that the 3rd confirmed case in this cluster in the UK, (discussed in further detail in the CIDRAP report below), did have a milder illness and was confirmed through laboratory testing, the 1st milder presentation of illness that has been laboratory confirmed.
In an earlier post, this moderator raised the possibility that we may well be seeing a prospective evolution of an outbreak similar to what we saw with SARS - early sporadic cases, followed by smaller clusters and then larger clusters and more "widespread" dissemination of the organism. While one hopes that there will be less of a nosocomial transmission of this organism in contrast with SARS, reading some of the details of the cases reported in earlier reports when patients were transferred from other countries, and of other suspected clusters, the absence of strict adherence to respiratory isolation in the early presentations of these cases may well be associated with nosocomial transmission.
There clearly are many unknowns about the epidemiology of this organism. Information on results of studies on the possible prevalence nCoV infection of animals in Saudi Arabia and Qatar are still pending. As mentioned above and in prior reports, genetic studies on this nCoV place it related to CoVs found in bats, but how did the jump from bats to humans occur? Is there an intermediate host animal? - Mod.MPP]
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[3] UK - CIDRAP report, details on 3rd case
Date: Tue 19 Feb 2013
Source: Center for Infectious Disease Research & Policy (CIDRAP) [edited]
http://www.cidrap.umn.edu/cidrap/conten ... onabr.html
British man dies from novel coronavirus infection
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One patient in a British family cluster of novel coronavirus (NCoV) infections, a 38-year-old man with an underlying medical condition, has died, and fresh details about a recently reported mild case have sparked new questions about how the virus is spreading and how big a threat it poses.
The man died [17 Feb 2013] in the critical care unit at Queen Elizabeth Hospital Birmingham, where he had been undergoing treatment for a chronic health condition, the hospital said in a statement today. He was immunocompromised, and health officials believe he was exposed to NCoV by sustained close contact with a sick relative, a 60-year-old man who was hospitalized in Manchester shortly after traveling in Pakistan and Saudi Arabia.
He received extracorporeal membrane oxygenation (ECMO), a heart-lung-bypass procedure designed to allow disease-damaged lungs to heal. His death raises the number of fatalities from the new virus to 6 of the 12 cases reported so far.
Mild infection raises transmission questions
The UK Health Protection Agency (HPA) today released new information about the 3rd patient in the family cluster, who has recovered from a milder version of the illnesses after more limited contact: visiting the older man in the hospital on 3 occasions. The 3rd patient had no contact with the man who died and, according to a new risk assessment from the European Centre for Disease Control and Prevention (ECDC), is a 30-year-old woman.
Neither the woman nor the patient who died had a recent travel history, and HPA and ECDC officials have said both cases provide further evidence of person-to-person NCoV spread, but so far there is no sign of sustained transmission.
The woman's limited contact with the man who died raises the possibility of an intermediary case within the extended family, the HPA said. The ECDC also noted the limited time the woman spent with the older patient, which it said might point to an intermediary case or fomite spread. "However, the investigation and intensive case finding around the 3 cases remain ongoing and the results cannot be prejudged," the agency said.
Public health authorities are tracing the contacts of the family members, including people who sat within 2 rows of the older man on a flight from Saudi Arabia to London, during which he first felt ill. Follow-up is also underway on health workers, patients, family, and friends who were in contact with the patients in hospital settings.
Health officials reconsider threat assessments
John Watson, MB BS, MSC, the HPA's head of respiratory diseases, said in the statement that the routes of NCoV transmission haven't been fully determined, but the recent UK cases show strong evidence of human-to-human spread in some circumstances.
"The 3 recent cases in the UK represent an important opportunity to obtain more information about the characteristics of this infection in humans and risk factors for its acquisition, particularly in the light of the 1st ever recorded instance of apparently lower severity of illness in one of the cases," he said.
The risk of infection in contacts is still considered low, and the threat to the general UK population remains very low, the HPA said.
Meanwhile, the ECDC said recent developments with the 3 UK cases increase the threat to the European Union, because the infection came to Europe on a commercial flight and resulted in 2 more illnesses, though the cluster is isolated to one family.
Emergence of a mild secondary case, the 1st of its kind, is worrisome, because other mild illnesses that are missed during NCoV detection efforts could spread the infection, the ECDC said. More work is needed to flesh out the illness spectrum, such as whether it causes severe disease of uncommon zoonotic origin, as well as mild or even asymptomatic infections, it said in the risk assessment.
Also, the emergence of the mild illness and the possibility that surveillance will find more of them raises questions about whether new case-finding strategies are needed, the ECDC said, noting that it is reviewing the issue with its member countries and global health partners.
Though it's reassuring that health officials have found no expanding case clusters, "the fact remains that there is a lot more that we do not know than we know about this virus," the ECDC said, adding that discussions are underway to provide guidance on research priorities.
Study finds NCoV easily infects lung lining
In a related development today, a European research group reported that the NCoV easily penetrates human airway passages and evades the immune system like other coronaviruses, such as one responsible for the common cold. The findings were published today in mBio, the online journal of the American Society for Microbiology (ASM).
The team used cultured bronchial cells that were engineered to mimic the epithelial lining to explore how well the new virus could infect and multiply. Their findings suggest that the airway cells are highly susceptible to NCoV infection, and the virus multiplied faster than the SARS virus, another member of the coronavirus family.
Volker Thiel, a study coauthor with the Institute of Immunobiology at Kantonal Hospital in St. Gallen, Switzerland, said today in an ASM press release that though data suggest the virus may have jumped from animals to humans very recently, it is just as well-adapted to infecting the human respiratory tract as other more familiar coronaviruses, which was surprising.
The investigators suspected that the NCoV uses the same strategy as other common coronaviruses to evade the immune system, and they tested the notion by pretreating epithelial cells with lambda-type interferon to boost their immune response.
They reported that the treatment significantly reduced the number of infected cells, which is encouraging, given that interferons are promising for treating SARS and hepatitis C.
In another lab-related development, the World Health Organization (WHO) today issued updated interim recommendations for managing NCoV lab risks. The document includes epidemiological developments that have occurred since the last update on [31 Oct 2012].
The guidance urges labs conducting routine tests to follow biosafety level 2 (BSL 2) practices, that labs working with viral isolates from clinical samples use additional containment practices, including those recommended for BSL 3, and that work with animals infected with NCoV take place in an animal BSL 3 facility [BSL 3 labs are used with biologic agents the may cause serious or potentially lethal disease through inhalation of the agent whereas BLS 2 labs are those working with biologic agents that pose moderate hazards to personnel and the environment. For background information on the 4 laboratory biosafety levels, see http://www.cdc.gov/biosafety/publicatio ... ect_iv.pdf. - Mod.MPP]
[Byline: Lisa Schnirring]
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Communicated by:
ProMED-mail
<promed@promedmail.org>
[The above report summarizes the information available on the descriptive epidemiology of the cases in the cluster, and raises the possibility of yet another case in the cluster. It also highlights the possible additional contacts of the index case who was apparently ill when flying back to the UK after visiting Saudi Arabia and Pakistan. In the HPA report on 19 Feb 2013, there was mention of followup on 100 known contacts of this cluster, presumably including individuals who were seated near this case while travelling to the UK from Saudi Arabia. - Mod.MPP]
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[4] Case investigation, Germany, 2nd Qatari case - Eurosurveillance
Date: Thu 21 Feb 2013
Source: Eurosurveillance, Volume 18, Issue 8, 21 February 2013 [edited]
http://www.eurosurveillance.org/ViewArt ... leId=20406
Contact investigation of a case of human novel coronavirus infection treated in a German hospital, October-November 2012
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On [24 Oct 2012], a patient with acute respiratory distress syndrome of unknown origin and symptom onset on [5 Oct 2012] was transferred from Qatar to a specialist lung clinic in Germany. Late diagnosis on [20 Nov 2012] of an infection with the novel Coronavirus (NCoV) resulted in potential exposure of a considerable number of healthcare workers. Using a questionnaire we asked 123 identified contacts (120 hospital and 3 out-of-hospital contacts) about exposure to the patient. 85 contacts provided blood for a serological test using a 2-stage approach with an initial immunofluorescence assay as screening test, followed by recombinant immunofluorescence assays and a NCoV-specific serum neutralisation test. Of 123 identified contacts 9 had performed aerosol-generating procedures within the 3rd or 4th week of illness, using personal protective equipment rarely or never, and 2 of these developed acute respiratory illness. Serology was negative for all 9. Further 76 hospital contacts also tested negative, including 2 sera initially reactive in the screening test. The contact investigation ruled out transmission to contacts after illness day 20. Our 2-stage approach for serological testing may be used as a template for similar situations.
Introduction
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A novel human coronavirus (NCoV) has recently emerged in the Arabian Peninsula. The first 2 reported cases infected by the novel agent, then provisionally termed hCoV-EMC, occurred in June and September 2012, respectively [1-3]. As of [18 Feb 2013], a total of 12 cases have been confirmed by WHO [4], including 5 deaths. Among 5 cases reported from the Kingdom of Saudi Arabia, 3 were part of a family cluster. Two further cases were linked to probable exposure in Qatar, and 2 cases were confirmed retrospectively, by diagnostic of respiratory specimens, from Jordan with disease onset in April 2012. The latter were part of a cluster of 11 patients with acute respiratory symptoms linked to a hospital [5]. The most recent 3 cases identified constitute another cluster that occurred in the United Kingdom (UK) in January to February 2013 [4]. The index case in this cluster is a UK citizen with travel history to Saudi-Arabia and Pakistan before symptom onset [5]. Two of his family members who had not travelled outside the UK and became ill were most likely infected through person-to-person transmission. While one of them had an underlying disease and died, the other presented with milder, influenza-like illness symptoms only.
Because of the long period, 10 months, over which the cases occurred, the source and transmission patterns of the virus remain elusive. Hypotheses include a predominance of zoonotic acquisitions with little potential for human-to-human transmission [5], widespread and unnoticed occurrence of clinically mild infections, and finally the possibility of an early-stage epidemic caused by a highly pathogenic novel human virus.
Because of the potential of human-to-human transmission in the hospital outbreak in Jordan and the family clusters, as well as the observed severity of disease, current recommendations regarding protective measures rely on experiences with severe acute respiratory syndrome (SARS) in 2003 [6]. The 1st of the 2 Qatari patients was treated in the UK where, under strict isolation measures, no secondary cases occurred. Investigations by polymerase chain reaction (PCR) of 10 healthcare workers (HCW) who had cared for the patient and subsequently developed mild respiratory disease yielded no evidence of infection [7]. However, to date, published investigations of individuals with proven exposure to NCoV have not presented a strategy how to identify retrospectively infections in a large group of (contact) persons through serological testing.
On [22 Nov 2012], the Robert Koch Institute in Berlin, Germany, was informed according to the International Health Regulations [8] about a case of NCoV infection in a Quatari patient in his 40s, treated in Germany (Figure). After an acute onset of symptoms on [5 Oct 2012], he had been admitted to a hospital in Doha, Qatar, on [13 Oct 2012], where he developed respiratory failure requiring ventilation, and was reported to have had temporary renal impairment. On [24 Oct 2012], he was transferred to a specialist lung hospital in Essen, Germany. A respiratory sample had been taken in Qatar on [17 Oct 2012]. After some delay due to difficulties with the shipment of specimens, the sample tested positive for NCoV in a laboratory in the UK. The result was consequently communicated by the UK Health Protection Agency to the World Health Organization (WHO) on [21 Nov 2012]. Until that date the hospital in Essen had not considered NCoV in the differential diagnoses for the patient. Only routine personal protection of HCW and no specific measures of respiratory protection had been followed during the whole course of treatment in the intensive care unit (ICU). After weeks of mechanical ventilation in ICU, the patient was discharged on [21 Nov 2012].
[Figure: Timeline of disease of novel coronavirus case and possible exposure of healthcare workers, Germany, October-November 2012, available at above given URL]
A lag time of 4 weeks between patient transfer and laboratory confirmation of the NCoV infection resulted in potential exposure of a considerable number of HCW in Germany. Here we report on an interview with the patient asking for potential sources of infection, the investigation of individuals exposed to the patient, virological investigation of respiratory samples from the patient as well as an approach used to test retrospectively a large number of contacts.
Methods [see above given URL for details of methods]
Results
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Patient interview
The patient reported to live in Doha, Qatar. He used to be a heavy smoker (2 to 3 packs of cigarettes per day), but denied smoking waterpipe or chewing qat [also known as khat, qat, gat or Arabian tea (Catha edulis), is a flowering plant native to the Horn of Africa and the Arabian Peninsula. It contains cathinone, an amphetamine-like stimulant, which is known produce excitement, decreased appetite and euphoria. see http://en.wikipedia.org/wiki/Khat. - Mod.MPP] Disease onset was rapid, with initial symptoms including fever (40 C), cough, runny nose, and shortness of breath. Subjective weakness was pronounced. After the 1st 2 days of illness he improved a little but deteriorated again, and was finally admitted to hospital on day 8 of illness because of increasing dyspnoea. He reported no subjective symptoms of renal impairment such as foamy urine, reduced urine output, or back pain. He had not travelled and had no known contact with any other reported cases of NCoV infection. The patient owned a camel and goat farm and reported a large number of casual contacts (approx. 50 persons per day) on a regular basis. He remembered that before his disease onset some goats were ill and had fever. He did not have direct contact with the goats or any other animals especially falcons or bats, but said he had eaten goat meat. He also reported to have had contact with one of his animal caretakers who was ill with severe cough and was hospitalised. Other than the animal caretaker, he did not remember persons with severe respiratory illnesses in his wider or closer social environment.
Patient samples
Virus detection in the initial sample from illness day 20 and preliminary serological investigations have been described by Corman et al. [10]. Isolation of virus in cell culture failed. Serological testing yielded an IgM titre against NCoV of 1:1000 and an IgG titre of 1:10 000 at day 20 (week 3) of illness. At week 8 of illness the IgG titre was still at 1:10 000 while the IgM titre had already decreased to 1:100. SNT titres against NCoV were 1:640 at week 3 and 1:640 at week 8 of illness. The pharyngeal wash sample taken on [23 Nov 2012] (week 8 of illness) tested negative by real-time RT-PCR.
Contact investigation
We identified 120 hospital and 3 out-of-hospital contacts, including the interpreter of the patient. Protective measures were largely limited to HCW wearing gloves and gowns when providing intimate care and use of surgical face masks during suctioning. From [31 Oct 2012 until 4 Nov 2012] (illness weeks 5 and 6), the patient was isolated using barrier nursing due to a concurrent Pseudomonas aeruginosa infection. This included use of surgical masks only. Among the 120 hospital contacts the largest group were nurses (n=59; 49 percent), followed by physicians (n=26; 22 percent) and laboratory technicians (n=15; 13 percent) [see Table 1: Profession, type of contact, occurrence of acute respiratory illness and serological results in contacts of case of novel coronavirus infection, Germany October-November 2012 at above given URL]. Median time from 1st contact to venipuncture was 39 days (range: 13-50 days).
85 (69 percent) of all respondents reported contact at a distance of less than or equal to 2 m, 14 (11 percent) of more than 2 m, and 24 (20 percent) of unknown distance to the patient. Frequency of ARI by week of 1st contact differed significantly among the groups (Table 1). However, there was no trend in the ARI proportion over time: 8 of 33 contacts with 1st exposure during illness weeks 3 or 4 experienced ARI within 10 days of last contact; 5 of 9 contacts with 1st exposure during the patient's 5th week of illness; and none of 14 with 1st contact during week 6 of illness developed ARI.
Among 81 contacts reporting exposure within 2 m, 21 had ARI compared to none of 14 with contact of more than 2 m (p value; 0.04) (Table 1). Among those with 1st exposure in week 3 or 4 of illness of the patient, the proportion of contacts with ARI was not significantly different between those considered to be at high risk and the remaining contacts (p value, 0.87) (Table 1). 13 HCW had contact to the patient in weeks 3 or 4 of illness, had contact within 2 m to the patient and had worn surgical face masks rarely or never. Among these, 9 were high-risk contacts, including one nurse who assisted in a bronchoscopy on [25 Oct 2012]. All 9 provided a blood sample. The median time after last contact with the patient for these 9 HCW was 32 days (range: 13-46 days). No sample was reactive by IFA.
Of the remaining 76 blood samples, one serum showed reactivity for IgM even at dilutions up to 1:100. This titre could be resolved as a cross-reacting recent infection with hCoV-NL63 by IFA using recombinant S and N proteins from major hCoVs [see Table 2: Cross-reactivity test on contact persons and of case of novel coronavirus infection (at week 3 and week 8 of illness) with recombinant spike and nucleocapsid indirect fluorescence antibody testa, Germany, October-November 2012
at above given URL], as well as absence of NCoV-specific neutralising antibodies. Another serum showed indeterminate IgG-reactivity in a 1:10 dilution. Specific anti-NCoV antibodies were ruled out by recombinant IFA, indicating earlier infection with hCoV-OC43 and hCoV-NL63, as well as absence of any significant titre in SNT (Table 2).
Discussion
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Here we describe a case and contact investigation of a laboratory-confirmed patient with NCoV infection for whom the suspicion of this possible aetiology had not been discussed with the treating hospital upon admission of the patient. The patient still tested PCR-positive late in his 3rd week of illness. Despite this we concluded from the laboratory findings that his infectiousness was then absent or very low. While at that time no consistent dedicated personal protective measures had been applied by HCW caring for the patient, our public health investigation did not show infection in any of the 85 serologically tested contact persons, mainly HCW. The conducted serological 2-stage approach was an effective method of screening a large number of contact persons for infection.
For initial risk assessment, after the information in November [2012] about the cause of the patient's disease, it was important to know if he had been potentially infectious at the time of arrival at the hospital in Germany in October [2012]. One stored respiratory sample taken at the time of admission, yielded clear, albeit very low quantities of NCoV RNA in the range of 66.5 to 100 copies per mL [10]. Attempts to isolate virus from this sample were unsuccessful. Even though the sample had been stored for prolonged time under less-than-optimal conditions, these combined RT-PCR and cell culture data suggested absent or very low infectiousness at the time of admission. Negative RT-PCR 4 weeks later, just after discharge from hospital, suggested the patient had cleared the virus, and no further respiratory precautions were necessary upon admission to the rehabilitation centre.
Nevertheless, anxiety and lack of any other epidemiological data made it necessary to gauge rapidly the significance of some cases of ARI experienced in HCW who had been in contact with the patient. Our data yielded no direct correlation of ARI rates with time of exposure. In particular, those contacts considered at highest risk had no more ARI than other contacts who also had their first contact with the patient during the third or fourth illness week.
In the context of a retrospective contact investigation, our 2-staged serological approach proved effective in ruling out any NCoV infections among contacts including those who developed acute respiratory disease. Preliminary screening using a generic serological test provides a reliable result for negative samples. Hereafter only positive or indeterminate results need to be further scrutinised using the described methods.
During 2 interviews that the patient kindly agreed to, we explored a wide spectrum of factors that he might have been exposed to. Even though NCoV is genetically similar to bat coronaviruses [1,13,14], other animals may serve as (intermediate) host as well. While our patient denied contact to bats, he remembered ill goats among the animals on his farm. Albarrak et al. reported that the first Saudi case was exposed to farm animals, but the 1st Qatari patient and the 2nd Saudi patient were not [15]. Although our patient reported no direct contact with his animals, one animal caretaker working for him was ill with cough and might have been an intermediate link in the chain of infection.
Coronaviruses do infect ruminants such as goats [16] and thus goats could be considered as a possible source of origin for the novel virus, particularly in the geographical and cultural context of our patient. Recent experimental studies have found that NCoV can infect and replicate in cells of various species including humans, swine, monkeys and bats, suggesting a more promiscuous host specificity compared to other human coronaviruses such as SARS CoV [17]. Susceptibility of goat cells was not tested, but it cannot be excluded that NCoV might infect this species as well.
Especially hospitals with ICU, specialist lung hospitals and similar facilities should consider NCoV in patients with severe respiratory disease of unknown aetiology. These patients should be tested for the novel virus as well as pathogens causing illnesses that need to be considered for differential diagnosis in severe lung disease. Full personal protective equipment such as recommended for handling patients with SARS, including N95 masks independent of the procedure performed, should be used by HCW in such cases, and responsible public health agencies should be informed timely. In general, it is prudent that HCW in contact with any patient with a severe respiratory illness of unknown origin apply droplet precautions. Should patients with suspected NCoV infections be transferred for special treatment it is important to fully inform the receiving hospital. Public health management recommendations should be further informed through future research that include the route, amount and duration of virus shedding. In addition, more information is needed on the ability of the virus to transmit from person to person.
Our investigation has some important limitations. We have not obtained a questionnaire and blood from all contacts of this patient. Nevertheless, response rate was high and information on contacts with the highest risk for infection was complete. Available information on the interval between exposure and venipuncture could only be approximated because contacts were exposed over more than one day. In our study we used the day of 1st contact because the patient was likely most infectious at this point in time. Theoretically, seroconversion may have occurred in some after contacts had provided blood. However, the need to rapidly evaluate the situation urged us to commence the contact investigation immediately. A further limitation is that the patient's negative result of virus isolation could have been due to the long storage time of the sample - in contrast to our favoured hypothesis of low RNA concentration.
In spite of this, we believe that it is fair to conclude the patient's infectiousness on illness day 20 was absent or very low. Our contact investigation has found no evidence of infection among hospital or out-of-hospital contacts. Our 2-staged approach to serological screening where a 1st-line testing is done by full-virus IFA and supplemented by confirmatory recombinant IFA and SNT should provide a template for similar investigations in the future. Finally, if patients suspected to be infected with NCoV are to be transferred for specialised treatment, receiving hospitals need to be informed so that appropriate infection control measures can be implemented.
References [available at above given URL].
[Reported by: U Buchholz 1,2, M A Müller 3,2, A Nitsche 1,2, A Sanewski 4,2, N Wevering 5, T Bauer-Balci 6, F Bonin 5, C Drosten 3, B Schweiger 1, T Wolff 1, D Muth 3, B Meyer 3, S Buda 1, G Krause 1, L Schaade 1, W Haas 1
1. Robert Koch Institute, Berlin, Germany
2. These authors contributed equally to this work
3. University Bonn, Department of Virology, Bonn, Germany
4. County health department of Essen, Essen, Germany
5. Ruhrland hospital, Essen, Germany
6. County health department Oberbergischer Kreis, Gummersbach, Germany]
--
Communicated by:
ProMED-mail
<promed@promedmail.org>
[Given the cluster in the UK currently under investigation, the above study provides a framework for addressing some of the questions re: contacts and illness, albeit the case under study in this report had 1st contact with the hospital staff in Germany on day 19 of illness. It would be interesting to conduct a similar study among health care personnel caring for this patient in Qatar, with contact exposure in the hospital in Qatar on day 8 of illness as well as family and friends of the patient who may have had contact with him during the 1st week of his illness. Laboratory testing of the animal caretaker on this case's farm might also be helpful as well as studies on the animals on the farm.
So many questions remain. We eagerly await results of additional studies conducted in the field in Saudi Arabia and Qatar. - Mod.MPP]
[
A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/r/1HAJ, http://healthmap.org/r/1lNY.]
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A ProMED-mail post
http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases
http://www.isid.org
In this report:
[1] Saudi Arabia, UK - WHO update
[2] UK - 4th case in cluster suspected
[3] UK - CIDRAP report
[4] Case investigation, Germany, 2nd Qatari case - Eurosurveillance
******
[1] Saudi Arabia, UK - WHO update
Date: Thu 21 Feb 2013
Source: WHO GAR [Global Alert and Response] [edited]
http://www.who.int/csr/don/2013_02_21/en/index.html
Novel coronavirus infection - update -- 21 Feb 2013
-----------------
The Ministry of Health in Saudi Arabia has informed WHO of another confirmed case of infection with the novel coronavirus (NCoV).
The patient was hospitalized on [29 Jan 2013] and died on [10 Feb 2013]. The case was laboratory-confirmed on [18 Feb 2013]. Further investigation into this case is ongoing.
In the United Kingdom, the Health Protection Agency continues to investigate the family cluster where 3 members of the family tested positive for NCoV infection. One member of this family, who had an underlying health condition, has died.
To date, WHO has been informed of a total of 13 confirmed cases of human infection with NCoV, including 7 deaths.
Based on the current situation and available information, WHO encourages all Member States (MS) to continue their surveillance for severe acute respiratory infections (SARI) and to carefully review any unusual patterns. Testing for the NCoV should be considered in patients with unexplained pneumonias, or in patients with unexplained, severe, progressive or complicated respiratory illness not responding to treatment, particularly in persons traveling from or resident in areas of the world known to be affected.
Any clusters of SARI or SARI in healthcare workers should be thoroughly investigated, regardless of where in the world they occur.
All MS are reminded to promptly assess and notify WHO of any new case or clusters of cases with NCoV infection.
WHO does not advise special screening at points of entry with regard to this event nor does it recommend that any travel or trade restrictions be applied.
WHO continues to closely monitor the situation.
--
Communicated by:
ProMED-mail Rapporteur Marianne Hopp
[The above report from WHO confirms another fatal case of severe acute respiratory illness (SARI) attributable to infection with the novel coronavirus (nCoV) in a Saudi Arabian resident, bringing the total number of confirmed cases to 13 including 7 fatalities. The breakdown of cases (and deaths) by country of report is:
Saudi Arabia: 6 (4 deaths)
Jordan: 2 (2 deaths)
UK: 4 (1 patient from Qatar - under treatment, 3 patients from UK (one with history of travel to Saudi Arabia and Pakistan prior to illness); 1 under treatment, 1 recovered, 1 death)
Germany: 1 (patient from Qatar - discharged).
For the interactive HealthMap/ProMED map of the Middle East, see http://healthmap.org/r/1HAJ.
For the interactive HealthMap/ProMED map of the UK, see http://healthmap.org/r/1lNY. - Mod.MPP]
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[2] UK - 4th case in cluster suspected
Date: Thu 21 Feb 2013
Source: The Canadian Press via The Province [edited]
http://www.theprovince.com/health/There ... story.html
There may have been a 4th case in UK coronavirus family cluster: WHO
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British authorities announced Tuesday [19 Feb 2013] that another person has died from infection with the new coronavirus as European scientists revealed the new virus easily infects the cells of the airways of the human lung.
The current cluster of novel coronavirus cases in Britain may have included another infection, a World Health Organization official says.
To date, 3 members of an extended family have tested positive for the new virus, which is a cousin of the SARS coronavirus. One of the 3 died earlier this week [see prior ProMED-mail post Novel coronavirus - Eastern Mediterranean (06): UK, fatality
20130220.1552014].
But officials investigating how the virus moved from one member of the family to the next suspect another relative may have contracted the virus and may even have spread it to the 3rd confirmed case in the cluster. This 4th family member had a respiratory illness but was not tested until after she recovered, at which point the test came back negative.
Dr. Anthony Mounts, the WHO's point person for the new coronavirus outbreak, says the U.K. cluster adds slightly to the WHO's concern over the virus, but in the main serves to confirm some things the organization has already strongly suspected.
Those are: In some circumstances, person-to-person spread can occur, though so far, it appears those chains of infection has been short. And while the 1st few cases spotted all involved severe illness, some infections can produce mild symptoms only.
The WHO revised its new coronavirus case definition this week to remind doctors not to automatically rule out people with mild symptoms when they look for possible cases. And Mounts says the organization's recommendations on how to do surveillance for cases will also be updated.
Mild infections are a mixed blessing. Obviously everyone would hope the virus didn't always cause severe disease. But people suffering only mild infections may be more likely to spread the virus, if the virus transmits easily.
That's because people sick enough to be in hospital ICUs mainly encounter health-care workers protected by masks, but people with mild respiratory infections generally go about their daily life. And mild infections are much harder to spot, especially when they occur during cold and flu season.
The 3rd confirmed case in this cluster had only mild symptoms and has since recovered. "The fact that she had such a mild illness really does raise our concerns about what we might be missing," Mounts admits.
Others share the WHO's concern. In fact, several of the researchers who were key players in the response to the 2002-2003 SARS epidemic admit the patterns they are seeing bring back memories.
"It is certainly beginning to look concerning, given the obvious fact that there can be onward transmission," says Malik Peiris, chair of the department of microbiology at the University of Hong Kong.
"It is somewhat reminiscent of the emergence of SARS in 2002."
Ron Fouchier, a virologist at Erasmus Medical Centre in Rotterdam, the Netherlands, also sees those similarities.
And Fouchier is concerned about how many infections may be going unnoticed, untested or unreported. He notes that several of the 12 confirmed cases were diagnosed in European hospitals.
In addition to the current family cluster in Britain, one case from Qatar was diagnosed in Britain in September [2012] [see prior ProMED-mail post: Novel coronavirus - Saudi Arabia (03): UK HPA, WHO, Qatar 20120923.1305982] and a 2nd from Qatar was diagnosed in Germany in October [2012] [see prior ProMED-mail post: Novel coronavirus - Saudi Arabia (18): WHO, new cases, cluster 20121123.1421664]. Both men got sick in Qatar but left the country for treatment - a practice that is not uncommon for wealthy residents of Middle Eastern countries.
"The fact that we are finding these cases in Europe and not anywhere else, that has to raise suspicion," Fouchier says. "What we're seeing in Europe is just the tip of the iceberg and we really have no clue how big the iceberg is."
Saudi Arabia has reported 5 cases, the most recent in late November [2012] [see above WHO report in section [1] -- there are now 6 confirmed cases in Saudi Arabia, most recent date of onset 29 Jan 2013 - Mod.MPP]. Qatar has had the 2 confirmed cases. And Jordan has reported 2 cases, but the confirmations came months after the 2 individuals died [see prior ProMED-mail posts below].
Samples taken during an unexplained respiratory outbreak at a Jordanian hospital last April [2012] were tested for the virus late last year [see prior ProMED-mail post from 30 Nov 2012: Novel coronavirus - Eastern Mediterranean: WHO, Jordan, conf., RFI 20121130.1432498 - Mod.MPP]. At the time of the outbreak, the existence of the virus was not yet known.
Fouchier feels not enough is being done to find cases or to track down the source of the virus.
The virus's genetic sequence indicates it likely comes from bats, but it still isn't clear how people are becoming infected. "We know that humans don't come into contact with bats a whole lot," Fouchier says.
He and other experts suspect there may be some intermediate host -- a domestic animal, perhaps -- that is being infected and is passing on the virus to people.
Mounts says the WHO is trying to get countries to look harder for the virus. "We're concerned and really watching it very closely and trying to push people to do more investigation."
He also says the organization is putting together networks of experts to help it with the coronavirus situation -- an approach the WHO used with much success during the SARS outbreak.
A laboratory network and a network of expert epidemiologists -- sometimes called disease detectives -- are being set up. As well, a group of clinical experts who have advised the WHO over the past decade on possible treatments for H5N1 -- bird flu -- and during the 2009 H1N1 pandemic is being reactivated to help with this situation, Mounts says.
[Byline: Helen Branswell]
--
Communicated by:
ProMED-mail Rapporteur Mary Marshall
[The information of a 4th family member with a history of a mild respiratory illness but negative on laboratory testing for infection with the novel coronavirus (nCoV) is a recurrent theme thus far in the history of laboratory confirmation of cases in suspected clusters -- mild respiratory illnesses have been observed in contacts of confirmed cases, but on laboratory testing (often retrospective testing) these individuals are found to be negative by current tests available. Of note was that the 3rd confirmed case in this cluster in the UK, (discussed in further detail in the CIDRAP report below), did have a milder illness and was confirmed through laboratory testing, the 1st milder presentation of illness that has been laboratory confirmed.
In an earlier post, this moderator raised the possibility that we may well be seeing a prospective evolution of an outbreak similar to what we saw with SARS - early sporadic cases, followed by smaller clusters and then larger clusters and more "widespread" dissemination of the organism. While one hopes that there will be less of a nosocomial transmission of this organism in contrast with SARS, reading some of the details of the cases reported in earlier reports when patients were transferred from other countries, and of other suspected clusters, the absence of strict adherence to respiratory isolation in the early presentations of these cases may well be associated with nosocomial transmission.
There clearly are many unknowns about the epidemiology of this organism. Information on results of studies on the possible prevalence nCoV infection of animals in Saudi Arabia and Qatar are still pending. As mentioned above and in prior reports, genetic studies on this nCoV place it related to CoVs found in bats, but how did the jump from bats to humans occur? Is there an intermediate host animal? - Mod.MPP]
******
[3] UK - CIDRAP report, details on 3rd case
Date: Tue 19 Feb 2013
Source: Center for Infectious Disease Research & Policy (CIDRAP) [edited]
http://www.cidrap.umn.edu/cidrap/conten ... onabr.html
British man dies from novel coronavirus infection
-----------------------------------------
One patient in a British family cluster of novel coronavirus (NCoV) infections, a 38-year-old man with an underlying medical condition, has died, and fresh details about a recently reported mild case have sparked new questions about how the virus is spreading and how big a threat it poses.
The man died [17 Feb 2013] in the critical care unit at Queen Elizabeth Hospital Birmingham, where he had been undergoing treatment for a chronic health condition, the hospital said in a statement today. He was immunocompromised, and health officials believe he was exposed to NCoV by sustained close contact with a sick relative, a 60-year-old man who was hospitalized in Manchester shortly after traveling in Pakistan and Saudi Arabia.
He received extracorporeal membrane oxygenation (ECMO), a heart-lung-bypass procedure designed to allow disease-damaged lungs to heal. His death raises the number of fatalities from the new virus to 6 of the 12 cases reported so far.
Mild infection raises transmission questions
The UK Health Protection Agency (HPA) today released new information about the 3rd patient in the family cluster, who has recovered from a milder version of the illnesses after more limited contact: visiting the older man in the hospital on 3 occasions. The 3rd patient had no contact with the man who died and, according to a new risk assessment from the European Centre for Disease Control and Prevention (ECDC), is a 30-year-old woman.
Neither the woman nor the patient who died had a recent travel history, and HPA and ECDC officials have said both cases provide further evidence of person-to-person NCoV spread, but so far there is no sign of sustained transmission.
The woman's limited contact with the man who died raises the possibility of an intermediary case within the extended family, the HPA said. The ECDC also noted the limited time the woman spent with the older patient, which it said might point to an intermediary case or fomite spread. "However, the investigation and intensive case finding around the 3 cases remain ongoing and the results cannot be prejudged," the agency said.
Public health authorities are tracing the contacts of the family members, including people who sat within 2 rows of the older man on a flight from Saudi Arabia to London, during which he first felt ill. Follow-up is also underway on health workers, patients, family, and friends who were in contact with the patients in hospital settings.
Health officials reconsider threat assessments
John Watson, MB BS, MSC, the HPA's head of respiratory diseases, said in the statement that the routes of NCoV transmission haven't been fully determined, but the recent UK cases show strong evidence of human-to-human spread in some circumstances.
"The 3 recent cases in the UK represent an important opportunity to obtain more information about the characteristics of this infection in humans and risk factors for its acquisition, particularly in the light of the 1st ever recorded instance of apparently lower severity of illness in one of the cases," he said.
The risk of infection in contacts is still considered low, and the threat to the general UK population remains very low, the HPA said.
Meanwhile, the ECDC said recent developments with the 3 UK cases increase the threat to the European Union, because the infection came to Europe on a commercial flight and resulted in 2 more illnesses, though the cluster is isolated to one family.
Emergence of a mild secondary case, the 1st of its kind, is worrisome, because other mild illnesses that are missed during NCoV detection efforts could spread the infection, the ECDC said. More work is needed to flesh out the illness spectrum, such as whether it causes severe disease of uncommon zoonotic origin, as well as mild or even asymptomatic infections, it said in the risk assessment.
Also, the emergence of the mild illness and the possibility that surveillance will find more of them raises questions about whether new case-finding strategies are needed, the ECDC said, noting that it is reviewing the issue with its member countries and global health partners.
Though it's reassuring that health officials have found no expanding case clusters, "the fact remains that there is a lot more that we do not know than we know about this virus," the ECDC said, adding that discussions are underway to provide guidance on research priorities.
Study finds NCoV easily infects lung lining
In a related development today, a European research group reported that the NCoV easily penetrates human airway passages and evades the immune system like other coronaviruses, such as one responsible for the common cold. The findings were published today in mBio, the online journal of the American Society for Microbiology (ASM).
The team used cultured bronchial cells that were engineered to mimic the epithelial lining to explore how well the new virus could infect and multiply. Their findings suggest that the airway cells are highly susceptible to NCoV infection, and the virus multiplied faster than the SARS virus, another member of the coronavirus family.
Volker Thiel, a study coauthor with the Institute of Immunobiology at Kantonal Hospital in St. Gallen, Switzerland, said today in an ASM press release that though data suggest the virus may have jumped from animals to humans very recently, it is just as well-adapted to infecting the human respiratory tract as other more familiar coronaviruses, which was surprising.
The investigators suspected that the NCoV uses the same strategy as other common coronaviruses to evade the immune system, and they tested the notion by pretreating epithelial cells with lambda-type interferon to boost their immune response.
They reported that the treatment significantly reduced the number of infected cells, which is encouraging, given that interferons are promising for treating SARS and hepatitis C.
In another lab-related development, the World Health Organization (WHO) today issued updated interim recommendations for managing NCoV lab risks. The document includes epidemiological developments that have occurred since the last update on [31 Oct 2012].
The guidance urges labs conducting routine tests to follow biosafety level 2 (BSL 2) practices, that labs working with viral isolates from clinical samples use additional containment practices, including those recommended for BSL 3, and that work with animals infected with NCoV take place in an animal BSL 3 facility [BSL 3 labs are used with biologic agents the may cause serious or potentially lethal disease through inhalation of the agent whereas BLS 2 labs are those working with biologic agents that pose moderate hazards to personnel and the environment. For background information on the 4 laboratory biosafety levels, see http://www.cdc.gov/biosafety/publicatio ... ect_iv.pdf. - Mod.MPP]
[Byline: Lisa Schnirring]
--
Communicated by:
ProMED-mail
<promed@promedmail.org>
[The above report summarizes the information available on the descriptive epidemiology of the cases in the cluster, and raises the possibility of yet another case in the cluster. It also highlights the possible additional contacts of the index case who was apparently ill when flying back to the UK after visiting Saudi Arabia and Pakistan. In the HPA report on 19 Feb 2013, there was mention of followup on 100 known contacts of this cluster, presumably including individuals who were seated near this case while travelling to the UK from Saudi Arabia. - Mod.MPP]
******
[4] Case investigation, Germany, 2nd Qatari case - Eurosurveillance
Date: Thu 21 Feb 2013
Source: Eurosurveillance, Volume 18, Issue 8, 21 February 2013 [edited]
http://www.eurosurveillance.org/ViewArt ... leId=20406
Contact investigation of a case of human novel coronavirus infection treated in a German hospital, October-November 2012
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On [24 Oct 2012], a patient with acute respiratory distress syndrome of unknown origin and symptom onset on [5 Oct 2012] was transferred from Qatar to a specialist lung clinic in Germany. Late diagnosis on [20 Nov 2012] of an infection with the novel Coronavirus (NCoV) resulted in potential exposure of a considerable number of healthcare workers. Using a questionnaire we asked 123 identified contacts (120 hospital and 3 out-of-hospital contacts) about exposure to the patient. 85 contacts provided blood for a serological test using a 2-stage approach with an initial immunofluorescence assay as screening test, followed by recombinant immunofluorescence assays and a NCoV-specific serum neutralisation test. Of 123 identified contacts 9 had performed aerosol-generating procedures within the 3rd or 4th week of illness, using personal protective equipment rarely or never, and 2 of these developed acute respiratory illness. Serology was negative for all 9. Further 76 hospital contacts also tested negative, including 2 sera initially reactive in the screening test. The contact investigation ruled out transmission to contacts after illness day 20. Our 2-stage approach for serological testing may be used as a template for similar situations.
Introduction
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A novel human coronavirus (NCoV) has recently emerged in the Arabian Peninsula. The first 2 reported cases infected by the novel agent, then provisionally termed hCoV-EMC, occurred in June and September 2012, respectively [1-3]. As of [18 Feb 2013], a total of 12 cases have been confirmed by WHO [4], including 5 deaths. Among 5 cases reported from the Kingdom of Saudi Arabia, 3 were part of a family cluster. Two further cases were linked to probable exposure in Qatar, and 2 cases were confirmed retrospectively, by diagnostic of respiratory specimens, from Jordan with disease onset in April 2012. The latter were part of a cluster of 11 patients with acute respiratory symptoms linked to a hospital [5]. The most recent 3 cases identified constitute another cluster that occurred in the United Kingdom (UK) in January to February 2013 [4]. The index case in this cluster is a UK citizen with travel history to Saudi-Arabia and Pakistan before symptom onset [5]. Two of his family members who had not travelled outside the UK and became ill were most likely infected through person-to-person transmission. While one of them had an underlying disease and died, the other presented with milder, influenza-like illness symptoms only.
Because of the long period, 10 months, over which the cases occurred, the source and transmission patterns of the virus remain elusive. Hypotheses include a predominance of zoonotic acquisitions with little potential for human-to-human transmission [5], widespread and unnoticed occurrence of clinically mild infections, and finally the possibility of an early-stage epidemic caused by a highly pathogenic novel human virus.
Because of the potential of human-to-human transmission in the hospital outbreak in Jordan and the family clusters, as well as the observed severity of disease, current recommendations regarding protective measures rely on experiences with severe acute respiratory syndrome (SARS) in 2003 [6]. The 1st of the 2 Qatari patients was treated in the UK where, under strict isolation measures, no secondary cases occurred. Investigations by polymerase chain reaction (PCR) of 10 healthcare workers (HCW) who had cared for the patient and subsequently developed mild respiratory disease yielded no evidence of infection [7]. However, to date, published investigations of individuals with proven exposure to NCoV have not presented a strategy how to identify retrospectively infections in a large group of (contact) persons through serological testing.
On [22 Nov 2012], the Robert Koch Institute in Berlin, Germany, was informed according to the International Health Regulations [8] about a case of NCoV infection in a Quatari patient in his 40s, treated in Germany (Figure). After an acute onset of symptoms on [5 Oct 2012], he had been admitted to a hospital in Doha, Qatar, on [13 Oct 2012], where he developed respiratory failure requiring ventilation, and was reported to have had temporary renal impairment. On [24 Oct 2012], he was transferred to a specialist lung hospital in Essen, Germany. A respiratory sample had been taken in Qatar on [17 Oct 2012]. After some delay due to difficulties with the shipment of specimens, the sample tested positive for NCoV in a laboratory in the UK. The result was consequently communicated by the UK Health Protection Agency to the World Health Organization (WHO) on [21 Nov 2012]. Until that date the hospital in Essen had not considered NCoV in the differential diagnoses for the patient. Only routine personal protection of HCW and no specific measures of respiratory protection had been followed during the whole course of treatment in the intensive care unit (ICU). After weeks of mechanical ventilation in ICU, the patient was discharged on [21 Nov 2012].
[Figure: Timeline of disease of novel coronavirus case and possible exposure of healthcare workers, Germany, October-November 2012, available at above given URL]
A lag time of 4 weeks between patient transfer and laboratory confirmation of the NCoV infection resulted in potential exposure of a considerable number of HCW in Germany. Here we report on an interview with the patient asking for potential sources of infection, the investigation of individuals exposed to the patient, virological investigation of respiratory samples from the patient as well as an approach used to test retrospectively a large number of contacts.
Methods [see above given URL for details of methods]
Results
------
Patient interview
The patient reported to live in Doha, Qatar. He used to be a heavy smoker (2 to 3 packs of cigarettes per day), but denied smoking waterpipe or chewing qat [also known as khat, qat, gat or Arabian tea (Catha edulis), is a flowering plant native to the Horn of Africa and the Arabian Peninsula. It contains cathinone, an amphetamine-like stimulant, which is known produce excitement, decreased appetite and euphoria. see http://en.wikipedia.org/wiki/Khat. - Mod.MPP] Disease onset was rapid, with initial symptoms including fever (40 C), cough, runny nose, and shortness of breath. Subjective weakness was pronounced. After the 1st 2 days of illness he improved a little but deteriorated again, and was finally admitted to hospital on day 8 of illness because of increasing dyspnoea. He reported no subjective symptoms of renal impairment such as foamy urine, reduced urine output, or back pain. He had not travelled and had no known contact with any other reported cases of NCoV infection. The patient owned a camel and goat farm and reported a large number of casual contacts (approx. 50 persons per day) on a regular basis. He remembered that before his disease onset some goats were ill and had fever. He did not have direct contact with the goats or any other animals especially falcons or bats, but said he had eaten goat meat. He also reported to have had contact with one of his animal caretakers who was ill with severe cough and was hospitalised. Other than the animal caretaker, he did not remember persons with severe respiratory illnesses in his wider or closer social environment.
Patient samples
Virus detection in the initial sample from illness day 20 and preliminary serological investigations have been described by Corman et al. [10]. Isolation of virus in cell culture failed. Serological testing yielded an IgM titre against NCoV of 1:1000 and an IgG titre of 1:10 000 at day 20 (week 3) of illness. At week 8 of illness the IgG titre was still at 1:10 000 while the IgM titre had already decreased to 1:100. SNT titres against NCoV were 1:640 at week 3 and 1:640 at week 8 of illness. The pharyngeal wash sample taken on [23 Nov 2012] (week 8 of illness) tested negative by real-time RT-PCR.
Contact investigation
We identified 120 hospital and 3 out-of-hospital contacts, including the interpreter of the patient. Protective measures were largely limited to HCW wearing gloves and gowns when providing intimate care and use of surgical face masks during suctioning. From [31 Oct 2012 until 4 Nov 2012] (illness weeks 5 and 6), the patient was isolated using barrier nursing due to a concurrent Pseudomonas aeruginosa infection. This included use of surgical masks only. Among the 120 hospital contacts the largest group were nurses (n=59; 49 percent), followed by physicians (n=26; 22 percent) and laboratory technicians (n=15; 13 percent) [see Table 1: Profession, type of contact, occurrence of acute respiratory illness and serological results in contacts of case of novel coronavirus infection, Germany October-November 2012 at above given URL]. Median time from 1st contact to venipuncture was 39 days (range: 13-50 days).
85 (69 percent) of all respondents reported contact at a distance of less than or equal to 2 m, 14 (11 percent) of more than 2 m, and 24 (20 percent) of unknown distance to the patient. Frequency of ARI by week of 1st contact differed significantly among the groups (Table 1). However, there was no trend in the ARI proportion over time: 8 of 33 contacts with 1st exposure during illness weeks 3 or 4 experienced ARI within 10 days of last contact; 5 of 9 contacts with 1st exposure during the patient's 5th week of illness; and none of 14 with 1st contact during week 6 of illness developed ARI.
Among 81 contacts reporting exposure within 2 m, 21 had ARI compared to none of 14 with contact of more than 2 m (p value; 0.04) (Table 1). Among those with 1st exposure in week 3 or 4 of illness of the patient, the proportion of contacts with ARI was not significantly different between those considered to be at high risk and the remaining contacts (p value, 0.87) (Table 1). 13 HCW had contact to the patient in weeks 3 or 4 of illness, had contact within 2 m to the patient and had worn surgical face masks rarely or never. Among these, 9 were high-risk contacts, including one nurse who assisted in a bronchoscopy on [25 Oct 2012]. All 9 provided a blood sample. The median time after last contact with the patient for these 9 HCW was 32 days (range: 13-46 days). No sample was reactive by IFA.
Of the remaining 76 blood samples, one serum showed reactivity for IgM even at dilutions up to 1:100. This titre could be resolved as a cross-reacting recent infection with hCoV-NL63 by IFA using recombinant S and N proteins from major hCoVs [see Table 2: Cross-reactivity test on contact persons and of case of novel coronavirus infection (at week 3 and week 8 of illness) with recombinant spike and nucleocapsid indirect fluorescence antibody testa, Germany, October-November 2012
at above given URL], as well as absence of NCoV-specific neutralising antibodies. Another serum showed indeterminate IgG-reactivity in a 1:10 dilution. Specific anti-NCoV antibodies were ruled out by recombinant IFA, indicating earlier infection with hCoV-OC43 and hCoV-NL63, as well as absence of any significant titre in SNT (Table 2).
Discussion
---------
Here we describe a case and contact investigation of a laboratory-confirmed patient with NCoV infection for whom the suspicion of this possible aetiology had not been discussed with the treating hospital upon admission of the patient. The patient still tested PCR-positive late in his 3rd week of illness. Despite this we concluded from the laboratory findings that his infectiousness was then absent or very low. While at that time no consistent dedicated personal protective measures had been applied by HCW caring for the patient, our public health investigation did not show infection in any of the 85 serologically tested contact persons, mainly HCW. The conducted serological 2-stage approach was an effective method of screening a large number of contact persons for infection.
For initial risk assessment, after the information in November [2012] about the cause of the patient's disease, it was important to know if he had been potentially infectious at the time of arrival at the hospital in Germany in October [2012]. One stored respiratory sample taken at the time of admission, yielded clear, albeit very low quantities of NCoV RNA in the range of 66.5 to 100 copies per mL [10]. Attempts to isolate virus from this sample were unsuccessful. Even though the sample had been stored for prolonged time under less-than-optimal conditions, these combined RT-PCR and cell culture data suggested absent or very low infectiousness at the time of admission. Negative RT-PCR 4 weeks later, just after discharge from hospital, suggested the patient had cleared the virus, and no further respiratory precautions were necessary upon admission to the rehabilitation centre.
Nevertheless, anxiety and lack of any other epidemiological data made it necessary to gauge rapidly the significance of some cases of ARI experienced in HCW who had been in contact with the patient. Our data yielded no direct correlation of ARI rates with time of exposure. In particular, those contacts considered at highest risk had no more ARI than other contacts who also had their first contact with the patient during the third or fourth illness week.
In the context of a retrospective contact investigation, our 2-staged serological approach proved effective in ruling out any NCoV infections among contacts including those who developed acute respiratory disease. Preliminary screening using a generic serological test provides a reliable result for negative samples. Hereafter only positive or indeterminate results need to be further scrutinised using the described methods.
During 2 interviews that the patient kindly agreed to, we explored a wide spectrum of factors that he might have been exposed to. Even though NCoV is genetically similar to bat coronaviruses [1,13,14], other animals may serve as (intermediate) host as well. While our patient denied contact to bats, he remembered ill goats among the animals on his farm. Albarrak et al. reported that the first Saudi case was exposed to farm animals, but the 1st Qatari patient and the 2nd Saudi patient were not [15]. Although our patient reported no direct contact with his animals, one animal caretaker working for him was ill with cough and might have been an intermediate link in the chain of infection.
Coronaviruses do infect ruminants such as goats [16] and thus goats could be considered as a possible source of origin for the novel virus, particularly in the geographical and cultural context of our patient. Recent experimental studies have found that NCoV can infect and replicate in cells of various species including humans, swine, monkeys and bats, suggesting a more promiscuous host specificity compared to other human coronaviruses such as SARS CoV [17]. Susceptibility of goat cells was not tested, but it cannot be excluded that NCoV might infect this species as well.
Especially hospitals with ICU, specialist lung hospitals and similar facilities should consider NCoV in patients with severe respiratory disease of unknown aetiology. These patients should be tested for the novel virus as well as pathogens causing illnesses that need to be considered for differential diagnosis in severe lung disease. Full personal protective equipment such as recommended for handling patients with SARS, including N95 masks independent of the procedure performed, should be used by HCW in such cases, and responsible public health agencies should be informed timely. In general, it is prudent that HCW in contact with any patient with a severe respiratory illness of unknown origin apply droplet precautions. Should patients with suspected NCoV infections be transferred for special treatment it is important to fully inform the receiving hospital. Public health management recommendations should be further informed through future research that include the route, amount and duration of virus shedding. In addition, more information is needed on the ability of the virus to transmit from person to person.
Our investigation has some important limitations. We have not obtained a questionnaire and blood from all contacts of this patient. Nevertheless, response rate was high and information on contacts with the highest risk for infection was complete. Available information on the interval between exposure and venipuncture could only be approximated because contacts were exposed over more than one day. In our study we used the day of 1st contact because the patient was likely most infectious at this point in time. Theoretically, seroconversion may have occurred in some after contacts had provided blood. However, the need to rapidly evaluate the situation urged us to commence the contact investigation immediately. A further limitation is that the patient's negative result of virus isolation could have been due to the long storage time of the sample - in contrast to our favoured hypothesis of low RNA concentration.
In spite of this, we believe that it is fair to conclude the patient's infectiousness on illness day 20 was absent or very low. Our contact investigation has found no evidence of infection among hospital or out-of-hospital contacts. Our 2-staged approach to serological screening where a 1st-line testing is done by full-virus IFA and supplemented by confirmatory recombinant IFA and SNT should provide a template for similar investigations in the future. Finally, if patients suspected to be infected with NCoV are to be transferred for specialised treatment, receiving hospitals need to be informed so that appropriate infection control measures can be implemented.
References [available at above given URL].
[Reported by: U Buchholz 1,2, M A Müller 3,2, A Nitsche 1,2, A Sanewski 4,2, N Wevering 5, T Bauer-Balci 6, F Bonin 5, C Drosten 3, B Schweiger 1, T Wolff 1, D Muth 3, B Meyer 3, S Buda 1, G Krause 1, L Schaade 1, W Haas 1
1. Robert Koch Institute, Berlin, Germany
2. These authors contributed equally to this work
3. University Bonn, Department of Virology, Bonn, Germany
4. County health department of Essen, Essen, Germany
5. Ruhrland hospital, Essen, Germany
6. County health department Oberbergischer Kreis, Gummersbach, Germany]
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[Given the cluster in the UK currently under investigation, the above study provides a framework for addressing some of the questions re: contacts and illness, albeit the case under study in this report had 1st contact with the hospital staff in Germany on day 19 of illness. It would be interesting to conduct a similar study among health care personnel caring for this patient in Qatar, with contact exposure in the hospital in Qatar on day 8 of illness as well as family and friends of the patient who may have had contact with him during the 1st week of his illness. Laboratory testing of the animal caretaker on this case's farm might also be helpful as well as studies on the animals on the farm.
So many questions remain. We eagerly await results of additional studies conducted in the field in Saudi Arabia and Qatar. - Mod.MPP]
[
A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/r/1HAJ, http://healthmap.org/r/1lNY.]
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Neuartiger Corona-Virus - UK
NOVEL CORONAVIRUS - EASTERN MEDITERRANEAN (08): UNITED KINGDOM, 4TH CASE, NOT
*****************************************************************************
A ProMED-mail post
http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases
http://www.isid.org
Date: Fri 22 Feb 2013
From: Nick Phin <nick.phin@hpa.org.uk>
Subject: Correction to ProMED-mail statement [in Novel coronavirus - East. Med. (07): Saudi Arabia, UK, Germany 20130221.155410
Re: UK - 4th case in cluster suspected
Date: Thu 21 Feb 2013
Source: The Canadian Press via The Province [edited]
http://www.theprovince.com/health/There ... story.html
There may have been a 4th case in UK coronavirus family cluster: WHO
In relation to the above post, we would like to confirm that the HPA is not currently investigating any 4th possible case associated with the UK cluster of novel coronavirus. The latest clinical update from the HPA was published on Tuesday [19 Feb 2013] http://www.hpa.org.uk/hpr/infections/respiratory.htm and the whole genome sequence of the 2nd UK case of coronavirus was published on Thursday [21 Feb 2013] http://www.hpa.org.uk/Topics/Infectious ... ronavirus/
--
Yours faithfully,
Professor Nick Phin
Consultant Epidemiologist
Preparedness and Response Section
Respiratory Diseases Department
Health Protection Agency
London, UK
<nick.phin@hpa.org.uk>
[ProMED-mail would like to thank Professor Nick Phin for this clarification as well as for providing URL links to the most recent information on this outbreak and viral genome sequence.
Of note, the interpretation of the sequencing of the whole genome of the novel coronavirus identified in the above cluster, referred to as England 2 CoV is stated at the above provided link: "Phylogenetic Analysis indicated that England 2 CoV clustered with England1 CoV and the virus identified in the Netherlands (EMC 2012, JX869059). The level of similarity within this cluster of novel coronaviruses was greater than 99.6 percent."
The HPA most recent report is included below:
"Novel coronavirus 2012 in the UK: situation at 19 Feb 2013
Since the 1st identification of a novel coronavirus in September 2012 [1], 4 confirmed cases had been identified in the United Kingdom (UK) by the Health Protection Agency (HPA) by [19 Feb 2013]: 2 imported cases and 2 indigenously acquired cases linked to the 2nd imported case.
"The 1st case of novel coronavirus identified in the UK was in a foreign national transferred to London for the treatment of a serious, unexplained respiratory illness in September 2012 [2]. Coronavirus testing was undertaken following the announcement that a new coronavirus had been discovered in a Saudi Arabian national with a similar illness. The patient was very unwell, requiring intensive care and extra corporeal membrane oxygenation (ECMO), and remains very unwell. Extensive follow up of all close contacts (household and health care) by the HPA identified a number of persons with mild respiratory illness in the 10 days following exposure but none of these contacts had novel coronavirus infection detected on respiratory sampling or serology [3].
"On [11 Feb 2013], the HPA published details of an adult UK resident (the index case), with confirmed novel coronavirus infection and influenza A infection, who had travelled to Pakistan and Saudi Arabia in the 10 days before illness onset. This individual had developed respiratory symptoms on [24 Jan 2013], prior to returning to the UK on [28 Jan 2013]. While staying with family at home in the UK, this individual's condition deteriorated and they were admitted to hospital in Birmingham, before being transferred to Manchester, where they remain in intensive care, with ECMO.
"On [6 Feb 2013], an adult household member of the case who had not recently travelled abroad -- but who had been in sustained close contact with the index case from their arrival in the UK until hospital admission -- became unwell with a febrile respiratory illness. This 3rd case, on admission to hospital in Birmingham, was confirmed to have novel coronavirus infection. Their condition worsened -- requiring intensive care and ECMO -- before the patient died on [17 Feb 2013]. This patient had an existing medical condition that may have made them more susceptible to a respiratory infection.
"On [5 Feb 2013], an adult member of the same extended family of the 2 confirmed cases -- who had not travelled abroad -- developed an influenza-like illness. The illness remained mild, not requiring hospital admission, and there has been a full recovery. A sputum sample from this case was later confirmed to contain novel coronavirus. This case had limited exposure to the index case on 3 occasions while the latter was in hospital, and had no contact with the 2nd case.
"Infection control measures around the 3 recent cases have followed UK national guidance [4] and contact tracing and follow-up is continuing for those persons who may have been in close contact with any of the 3 cases.
"Contacts in 3 main settings are being followed up:
- Aircraft: the aircraft passengers in the same row and the 2 rows in front and behind the case on a flight from Saudi Arabia to London when the 1st case had been unwell;
- Household: the family and friend household contacts of all 3 cases;
- Health care: the health care workers, patients and family and friends who were in contact with the cases in a health care setting.
- Follow-up of contacts of the 3 confirmed cases had not detected any further probable or confirmed secondary cases by [18 Feb 2013].
"The routes of transmission to humans of the novel coronavirus have not yet been fully determined, but the recent UK experience provides strong evidence of human-to-human transmission in at least some circumstances. The limited contact that one of the cases had with the index case, however, leaves open the possibility of an intermediary case within the extended family.
"The 3 recent cases in the UK represent an important opportunity to obtain more information about the characteristics of this infection in humans and risk factors for its acquisition, particularly in the light of the first ever recorded instance of apparently lower severity of illness in one of the cases, and the occurrence of dual infection in the index case.
References
1. Corman VM, et al. Detection of a novel human coronavirus by real-time reverse-transcription polymerase chain reaction. Euro Surveill. 2012 Sep 27; 17(39). pii: 20285. http://www.eurosurveillance.org/ViewArt ... leId=20285.
2. Bermingham A, et al. Severe respiratory illness caused by a novel coronavirus, in a patient transferred to the United Kingdom from the Middle East, September 2012. Euro Surveill. 2012 Oct 4; 17(40): 20290. http://www.eurosurveillance.org/ViewArt ... leId=20290.
3. Pebody RG, et al. The United Kingdom public health response to an imported laboratory confirmed case of a novel coronavirus in September 2012. Euro Surveill. 2012 Oct 4; 17(40): 20292. http://www.eurosurveillance.org/ViewArt ... leId=20292.
4. Health Protection Agency. Infection Control Advice - Novel coronavirus cases Version 1.3, HPA, 4 October 2012 http://www.hpa.org.uk/webc/HPAwebFile/H ... 7136232722.
For the interactive HealthMap/ProMED map of the UK, see http://healthmap.org/r/1lNY. - Mod.MPP]
*****************************************************************************
A ProMED-mail post
http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases
http://www.isid.org
Date: Fri 22 Feb 2013
From: Nick Phin <nick.phin@hpa.org.uk>
Subject: Correction to ProMED-mail statement [in Novel coronavirus - East. Med. (07): Saudi Arabia, UK, Germany 20130221.155410
Re: UK - 4th case in cluster suspected
Date: Thu 21 Feb 2013
Source: The Canadian Press via The Province [edited]
http://www.theprovince.com/health/There ... story.html
There may have been a 4th case in UK coronavirus family cluster: WHO
In relation to the above post, we would like to confirm that the HPA is not currently investigating any 4th possible case associated with the UK cluster of novel coronavirus. The latest clinical update from the HPA was published on Tuesday [19 Feb 2013] http://www.hpa.org.uk/hpr/infections/respiratory.htm and the whole genome sequence of the 2nd UK case of coronavirus was published on Thursday [21 Feb 2013] http://www.hpa.org.uk/Topics/Infectious ... ronavirus/
--
Yours faithfully,
Professor Nick Phin
Consultant Epidemiologist
Preparedness and Response Section
Respiratory Diseases Department
Health Protection Agency
London, UK
<nick.phin@hpa.org.uk>
[ProMED-mail would like to thank Professor Nick Phin for this clarification as well as for providing URL links to the most recent information on this outbreak and viral genome sequence.
Of note, the interpretation of the sequencing of the whole genome of the novel coronavirus identified in the above cluster, referred to as England 2 CoV is stated at the above provided link: "Phylogenetic Analysis indicated that England 2 CoV clustered with England1 CoV and the virus identified in the Netherlands (EMC 2012, JX869059). The level of similarity within this cluster of novel coronaviruses was greater than 99.6 percent."
The HPA most recent report is included below:
"Novel coronavirus 2012 in the UK: situation at 19 Feb 2013
Since the 1st identification of a novel coronavirus in September 2012 [1], 4 confirmed cases had been identified in the United Kingdom (UK) by the Health Protection Agency (HPA) by [19 Feb 2013]: 2 imported cases and 2 indigenously acquired cases linked to the 2nd imported case.
"The 1st case of novel coronavirus identified in the UK was in a foreign national transferred to London for the treatment of a serious, unexplained respiratory illness in September 2012 [2]. Coronavirus testing was undertaken following the announcement that a new coronavirus had been discovered in a Saudi Arabian national with a similar illness. The patient was very unwell, requiring intensive care and extra corporeal membrane oxygenation (ECMO), and remains very unwell. Extensive follow up of all close contacts (household and health care) by the HPA identified a number of persons with mild respiratory illness in the 10 days following exposure but none of these contacts had novel coronavirus infection detected on respiratory sampling or serology [3].
"On [11 Feb 2013], the HPA published details of an adult UK resident (the index case), with confirmed novel coronavirus infection and influenza A infection, who had travelled to Pakistan and Saudi Arabia in the 10 days before illness onset. This individual had developed respiratory symptoms on [24 Jan 2013], prior to returning to the UK on [28 Jan 2013]. While staying with family at home in the UK, this individual's condition deteriorated and they were admitted to hospital in Birmingham, before being transferred to Manchester, where they remain in intensive care, with ECMO.
"On [6 Feb 2013], an adult household member of the case who had not recently travelled abroad -- but who had been in sustained close contact with the index case from their arrival in the UK until hospital admission -- became unwell with a febrile respiratory illness. This 3rd case, on admission to hospital in Birmingham, was confirmed to have novel coronavirus infection. Their condition worsened -- requiring intensive care and ECMO -- before the patient died on [17 Feb 2013]. This patient had an existing medical condition that may have made them more susceptible to a respiratory infection.
"On [5 Feb 2013], an adult member of the same extended family of the 2 confirmed cases -- who had not travelled abroad -- developed an influenza-like illness. The illness remained mild, not requiring hospital admission, and there has been a full recovery. A sputum sample from this case was later confirmed to contain novel coronavirus. This case had limited exposure to the index case on 3 occasions while the latter was in hospital, and had no contact with the 2nd case.
"Infection control measures around the 3 recent cases have followed UK national guidance [4] and contact tracing and follow-up is continuing for those persons who may have been in close contact with any of the 3 cases.
"Contacts in 3 main settings are being followed up:
- Aircraft: the aircraft passengers in the same row and the 2 rows in front and behind the case on a flight from Saudi Arabia to London when the 1st case had been unwell;
- Household: the family and friend household contacts of all 3 cases;
- Health care: the health care workers, patients and family and friends who were in contact with the cases in a health care setting.
- Follow-up of contacts of the 3 confirmed cases had not detected any further probable or confirmed secondary cases by [18 Feb 2013].
"The routes of transmission to humans of the novel coronavirus have not yet been fully determined, but the recent UK experience provides strong evidence of human-to-human transmission in at least some circumstances. The limited contact that one of the cases had with the index case, however, leaves open the possibility of an intermediary case within the extended family.
"The 3 recent cases in the UK represent an important opportunity to obtain more information about the characteristics of this infection in humans and risk factors for its acquisition, particularly in the light of the first ever recorded instance of apparently lower severity of illness in one of the cases, and the occurrence of dual infection in the index case.
References
1. Corman VM, et al. Detection of a novel human coronavirus by real-time reverse-transcription polymerase chain reaction. Euro Surveill. 2012 Sep 27; 17(39). pii: 20285. http://www.eurosurveillance.org/ViewArt ... leId=20285.
2. Bermingham A, et al. Severe respiratory illness caused by a novel coronavirus, in a patient transferred to the United Kingdom from the Middle East, September 2012. Euro Surveill. 2012 Oct 4; 17(40): 20290. http://www.eurosurveillance.org/ViewArt ... leId=20290.
3. Pebody RG, et al. The United Kingdom public health response to an imported laboratory confirmed case of a novel coronavirus in September 2012. Euro Surveill. 2012 Oct 4; 17(40): 20292. http://www.eurosurveillance.org/ViewArt ... leId=20292.
4. Health Protection Agency. Infection Control Advice - Novel coronavirus cases Version 1.3, HPA, 4 October 2012 http://www.hpa.org.uk/webc/HPAwebFile/H ... 7136232722.
For the interactive HealthMap/ProMED map of the UK, see http://healthmap.org/r/1lNY. - Mod.MPP]
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Neuartiger Corona-Virus - WHO update - Saudi Arabien
Novel coronavirus infection - update
06.03.2013 - WHO
The Ministry of Health in Saudi Arabia has informed WHO of a new confirmed case of infection with the novel coronavirus (NCoV).
The patient, a 69-year-old male, was hospitalized on 10 February 2013 and died on 19 February 2013. Preliminary investigation indicated that the patient had no contact with previously reported cases of NCoV infection and did not have recent history of travel.
To date, WHO has been informed of a global total of 14 confirmed cases of human infection with NCoV, including eight deaths. Of the total number, seven cases, including five deaths, have been reported from Saudi Arabia.
Based on the current situation and available information, WHO encourages all Member States (MS) to continue their surveillance for severe acute respiratory infections (SARI) and to carefully review any unusual patterns. WHO is currently working with international experts and countries where cases have been reported to assess the situation and review recommendations for surveillance and monitoring.
All MS are reminded to promptly assess and notify WHO of any new case of infection with NCoV along with information about potential exposures that may have resulted in infection and a description of the clinical course.
WHO does not advise special screening at points of entry with regard to this event nor does it recommend that any travel or trade restrictions be applied.
WHO continues to closely monitor the situation.
Gruß
Birgitt
06.03.2013 - WHO
The Ministry of Health in Saudi Arabia has informed WHO of a new confirmed case of infection with the novel coronavirus (NCoV).
The patient, a 69-year-old male, was hospitalized on 10 February 2013 and died on 19 February 2013. Preliminary investigation indicated that the patient had no contact with previously reported cases of NCoV infection and did not have recent history of travel.
To date, WHO has been informed of a global total of 14 confirmed cases of human infection with NCoV, including eight deaths. Of the total number, seven cases, including five deaths, have been reported from Saudi Arabia.
Based on the current situation and available information, WHO encourages all Member States (MS) to continue their surveillance for severe acute respiratory infections (SARI) and to carefully review any unusual patterns. WHO is currently working with international experts and countries where cases have been reported to assess the situation and review recommendations for surveillance and monitoring.
All MS are reminded to promptly assess and notify WHO of any new case of infection with NCoV along with information about potential exposures that may have resulted in infection and a description of the clinical course.
WHO does not advise special screening at points of entry with regard to this event nor does it recommend that any travel or trade restrictions be applied.
WHO continues to closely monitor the situation.
Gruß
Birgitt
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Neuartiger Corona-Virus - WHO update - Saudi Arabien
NOVEL CORONAVIRUS - EASTERN MEDITERRANEAN (10): SAUDI ARABIA, WHO
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A ProMED-mail post
http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases
http://www.isid.org
Date: Tue 12 Mar 2013
Source: WHO Global Alert and Response (GAR), Disease Outbreak News [edited]
http://www.who.int/csr/don/2013_03_12/en/index.html
Novel coronavirus infection - update 12 Mar 2013
------------------------------------------------
The Ministry of Health in Saudi Arabia has informed WHO of a new confirmed case of infection with the novel coronavirus (nCoV).
The patient, a 39 year old male, developed symptoms on [24 Feb 2013]. He was hospitalized on [28 Feb 2013] and died on [2 Mar 2013]. Preliminary investigation indicated that the patient had no contact with previously reported cases of nCoV infection. Other potential exposures are under investigation.
To date, WHO has been informed of a global total of 15 confirmed cases of human infection with nCoV, including 9 deaths.
Based on the current situation and available information, WHO encourages all Member States (MS) to continue their surveillance for severe acute respiratory infections (SARI) and to carefully review any unusual patterns. WHO is currently working with international experts and countries where cases have been reported to assess the situation and review recommendations for surveillance and monitoring.
All MS are reminded to promptly assess and notify WHO of any new case of infection with nCoV, along with information about potential exposures that may have resulted in infection and a description of the clinical course.
WHO does not advise special screening at points of entry with regard to this event nor does it recommend that any travel or trade restrictions be applied.
WHO continues to closely monitor the situation.
--
communicated by:
ProMED-mail
<promed@promedmail.org>
[As stated above, the total number of confirmed cases of illness associated with infection with the novel coronavirus (nCoV) is now 15, of which 9 had a fatal outcome, a case fatality rate (CFR) of 60 per cent. As mentioned in an earlier report, the total number of confirmed cases to date is small (15), the observed CFR of 60 may be a reflection of non-confirmation of milder illness associated with infection with this nCoV.
The breakdown of cases (and deaths) by country of report is:
- Saudi Arabia: 8 (6 deaths)
- Jordan: 2 (2 deaths)
- UK: 4 (1 patient from Qatar -- under treatment, 3 patients from UK -- one with history of travel to Saudi Arabia and Pakistan prior to illness; 1 under treatment, 1 recovered, 1 death)
- Germany: 1 (patient from Qatar -- discharged).
More information on the epidemiologic investigation surrounding this case's potential exposures, such as animals, including bats, would be greatly appreciated. More information on the epidemiologic investigations of the other recent cases in Saudi Arabia would also be greatly appreciated.
For the HealthMap/ProMED map of the Middle East and Saudi Arabia, see http://healthmap.org/r/1HAJ. - Mod.MPP]
*****************************************************************
A ProMED-mail post
http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases
http://www.isid.org
Date: Tue 12 Mar 2013
Source: WHO Global Alert and Response (GAR), Disease Outbreak News [edited]
http://www.who.int/csr/don/2013_03_12/en/index.html
Novel coronavirus infection - update 12 Mar 2013
------------------------------------------------
The Ministry of Health in Saudi Arabia has informed WHO of a new confirmed case of infection with the novel coronavirus (nCoV).
The patient, a 39 year old male, developed symptoms on [24 Feb 2013]. He was hospitalized on [28 Feb 2013] and died on [2 Mar 2013]. Preliminary investigation indicated that the patient had no contact with previously reported cases of nCoV infection. Other potential exposures are under investigation.
To date, WHO has been informed of a global total of 15 confirmed cases of human infection with nCoV, including 9 deaths.
Based on the current situation and available information, WHO encourages all Member States (MS) to continue their surveillance for severe acute respiratory infections (SARI) and to carefully review any unusual patterns. WHO is currently working with international experts and countries where cases have been reported to assess the situation and review recommendations for surveillance and monitoring.
All MS are reminded to promptly assess and notify WHO of any new case of infection with nCoV, along with information about potential exposures that may have resulted in infection and a description of the clinical course.
WHO does not advise special screening at points of entry with regard to this event nor does it recommend that any travel or trade restrictions be applied.
WHO continues to closely monitor the situation.
--
communicated by:
ProMED-mail
<promed@promedmail.org>
[As stated above, the total number of confirmed cases of illness associated with infection with the novel coronavirus (nCoV) is now 15, of which 9 had a fatal outcome, a case fatality rate (CFR) of 60 per cent. As mentioned in an earlier report, the total number of confirmed cases to date is small (15), the observed CFR of 60 may be a reflection of non-confirmation of milder illness associated with infection with this nCoV.
The breakdown of cases (and deaths) by country of report is:
- Saudi Arabia: 8 (6 deaths)
- Jordan: 2 (2 deaths)
- UK: 4 (1 patient from Qatar -- under treatment, 3 patients from UK -- one with history of travel to Saudi Arabia and Pakistan prior to illness; 1 under treatment, 1 recovered, 1 death)
- Germany: 1 (patient from Qatar -- discharged).
More information on the epidemiologic investigation surrounding this case's potential exposures, such as animals, including bats, would be greatly appreciated. More information on the epidemiologic investigations of the other recent cases in Saudi Arabia would also be greatly appreciated.
For the HealthMap/ProMED map of the Middle East and Saudi Arabia, see http://healthmap.org/r/1HAJ. - Mod.MPP]
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Neuartiger Corona-Virus - Übertragungswege
NOVEL CORONAVIRUS - EASTERN MEDITERRANEAN (11): UK, PERSON TO PERSON TRANSMISSION
*********************************************************************************
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International Society for Infectious Diseases
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Date: 14 Mar 2013
Source: Eurosurveillance, Volume 18, Issue 11, 14 Mar 2013 [edited]
http://eurosurveillance.org/ViewArticle ... leId=20427
Evidence of person-to-person transmission within a family cluster of novel coronavirus infections, UK, Feb 2013
------------------------------------------
In February 2013, novel coronavirus (nCoV) infection was diagnosed in an adult male in the United Kingdom with severe respiratory illness, who had travelled to Pakistan and Saudi Arabia 10 days before symptom onset. Contact tracing identified 2 secondary cases among family members without recent travel: one developed severe respiratory illness and died, the other an influenza-like illness. No other severe cases were identified or nCoV detected in respiratory samples among 135 contacts followed for 10 days.
On [8 Feb 2013], the Health Protection Agency (HPA) in London, United Kingdom (UK), confirmed infection with novel coronavirus (nCoV) in a patient in an intensive care unit, who had travelled to both Pakistan and Saudi Arabia in the 10 days before the onset of symptoms [1]. This patient (hereafter referred to as Case 1) was the 10th confirmed case reported internationally of a severe acute respiratory illness caused by nCoV. A total of 2 secondary cases of nCoV were subsequently detected. We describe the public health investigation of this cluster and the clinical and virological follow-up of their close contacts.
The nCoV was 1st described in September 2012 in a Saudi Arabian national who died in June 2012 [2,3]. The UK detected its 1st case of nCoV infection in a male foreign national transferred from Qatar to London in September 2012 [4]. By February 2013, a total of 2 clusters had been described globally: one cluster (n=2) among staff in a hospital in Jordan and a family cluster (n=3) in Saudi Arabia [5]. No clear evidence of person-to-person transmission was documented in either cluster [6].
Index case exposure history and laboratory investigations
---------------------------------------------------------
The index case was a middle-aged UK resident, who had travelled to Pakistan for 5 weeks. He then travelled directly to Saudi Arabia on [20 Jan 2013] where he remained until his return to the UK on [28 Jan 2013]. During his stay in Saudi Arabia, he spent time in Mecca and Medina on pilgrimage. On [24 Jan 2013], while in Saudi Arabia, he developed fever and upper respiratory tract symptoms (Figure 1 Timeline of 3 novel coronavirus cases, United Kingdom, December 2012 to February 2013 -- [Figure available at above provided URL]). No direct contact with animals or with persons with severe respiratory illness was reported in the 10 days before the onset of illness.
When back in the UK, the patient's respiratory symptoms worsened and he visited his GP {general practitioner) on [30 Jan 2013]; he was admitted to hospital on [31 Jan 2013]. He rapidly deteriorated and required invasive ventilation for respiratory support. Due to further deterioration, he needed extracorporeal membrane oxygenation (ECMO) and was thus transferred to a tertiary centre on [5 Feb 2013], where he remains severely ill on ECMO as of [1 Mar 2013].
Initial laboratory investigation included a respiratory virus screen, with confirmation of influenza A infection on [1 Feb 2013]. This was subsequently characterised as influenza A(H1N1)pdm09. As the patient's clinical condition failed to improve following administration of influenza-specific antiviral drugs, he was subsequently investigated for nCoV infection in line with HPA guidance [7]. On [7 Feb 2013], nCoV was detected initially in a throat swab with a real-time PCR assay at a local laboratory, and nCoV was confirmed on [8 Feb 2013] by the HPA Respiratory Virus Reference Unit.
Public health management
------------------------
Following the confirmation of this imported nCoV case, the UK public health authorities implemented enhanced infection control measures to minimise possible onward transmission of infection: identification and follow-up of contacts to investigate whether transmission had occurred and prompt diagnosis and appropriate management of any further cases. The HPA protocol for investigation of nCoV cases and their close contacts was used [8]. For the purpose of the investigation, a close contact was defined as:
- aeroplane setting: the aircraft passengers in the same row and the 2 rows in front and behind a symptomatic case;
- household setting: any person who had prolonged (greater than 15 minutes) face-to-face contact with the confirmed case(s) any time during the illness in a household setting;
- health care setting: either (i) a worker who provided direct clinical or personal care to or examined a symptomatic confirmed case or was within close vicinity of an aerosol-generating procedure AND who was not wearing full personal protective equipment (PPE) at the time; or (ii) a visitor to the hospital who was not wearing PPE at the bedside of a confirmed case; full PPE was defined as correctly fitted high filtration mask (FFP3), gown, gloves and eye protection;
- other setting: any person who had prolonged (greater than 15 minutes) face-to-face contact with a confirmed symptomatic case in any other enclosed setting.
Identification and follow-up of individuals who had close contact with the index case from entry into the UK at any time during his symptomatic period was rapidly initiated by the HPA together with staff from the 2 hospitals the patient had attended (including the Infection Prevention and Control Teams and Occupational Health).
Close contacts were followed up for a minimum period of 10 days after last exposure to the index case. Following the identification of 2 secondary nCoV cases among symptomatic family contacts of the index case, contact tracing was initiated for their respective additional contacts. Follow-up included collection of information on the date and setting of contact with the index case, PPE use (health care workers) and any symptoms of respiratory infection in the 10 days after last exposure. Contacts who developed any symptoms of acute respiratory infection in this period were asked to self-isolate in their homes (or were isolated in hospital if admitted) until asymptomatic.
The airline provided details of passengers to the HPA to allow follow-up of those persons in the same row as the case and the 2 adjacent rows to the patient as per World Health Organization (WHO) guidance for severe acute respiratory syndrome (SARS) [9]. Passengers who were in the UK were followed up by the HPA to inform them of the potential exposure and determine whether they had developed symptoms of acute respiratory illness in the 10 days post exposure. UK authorities informed relevant overseas national authorities directly about non-UK resident contacts on the flight through International Health Regulation mechanisms.
Laboratory investigation
------------------------
Symptomatic contacts had respiratory samples taken (nose and throat swab, and sputum if they had a productive cough) for testing for a panel of respiratory viruses (influenza virus, respiratory syncytial virus, parainfluenza virus types 1,2,3 and 4, adenovirus, rhinovirus, human metapneumovirus) and for nCoV. Criteria for laboratory confirmation of nCoV were Up E real-time PCR detection in 2 different laboratories [3] and detection of 2 other regions of the nCoV genome [3, HPA unpublished data].
In addition, nose and throat swabs were taken from a group of asymptomatic contacts of the 3 confirmed cases for nCoV testing to determine if there was evidence of asymptomatic carriage.
Paired serum samples are being taken from all household and health care contacts regardless of symptoms with the initial sample taken within 7 days of last exposure and the 2nd at least 21 days after the 1st. Once collected, samples will be tested for serological reactivity to nCoV.
Initial epidemiological investigation of cluster
------------------------------------------------
By [28 Feb 2013], tracing of contacts of the index case (Case 1) had identified 103 close contacts in the UK, including 59 health care workers in the 2 hospitals, 20 household contacts of whom 15 also visited him at the hospital, 13 family and friends who visited the case in hospital, and 11 contacts during the flight who were UK residents or nationals. In addition there were 9 non-UK flight contacts.
Based on available information, a number of health care workers with direct contact with Case 1 did not have full PPE; -- for example, were not wearing an FFP3 mask. 7 of 59 health care workers developed mild, self-limiting respiratory symptoms in the 10 days after last contact. The nCoV was not detected by PCR in the respiratory samples of any of these 7 symptomatic contacts (Figure 2 Outcome of contacts follow-up for 10 days after last exposure to index case for respiratory illness and nCoV infection, after entry to the United Kingdom, February 2013 (n=92), available at above given URL]).
A total of 6 of the 20 household contacts of the index case developed acute respiratory symptoms in the 10 days since last exposure, of whom one progressed to severe illness requiring hospitalisation. This single hospitalised contact was subsequently confirmed to have nCoV infection (hereafter referred to as Case 2), and was also positive for type 2 parainfluenza virus. The remaining 5 symptomatic household contacts had mild self-limiting disease, and nCoV was not detected from their respiratory samples nor in any of the asymptomatic household contacts of Case 1 that were tested (Figure 2).
One of the 13 non-household contacts visiting Case 1 at the hospital, hereafter referred to as Case 3, developed an acute mild, respiratory illness, and nCoV was detected in a respiratory sample, as was type 2 parainfluenza virus. 2 of the 11 UK-based passengers reported respiratory symptoms: one had recovered by the time of interview and did not have respiratory samples taken. In the other, nCoV was not detected from respiratory samples.
The periods of exposure of Case 2 and Case 3 to Case 1 and the timelines of their illnesses are represented in Figure 1.
Case 2 and his contacts
-----------------------
Case 2 was a male household member, who had an underlying malignant condition, the treatment of which is likely to have resulted in immunosuppression. He had not travelled overseas. Contact with the index case in a household setting occurred from the arrival of Case 1 in the UK until Case 1 was admitted to hospital on [31 Jan 2013]. Case 2 reportedly became unwell on [6 Feb 2013] and was admitted to hospital on [9 Feb 2013]. He required intensive care and ECMO treatment. In a nose and throat swab taken on [10 Feb 2013], nCoV and type 2 parainfluenza virus were detected. His respiratory condition deteriorated and he died on [17 Feb 2013].
A number of household contacts (4 of 10), hospital visitors (one of one) and health care contacts (one of 6) of Case 2 developed mild self-limiting respiratory illness in the 10 days after last exposure. In addition, case 2 had one neighbouring patient contact in the hospital, who did not develop symptoms. None had nCoV detected in respiratory samples (Figure 3 - Outcome of contact follow-up for 10 days after last exposure to Case 2 (secondary case) for respiratory illness and nCoV infection, United Kingdom, February 2013 (n=18), available at above given URL link]
Case 3 and her contacts
-----------------------
Case 3 is an adult female family member of Case 1 who lived in a different household and had not recently travelled abroad. She was exposed to Case 1 only while visiting him in hospital on 3 separate occasions from [1 to 4 Feb 2013] for a cumulative period of 2.5 hours, during which full PPE was not worn. During these visits Case 1 was intubated on a closed ventilator circuit. Case 3 had no contact with Case 2 while he was unwell. Case 3 developed a self-limiting influenza-like illness starting on [5 Feb 2013], one day after her last contact with Case 1. She did not require medical attendance for her illness and fully recovered after 9 days. She tested positive for nCoV on a single sputum sample taken on [13 Feb 2013] and positive for type 2 parainfluenza virus on a nose and throat swab taken on [15 Feb 2013]. Serology results are awaited.
A total of 25 close contacts of Case 3 were identified (9 household contacts, 14 other contacts, and 2 health care workers) of whom 3 developed mild self-limiting respiratory illness in the 10 days post exposure. None of these, nor the asymptomatic contacts that were tested, were found to have nCoV in respiratory samples (Figure 4 - Outcome of contact follow-up for 10 days after last exposure to Case 3 (secondary case) for respiratory illness and nCoV infection, United Kingdom, February 2013 (n=25), available at above given URL link]).
Of the 44 contacts of Cases 1, 2 and 3 who were swabbed, 11 had another respiratory virus detected in respiratory samples: rhinovirus (n=7), influenza A(H3) and type 2 parainfluenza virus (n=1), type 2 parainfluenza virus (n=1), type 3 parainfluenza virus (n=1) and metapneumovirus (n=2).
Public health implications
--------------------------
We present evidence of limited person-to-person transmission of nCoV following contact with an index case returning to the UK from travel to Pakistan and Saudi Arabia. Neither of the 2 secondary cases that were detected had recently travelled and must therefore have acquired their infection in the UK. Both were extended family members and reported contact with the index case. One probably acquired the infection in a household setting and the other while visiting the index case in hospital. The nCoV was not detected among an additional 92 close contacts of the index case, or among the close contacts of the 2 secondary cases. These findings suggest that although person-to-person infection is possible, there is no evidence at present of sustained person-to-person transmission of nCoV in the UK in relation to this cluster. The limited transmissibility is consistent with the data available to date, with only 2 other reports of small, self-limited clusters of severe disease in the Middle East: one in a health care setting and the other in a household setting [5]. Furthermore, intensive follow-up of close contacts of 2 other cases imported to European countries has failed to demonstrate onward transmission [10,11].
We found that the index case in this cluster was co-infected with influenza. Type 2 parainfluenza virus was detected in the 2 secondary cases. This raises questions about what roles these other infections might play in relation to nCoV transmissibility and/or the severity of the illness. In addition, as the index case was diagnosed initially with influenza, this lead to a delay in recognition of nCoV. This highlights the importance of considering a diagnosis of nCoV in atypical cases (in this case the poor response to antiviral drugs), even if a putative alternative diagnosis has already been made. HPA guidance has been adapted accordingly [7].
Although the transmissibility patterns of nCoV and SARS have been different to date, confirmed cases of nCoV reported globally have suggested a clinical picture similar to SARS, in particular the presentation with severe respiratory illness, with 9 of the 15 cases reported globally to date having died [12]. 2 of the 3 cases we describe fit this clinical picture: 2 required ECMO treatment and one of them died. However, the 3rd case presented with an acute self-limiting respiratory infection that did not require hospitalisation or medical attention. This 1st reported case of a milder nCoV illness raises the possibility that the spectrum of clinical disease maybe wider than initially envisaged, and that a significant proportion of cases now or in the future might be milder or even asymptomatic. This highlights the importance of intensive contact tracing and virological and serological follow-up around all confirmed cases of nCoV. The application of recently developed serological assays in one case-contact study did not provide evidence of asymptomatic infection, although the contacts investigated were exposed late in the case's illness, when the viral load might be lower [11]. Paired sera are being gathered from contacts in this current investigation to determine whether there may have been more widespread mild or asymptomatic infection.
The fact that the 2 secondary cases acquired their infection from an imported sporadic case has enabled a preliminary estimation of the incubation and serial intervals. The timing of onset of symptoms in the index and the 2 secondary cases and of exposure suggests a putative incubation period ranging from one to 9 days and a serial interval (time between onset of illness in index case and secondary case) of 13 to 14 days. Although the data are extremely limited, the observed upper range of the incubation period is perhaps more similar to that seen for SARS (usual range: 2 to 10 days) rather than seasonal coronavirus infection (usual range: 2 to 5 days) [13]. It is therefore not possible to ascertain with certainty whether the index case acquired his infection in Saudi Arabia or in Pakistan, although previous nCoV cases have been linked to the Middle East. This highlights the importance of gathering more information to determine risk factors for acquisition of infection.
All confirmed nCoV cases detected to date, apart from the 2 secondary cases in the UK cluster, spent time in the Middle East during the putative incubation period. This, together with our observations of limited secondary transmission, highlights the importance of ongoing vigilance and rapid investigation of cases of severe respiratory illness in residents of and travellers from that area. Further work is required to determine how widely nCoV is circulating globally. In particular serological investigations are needed on the extent of recent infection in various populations, as well as virological investigation of cases of severe undiagnosed respiratory illness in settings both in and beyond the Middle East.
References
1. Novel coronavirus 2012 in the UK: situation at 19 February 2013. Health Protection Report. 2013;7(8). Available from http://www.hpa.org.uk/hpr/archives/2013/hpr0813.pdf
2. ProMED-mail. Novel coronavirus - Saudi Arabia: human isolate. Archive No.: 20120920.1302733. 20 Sep 2012. Available from: http://www.promedmail.org/?archiveid=302733
3. Corman VM, Eckerle I, Bleicker T, Zaki A, Landt O, Eschbach-Bludau M, et al. Detection of a novel human coronavirus by real-time reverse-transcription polymerase chain reaction. Euro Surveill. 2012;17(39):pii=20285. Available from: http://www.eurosurveillance.org/ViewArt ... leId=20285
4. Bermingham A, Chand MA, Brown CS, Aarons E, Tong C, Langrish C, et al. Severe respiratory illness caused by a novel coronavirus, in a patient transferred to the United Kingdom from the Middle East, September 2012. Euro Surveill. 2012;17(40):pii=20290. Available from: http://www.eurosurveillance.org/ViewArt ... leId=20290
5. WHO. Novel Coronavirus infection - update. Geneva: WHO; 30 Nov 2012. Available from: http://www.who.int/csr/don/2012_11_30/en/index.html
6. European Centre for Disease prevention and Control (ECDC). Rapid risk assessment. Severe respiratory disease associated with a novel coronavirus. Stockholm: ECDC; 19 February 2013. Available from: http://www.ecdc.europa.eu/en/publicatio ... update.pdf
7. Health Protection Agency. HPS nCoV case algorithm. Version case_v13. London: HPA; 19 Feb 2013. Available from: http://www.hpa.org.uk/webc/HPAwebFile/H ... 7136270914
8. HPA. "The first few hundred (FF100)". Enhanced Case and Contact Protocol v4.0. Epidemiological Protocols for Comprehensive Assessment of Early Novel Coronavirus Cases and their close contacts in the United Kingdom. London: HPA. [Accessed: 19 Feb 2013]. Available from: http://www.hpa.org.uk/webc/HPAwebFile/H ... 7136300809
9. WHO recommended measures for persons undertaking international travel from areas affected by Severe Acute Respiratory Syndrome (SARS). Wkly Epidemiol Rec. 2003;78(14):97-9. PMid:12723281. [available for download from: http://www.who.int/wer/2003/wer7814/en/index.html]
10. Pebody RG, Chand MA, Thomas HL, Green HK, Boddington NL, Carvalho C, et al. The United Kingdom public health response to an imported laboratory confirmed case of a novel coronavirus in September 2012. Euro Surveill. 2012;17(40):pii=20292. Available from: http://www.eurosurveillance.org/ViewArt ... leId=20292
11. Buchholz U, Müller MA, Nitsche A, Sanewski A, Wevering N, Bauer-Balci T, et al. Contact investigation of a case of human novel coronavirus infection treated in a German hospital, October-November 2012. Euro Surveill. 2013;18(8):pii=20406. Available from: http://www.eurosurveillance.org/ViewArt ... leId=20406. PMid:23449231.
12. WHO. Novel coronavirus update. Geneva: WHO; 12 Mar 2013. Available from: http://www.who.int/csr/don/2013_03_12/en/index.html
13. Lessler J, Reich NG, Brookmeyer R, Perl TM, Nelson KE, Cummings DA. Incubation periods of acute respiratory viral infections: a systematic review. Lancet Infect Dis. 2009;9(5):291-300. http://dx.doi.org/10.1016/S1473-3099(09)70069-6. [abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/19393959]
[reported by: The Health Protection Agency (HPA) UK Novel Coronavirus Investigation team [see original article for list of team members.]
--
communicated by:
ProMED-mail
<promed@promedmail.org>
[The above report details the extensive investigations surrounding this cluster of nCoV cases, the 1st documented cluster involving person-to-person transmission of the virus. We anxiously await the results of serologic testing of contacts, especially those with a history of self-resolving respiratory illnesses occurring within the estimated incubation periods observed for nCoV transmission.
A curious observation is the existence of co-infection with other respiratory agents on the part of this index case and the 2 contact cases. The index case (with history of exposure in the Middle East and possibly Pakistan) was also documented to have a coinfection with influenza A(H1N1)pdm09 and nCoV. Case 2 in this cluster was documented to have a coinfection with type 2 parainfluenza virus and nCoV, and Case 3 was documented to have an infection with nCoV on a single sputum sample taken on [13 Feb 2013] and for type 2 parainfluenza virus on a nose and throat swab taken on [15 Feb 2013]. - Mod.MPP
A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/r/1lNY.]
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ProMED-mail is a program of the
International Society for Infectious Diseases
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Date: 14 Mar 2013
Source: Eurosurveillance, Volume 18, Issue 11, 14 Mar 2013 [edited]
http://eurosurveillance.org/ViewArticle ... leId=20427
Evidence of person-to-person transmission within a family cluster of novel coronavirus infections, UK, Feb 2013
------------------------------------------
In February 2013, novel coronavirus (nCoV) infection was diagnosed in an adult male in the United Kingdom with severe respiratory illness, who had travelled to Pakistan and Saudi Arabia 10 days before symptom onset. Contact tracing identified 2 secondary cases among family members without recent travel: one developed severe respiratory illness and died, the other an influenza-like illness. No other severe cases were identified or nCoV detected in respiratory samples among 135 contacts followed for 10 days.
On [8 Feb 2013], the Health Protection Agency (HPA) in London, United Kingdom (UK), confirmed infection with novel coronavirus (nCoV) in a patient in an intensive care unit, who had travelled to both Pakistan and Saudi Arabia in the 10 days before the onset of symptoms [1]. This patient (hereafter referred to as Case 1) was the 10th confirmed case reported internationally of a severe acute respiratory illness caused by nCoV. A total of 2 secondary cases of nCoV were subsequently detected. We describe the public health investigation of this cluster and the clinical and virological follow-up of their close contacts.
The nCoV was 1st described in September 2012 in a Saudi Arabian national who died in June 2012 [2,3]. The UK detected its 1st case of nCoV infection in a male foreign national transferred from Qatar to London in September 2012 [4]. By February 2013, a total of 2 clusters had been described globally: one cluster (n=2) among staff in a hospital in Jordan and a family cluster (n=3) in Saudi Arabia [5]. No clear evidence of person-to-person transmission was documented in either cluster [6].
Index case exposure history and laboratory investigations
---------------------------------------------------------
The index case was a middle-aged UK resident, who had travelled to Pakistan for 5 weeks. He then travelled directly to Saudi Arabia on [20 Jan 2013] where he remained until his return to the UK on [28 Jan 2013]. During his stay in Saudi Arabia, he spent time in Mecca and Medina on pilgrimage. On [24 Jan 2013], while in Saudi Arabia, he developed fever and upper respiratory tract symptoms (Figure 1 Timeline of 3 novel coronavirus cases, United Kingdom, December 2012 to February 2013 -- [Figure available at above provided URL]). No direct contact with animals or with persons with severe respiratory illness was reported in the 10 days before the onset of illness.
When back in the UK, the patient's respiratory symptoms worsened and he visited his GP {general practitioner) on [30 Jan 2013]; he was admitted to hospital on [31 Jan 2013]. He rapidly deteriorated and required invasive ventilation for respiratory support. Due to further deterioration, he needed extracorporeal membrane oxygenation (ECMO) and was thus transferred to a tertiary centre on [5 Feb 2013], where he remains severely ill on ECMO as of [1 Mar 2013].
Initial laboratory investigation included a respiratory virus screen, with confirmation of influenza A infection on [1 Feb 2013]. This was subsequently characterised as influenza A(H1N1)pdm09. As the patient's clinical condition failed to improve following administration of influenza-specific antiviral drugs, he was subsequently investigated for nCoV infection in line with HPA guidance [7]. On [7 Feb 2013], nCoV was detected initially in a throat swab with a real-time PCR assay at a local laboratory, and nCoV was confirmed on [8 Feb 2013] by the HPA Respiratory Virus Reference Unit.
Public health management
------------------------
Following the confirmation of this imported nCoV case, the UK public health authorities implemented enhanced infection control measures to minimise possible onward transmission of infection: identification and follow-up of contacts to investigate whether transmission had occurred and prompt diagnosis and appropriate management of any further cases. The HPA protocol for investigation of nCoV cases and their close contacts was used [8]. For the purpose of the investigation, a close contact was defined as:
- aeroplane setting: the aircraft passengers in the same row and the 2 rows in front and behind a symptomatic case;
- household setting: any person who had prolonged (greater than 15 minutes) face-to-face contact with the confirmed case(s) any time during the illness in a household setting;
- health care setting: either (i) a worker who provided direct clinical or personal care to or examined a symptomatic confirmed case or was within close vicinity of an aerosol-generating procedure AND who was not wearing full personal protective equipment (PPE) at the time; or (ii) a visitor to the hospital who was not wearing PPE at the bedside of a confirmed case; full PPE was defined as correctly fitted high filtration mask (FFP3), gown, gloves and eye protection;
- other setting: any person who had prolonged (greater than 15 minutes) face-to-face contact with a confirmed symptomatic case in any other enclosed setting.
Identification and follow-up of individuals who had close contact with the index case from entry into the UK at any time during his symptomatic period was rapidly initiated by the HPA together with staff from the 2 hospitals the patient had attended (including the Infection Prevention and Control Teams and Occupational Health).
Close contacts were followed up for a minimum period of 10 days after last exposure to the index case. Following the identification of 2 secondary nCoV cases among symptomatic family contacts of the index case, contact tracing was initiated for their respective additional contacts. Follow-up included collection of information on the date and setting of contact with the index case, PPE use (health care workers) and any symptoms of respiratory infection in the 10 days after last exposure. Contacts who developed any symptoms of acute respiratory infection in this period were asked to self-isolate in their homes (or were isolated in hospital if admitted) until asymptomatic.
The airline provided details of passengers to the HPA to allow follow-up of those persons in the same row as the case and the 2 adjacent rows to the patient as per World Health Organization (WHO) guidance for severe acute respiratory syndrome (SARS) [9]. Passengers who were in the UK were followed up by the HPA to inform them of the potential exposure and determine whether they had developed symptoms of acute respiratory illness in the 10 days post exposure. UK authorities informed relevant overseas national authorities directly about non-UK resident contacts on the flight through International Health Regulation mechanisms.
Laboratory investigation
------------------------
Symptomatic contacts had respiratory samples taken (nose and throat swab, and sputum if they had a productive cough) for testing for a panel of respiratory viruses (influenza virus, respiratory syncytial virus, parainfluenza virus types 1,2,3 and 4, adenovirus, rhinovirus, human metapneumovirus) and for nCoV. Criteria for laboratory confirmation of nCoV were Up E real-time PCR detection in 2 different laboratories [3] and detection of 2 other regions of the nCoV genome [3, HPA unpublished data].
In addition, nose and throat swabs were taken from a group of asymptomatic contacts of the 3 confirmed cases for nCoV testing to determine if there was evidence of asymptomatic carriage.
Paired serum samples are being taken from all household and health care contacts regardless of symptoms with the initial sample taken within 7 days of last exposure and the 2nd at least 21 days after the 1st. Once collected, samples will be tested for serological reactivity to nCoV.
Initial epidemiological investigation of cluster
------------------------------------------------
By [28 Feb 2013], tracing of contacts of the index case (Case 1) had identified 103 close contacts in the UK, including 59 health care workers in the 2 hospitals, 20 household contacts of whom 15 also visited him at the hospital, 13 family and friends who visited the case in hospital, and 11 contacts during the flight who were UK residents or nationals. In addition there were 9 non-UK flight contacts.
Based on available information, a number of health care workers with direct contact with Case 1 did not have full PPE; -- for example, were not wearing an FFP3 mask. 7 of 59 health care workers developed mild, self-limiting respiratory symptoms in the 10 days after last contact. The nCoV was not detected by PCR in the respiratory samples of any of these 7 symptomatic contacts (Figure 2 Outcome of contacts follow-up for 10 days after last exposure to index case for respiratory illness and nCoV infection, after entry to the United Kingdom, February 2013 (n=92), available at above given URL]).
A total of 6 of the 20 household contacts of the index case developed acute respiratory symptoms in the 10 days since last exposure, of whom one progressed to severe illness requiring hospitalisation. This single hospitalised contact was subsequently confirmed to have nCoV infection (hereafter referred to as Case 2), and was also positive for type 2 parainfluenza virus. The remaining 5 symptomatic household contacts had mild self-limiting disease, and nCoV was not detected from their respiratory samples nor in any of the asymptomatic household contacts of Case 1 that were tested (Figure 2).
One of the 13 non-household contacts visiting Case 1 at the hospital, hereafter referred to as Case 3, developed an acute mild, respiratory illness, and nCoV was detected in a respiratory sample, as was type 2 parainfluenza virus. 2 of the 11 UK-based passengers reported respiratory symptoms: one had recovered by the time of interview and did not have respiratory samples taken. In the other, nCoV was not detected from respiratory samples.
The periods of exposure of Case 2 and Case 3 to Case 1 and the timelines of their illnesses are represented in Figure 1.
Case 2 and his contacts
-----------------------
Case 2 was a male household member, who had an underlying malignant condition, the treatment of which is likely to have resulted in immunosuppression. He had not travelled overseas. Contact with the index case in a household setting occurred from the arrival of Case 1 in the UK until Case 1 was admitted to hospital on [31 Jan 2013]. Case 2 reportedly became unwell on [6 Feb 2013] and was admitted to hospital on [9 Feb 2013]. He required intensive care and ECMO treatment. In a nose and throat swab taken on [10 Feb 2013], nCoV and type 2 parainfluenza virus were detected. His respiratory condition deteriorated and he died on [17 Feb 2013].
A number of household contacts (4 of 10), hospital visitors (one of one) and health care contacts (one of 6) of Case 2 developed mild self-limiting respiratory illness in the 10 days after last exposure. In addition, case 2 had one neighbouring patient contact in the hospital, who did not develop symptoms. None had nCoV detected in respiratory samples (Figure 3 - Outcome of contact follow-up for 10 days after last exposure to Case 2 (secondary case) for respiratory illness and nCoV infection, United Kingdom, February 2013 (n=18), available at above given URL link]
Case 3 and her contacts
-----------------------
Case 3 is an adult female family member of Case 1 who lived in a different household and had not recently travelled abroad. She was exposed to Case 1 only while visiting him in hospital on 3 separate occasions from [1 to 4 Feb 2013] for a cumulative period of 2.5 hours, during which full PPE was not worn. During these visits Case 1 was intubated on a closed ventilator circuit. Case 3 had no contact with Case 2 while he was unwell. Case 3 developed a self-limiting influenza-like illness starting on [5 Feb 2013], one day after her last contact with Case 1. She did not require medical attendance for her illness and fully recovered after 9 days. She tested positive for nCoV on a single sputum sample taken on [13 Feb 2013] and positive for type 2 parainfluenza virus on a nose and throat swab taken on [15 Feb 2013]. Serology results are awaited.
A total of 25 close contacts of Case 3 were identified (9 household contacts, 14 other contacts, and 2 health care workers) of whom 3 developed mild self-limiting respiratory illness in the 10 days post exposure. None of these, nor the asymptomatic contacts that were tested, were found to have nCoV in respiratory samples (Figure 4 - Outcome of contact follow-up for 10 days after last exposure to Case 3 (secondary case) for respiratory illness and nCoV infection, United Kingdom, February 2013 (n=25), available at above given URL link]).
Of the 44 contacts of Cases 1, 2 and 3 who were swabbed, 11 had another respiratory virus detected in respiratory samples: rhinovirus (n=7), influenza A(H3) and type 2 parainfluenza virus (n=1), type 2 parainfluenza virus (n=1), type 3 parainfluenza virus (n=1) and metapneumovirus (n=2).
Public health implications
--------------------------
We present evidence of limited person-to-person transmission of nCoV following contact with an index case returning to the UK from travel to Pakistan and Saudi Arabia. Neither of the 2 secondary cases that were detected had recently travelled and must therefore have acquired their infection in the UK. Both were extended family members and reported contact with the index case. One probably acquired the infection in a household setting and the other while visiting the index case in hospital. The nCoV was not detected among an additional 92 close contacts of the index case, or among the close contacts of the 2 secondary cases. These findings suggest that although person-to-person infection is possible, there is no evidence at present of sustained person-to-person transmission of nCoV in the UK in relation to this cluster. The limited transmissibility is consistent with the data available to date, with only 2 other reports of small, self-limited clusters of severe disease in the Middle East: one in a health care setting and the other in a household setting [5]. Furthermore, intensive follow-up of close contacts of 2 other cases imported to European countries has failed to demonstrate onward transmission [10,11].
We found that the index case in this cluster was co-infected with influenza. Type 2 parainfluenza virus was detected in the 2 secondary cases. This raises questions about what roles these other infections might play in relation to nCoV transmissibility and/or the severity of the illness. In addition, as the index case was diagnosed initially with influenza, this lead to a delay in recognition of nCoV. This highlights the importance of considering a diagnosis of nCoV in atypical cases (in this case the poor response to antiviral drugs), even if a putative alternative diagnosis has already been made. HPA guidance has been adapted accordingly [7].
Although the transmissibility patterns of nCoV and SARS have been different to date, confirmed cases of nCoV reported globally have suggested a clinical picture similar to SARS, in particular the presentation with severe respiratory illness, with 9 of the 15 cases reported globally to date having died [12]. 2 of the 3 cases we describe fit this clinical picture: 2 required ECMO treatment and one of them died. However, the 3rd case presented with an acute self-limiting respiratory infection that did not require hospitalisation or medical attention. This 1st reported case of a milder nCoV illness raises the possibility that the spectrum of clinical disease maybe wider than initially envisaged, and that a significant proportion of cases now or in the future might be milder or even asymptomatic. This highlights the importance of intensive contact tracing and virological and serological follow-up around all confirmed cases of nCoV. The application of recently developed serological assays in one case-contact study did not provide evidence of asymptomatic infection, although the contacts investigated were exposed late in the case's illness, when the viral load might be lower [11]. Paired sera are being gathered from contacts in this current investigation to determine whether there may have been more widespread mild or asymptomatic infection.
The fact that the 2 secondary cases acquired their infection from an imported sporadic case has enabled a preliminary estimation of the incubation and serial intervals. The timing of onset of symptoms in the index and the 2 secondary cases and of exposure suggests a putative incubation period ranging from one to 9 days and a serial interval (time between onset of illness in index case and secondary case) of 13 to 14 days. Although the data are extremely limited, the observed upper range of the incubation period is perhaps more similar to that seen for SARS (usual range: 2 to 10 days) rather than seasonal coronavirus infection (usual range: 2 to 5 days) [13]. It is therefore not possible to ascertain with certainty whether the index case acquired his infection in Saudi Arabia or in Pakistan, although previous nCoV cases have been linked to the Middle East. This highlights the importance of gathering more information to determine risk factors for acquisition of infection.
All confirmed nCoV cases detected to date, apart from the 2 secondary cases in the UK cluster, spent time in the Middle East during the putative incubation period. This, together with our observations of limited secondary transmission, highlights the importance of ongoing vigilance and rapid investigation of cases of severe respiratory illness in residents of and travellers from that area. Further work is required to determine how widely nCoV is circulating globally. In particular serological investigations are needed on the extent of recent infection in various populations, as well as virological investigation of cases of severe undiagnosed respiratory illness in settings both in and beyond the Middle East.
References
1. Novel coronavirus 2012 in the UK: situation at 19 February 2013. Health Protection Report. 2013;7(8). Available from http://www.hpa.org.uk/hpr/archives/2013/hpr0813.pdf
2. ProMED-mail. Novel coronavirus - Saudi Arabia: human isolate. Archive No.: 20120920.1302733. 20 Sep 2012. Available from: http://www.promedmail.org/?archiveid=302733
3. Corman VM, Eckerle I, Bleicker T, Zaki A, Landt O, Eschbach-Bludau M, et al. Detection of a novel human coronavirus by real-time reverse-transcription polymerase chain reaction. Euro Surveill. 2012;17(39):pii=20285. Available from: http://www.eurosurveillance.org/ViewArt ... leId=20285
4. Bermingham A, Chand MA, Brown CS, Aarons E, Tong C, Langrish C, et al. Severe respiratory illness caused by a novel coronavirus, in a patient transferred to the United Kingdom from the Middle East, September 2012. Euro Surveill. 2012;17(40):pii=20290. Available from: http://www.eurosurveillance.org/ViewArt ... leId=20290
5. WHO. Novel Coronavirus infection - update. Geneva: WHO; 30 Nov 2012. Available from: http://www.who.int/csr/don/2012_11_30/en/index.html
6. European Centre for Disease prevention and Control (ECDC). Rapid risk assessment. Severe respiratory disease associated with a novel coronavirus. Stockholm: ECDC; 19 February 2013. Available from: http://www.ecdc.europa.eu/en/publicatio ... update.pdf
7. Health Protection Agency. HPS nCoV case algorithm. Version case_v13. London: HPA; 19 Feb 2013. Available from: http://www.hpa.org.uk/webc/HPAwebFile/H ... 7136270914
8. HPA. "The first few hundred (FF100)". Enhanced Case and Contact Protocol v4.0. Epidemiological Protocols for Comprehensive Assessment of Early Novel Coronavirus Cases and their close contacts in the United Kingdom. London: HPA. [Accessed: 19 Feb 2013]. Available from: http://www.hpa.org.uk/webc/HPAwebFile/H ... 7136300809
9. WHO recommended measures for persons undertaking international travel from areas affected by Severe Acute Respiratory Syndrome (SARS). Wkly Epidemiol Rec. 2003;78(14):97-9. PMid:12723281. [available for download from: http://www.who.int/wer/2003/wer7814/en/index.html]
10. Pebody RG, Chand MA, Thomas HL, Green HK, Boddington NL, Carvalho C, et al. The United Kingdom public health response to an imported laboratory confirmed case of a novel coronavirus in September 2012. Euro Surveill. 2012;17(40):pii=20292. Available from: http://www.eurosurveillance.org/ViewArt ... leId=20292
11. Buchholz U, Müller MA, Nitsche A, Sanewski A, Wevering N, Bauer-Balci T, et al. Contact investigation of a case of human novel coronavirus infection treated in a German hospital, October-November 2012. Euro Surveill. 2013;18(8):pii=20406. Available from: http://www.eurosurveillance.org/ViewArt ... leId=20406. PMid:23449231.
12. WHO. Novel coronavirus update. Geneva: WHO; 12 Mar 2013. Available from: http://www.who.int/csr/don/2013_03_12/en/index.html
13. Lessler J, Reich NG, Brookmeyer R, Perl TM, Nelson KE, Cummings DA. Incubation periods of acute respiratory viral infections: a systematic review. Lancet Infect Dis. 2009;9(5):291-300. http://dx.doi.org/10.1016/S1473-3099(09)70069-6. [abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/19393959]
[reported by: The Health Protection Agency (HPA) UK Novel Coronavirus Investigation team [see original article for list of team members.]
--
communicated by:
ProMED-mail
<promed@promedmail.org>
[The above report details the extensive investigations surrounding this cluster of nCoV cases, the 1st documented cluster involving person-to-person transmission of the virus. We anxiously await the results of serologic testing of contacts, especially those with a history of self-resolving respiratory illnesses occurring within the estimated incubation periods observed for nCoV transmission.
A curious observation is the existence of co-infection with other respiratory agents on the part of this index case and the 2 contact cases. The index case (with history of exposure in the Middle East and possibly Pakistan) was also documented to have a coinfection with influenza A(H1N1)pdm09 and nCoV. Case 2 in this cluster was documented to have a coinfection with type 2 parainfluenza virus and nCoV, and Case 3 was documented to have an infection with nCoV on a single sputum sample taken on [13 Feb 2013] and for type 2 parainfluenza virus on a nose and throat swab taken on [15 Feb 2013]. - Mod.MPP
A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/r/1lNY.]
-
Birgitt
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- Beiträge: 35341
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Neuartiger Corona-Virus - Saudia Arabien / UK
NOVEL CORONAVIRUS - EASTERN MEDITERRANEAN (12): SAUDI ARABIA, UK FATALITY, REQUEST FOR INFORMATION
**************************************************************************************************
A ProMED-mail post
http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases
http://www.isid.org
In this update:
[1] Saudi Arabia - WHO, new case
[2] Saudi Arabia - new case
[3] UK - fatality
******
[1] Saudi Arabia - WHO, new case
Date: 23 Mar 2013
Source: WHO GAR (Global Alert and Response) [edited]
http://www.who.int/csr/don/2013_03_23/en/index.html
Novel coronavirus infection - update [23 Mar 2013]
---------------------
The Ministry of Health in Saudi Arabia has informed the World Health Organization (WHO) of a new confirmed case of infection with the novel coronavirus (nCoV).
The patient is a contact of the previous case reported in the Disease Outbreak News on [12 Mar 2012]. This person suffered a mild illness, and has recovered and been discharged from hospital. Currently, there is insufficient information available to allow a conclusive assessment of the mode and source of transmission.
To date, the WHO has been informed of a global total of 16 confirmed cases of human infection with nCoV, including 9 deaths [see below newswire in section [3] reporting a 10th death - Mod.MPP].
Based on the current situation and available information, WHO encourages all Member States (MS) to continue their surveillance for severe acute respiratory infections (SARI) and to carefully review any unusual patterns. The WHO is currently working with international experts and countries where cases have been reported to assess the situation and review recommendations for surveillance and monitoring.
All MS are reminded to promptly assess and notify the WHO of any new case of infection with nCoV, along with information about potential exposures that may have resulted in infection and a description of the clinical course.
The WHO does not advise special screening at points of entry with regard to this event nor does it recommend that any travel or trade restrictions be applied.
The WHO continues to closely monitor the situation.
--
Communicated by:
ProMED-mail
<promed@promedmail.org>
******
[2] Saudi Arabia - new case
Date: 23 Mar 2013
Source: CTV (Canadian TV) [edited]
http://www.ctvnews.ca/politics/new-coro ... -1.1208249
The World Health Organization says there has been another infection with the new coronavirus, this time in someone who was a contact of an earlier case. But the Geneva-based global health agency says it doesn't have enough information to estimate whether the new infection was the result of person-to-person spread. The case is from Saudi Arabia, the 9th from that country.
Globally there have now been 16 confirmed infections from the new virus -- which is from the same family as SARS -- with at least 9 deaths.
The WHO statement says the newest case was a contact of a 39-year-old Saudi man who died from the infection on [2 Mar 2013]. The newest case is a person who had mild illness only; the person has recovered and has been released from hospital. The WHO says currently it doesn't know enough to gauge whether the new case was infected by the 39-year-old man, or contracted the virus from the same source as he did. In fact, it appears that the WHO may know very little about the new case.
The press release from the agency does not reveal the individual's gender or age. Nor does it say when the person fell ill, was hospitalized and released from hospital.
WHO press releases announcing infections with the new coronavirus -- which it calls NCoV -- generally contain those kinds of details when the health agency has them.
If it turns out this is a case of person-to-person spread, it would not be the 1st time that has been seen. There have been at least 3 instances where human-to-human spread is suspected, and in one of those cases it is assumed to have happened. That instance involved a cluster of cases in Britain, started by a man who returned home ill after a trip to Pakistan and Saudi Arabia. The man's son, who had cancer, became infected and died. Another member of their extended family was infected, but she had only mild illness. As the son and the 3rd case in that cluster had not travelled outside Britain before becoming ill, it is believed they contracted the virus from the man who had travelled.
A British newspaper, the Birmingham Mail, reported Saturday [23 Mar 2013] that the 1st case in that cluster succumbed to his illness this week. But the WHO's statement Saturday [23 Mar 2013] does not reflect an additional death caused by the coronavirus.
The new virus was 1st spotted last June [2012] after a man from the Saudi capital, Riyadh, died from an infection for which a cause could not initially be discovered.
Subsequently it was recognized that earlier cases had occurred in Jordan, where 11 people fell ill last April [2012] in a cluster of mysterious infections in a hospital. Stored samples from the 2 fatal cases in that cluster later revealed they had been infected with the coronavirus.
When a blood test to determine past infection becomes available, it may be possible to determine if others in that cluster were also infected. But to date laboratories working to develop a blood test that picks up these cases has proved difficult to develop.
To date 4 countries have recorded infections: Saudi Arabia, with 9 cases and 6 deaths; Qatar, with 2 cases; Britain, with 3 cases and one (or 2) deaths; and Jordan, with 2 fatal cases.
--
Communicated by:
ProMED-mail
<promed@promedmail.org>
******
[3] UK - fatality
Date: 23 Mar 2013
Source: Birmingham Mail [edited]
http://www.birminghammail.co.uk/lifesty ... ks-1877516
Birmingham grandad is UK's 2nd Coronavirus victim
-------------------
[The Birmingham resident], of Winson Green, lost a battle against a SARS-like bug in hospital on Tuesday [19 Mar 2013]. [The Birmingham resident] has become the UK's 2nd victim to the new SARS-like bug Coronavirus. The tragedy comes as his wife and daughter were in Pakistan after burying his [38-year-old son], who had also fallen victim to the killer disease.
The dad-of-2, in his 60s, of Winson Green, was being treated at Wythenshawe Hospital, in Manchester, and seemed to be improving. But he took a turn for the worse and lost his battle on Tuesday [19 Mar 2013]. His funeral was held at a mosque in Small Heath, on Wednesday [20 Mar 2013] and his body has now been taken to Pakistan for burial.
[The 60 year old man] had contracted the disease after a trip to Saudi Arabia with his daughter. He complained of a temperature and chest problems upon his return at the end of January [2013] and within a few days he was admitted to City Hospital, in Birmingham.
It's thought during this period that his [38-year-old] son, dad-of-2, suffering from cancer, picked up the bug from his father. [The son] was undergoing chemotherapy at the Queen Elizabeth Hospital, in Edgbaston. He continued to be treated there for both conditions and died on [17 Feb 2013].
The 1st patients infected with the coronavirus fell ill in Jordan, Qatar and Saudi Arabia last year [2012], but the source of the infection remains unknown, despite missions by the World Health Organisation and other international groups. As with SARS, the virus has most likely jumped from bats into other animals, in this case perhaps goats or other livestock, which have gone on to infect humans.
It has infected at least 15 people since it emerged in the Middle East last year [2013] - more than half of whom have died of pneumonia and multiple organ failure, symptoms that were common in SARS patients.
A Wythenshawe Hospital spokesman confirmed [that the patient] had died on Tuesday [19 Mar 2013].
[Byline: Anuji Varma]
--
Communicated by:
ProMED-mail
<promed@promedmail.org>
[As stated above, the total number of confirmed cases of illness associated with infection with the novel coronavirus (nCoV) is now 16, of which 10 had a fatal outcome, a case fatality rate (CFR) of 62.5 per cent. As mentioned in an earlier report, the total number of confirmed cases to date is small (16), the observed CFR of 62.5 may be a reflection of non-confirmation of milder illness associated with infection with this nCoV. The newswire in [3] seems to confirm the report of the death of the index case in the UK cluster of nCoV infections. As a reminder, the index case had a history of travel to Pakistan and Saudi Arabia during the incubation period for nCoV infection.
The breakdown of cases (and deaths) by country of report is:
- Saudi Arabia: 9 (6 deaths)
- Jordan: 2 (2 deaths)
- UK: 4 (1 patient from Qatar -- under treatment, 3 patients from UK -- one with history of travel to Saudi Arabia and Pakistan prior to illness; one recovered, 2 deaths)
- Germany: one (patient from Qatar -- discharged).
As mentioned in the newswire in report [2] above, at present, retrospective identification of cases with milder clinical illness infected with this nCoV has not been successful to date. One suspects that the report of the cluster of ICU staff in Jordan did have more cases than were confirmed, but in the absence of laboratory confirmation it is difficult to definitively state they were infected with the nCoV.
The absence of more information on the newly reported case in Saudi Arabia makes any interpretation/discussion of the possible route of transmission difficult at this time. This moderator attempted a search of the Arabic language media [using an online translation tool] to see if there were any local reports on this case that might shed more information. Unfortunately the only articles found were summaries of the current WHO announcement. More information from knowledgeable sources in the region would be greatly appreciated.
For the HealthMap/ProMED map of the middle eastern region showing Saudi Arabia and surrounding countries, see http://healthmap.org/r/1HAJ. - Mod.MPP]
**************************************************************************************************
A ProMED-mail post
http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases
http://www.isid.org
In this update:
[1] Saudi Arabia - WHO, new case
[2] Saudi Arabia - new case
[3] UK - fatality
******
[1] Saudi Arabia - WHO, new case
Date: 23 Mar 2013
Source: WHO GAR (Global Alert and Response) [edited]
http://www.who.int/csr/don/2013_03_23/en/index.html
Novel coronavirus infection - update [23 Mar 2013]
---------------------
The Ministry of Health in Saudi Arabia has informed the World Health Organization (WHO) of a new confirmed case of infection with the novel coronavirus (nCoV).
The patient is a contact of the previous case reported in the Disease Outbreak News on [12 Mar 2012]. This person suffered a mild illness, and has recovered and been discharged from hospital. Currently, there is insufficient information available to allow a conclusive assessment of the mode and source of transmission.
To date, the WHO has been informed of a global total of 16 confirmed cases of human infection with nCoV, including 9 deaths [see below newswire in section [3] reporting a 10th death - Mod.MPP].
Based on the current situation and available information, WHO encourages all Member States (MS) to continue their surveillance for severe acute respiratory infections (SARI) and to carefully review any unusual patterns. The WHO is currently working with international experts and countries where cases have been reported to assess the situation and review recommendations for surveillance and monitoring.
All MS are reminded to promptly assess and notify the WHO of any new case of infection with nCoV, along with information about potential exposures that may have resulted in infection and a description of the clinical course.
The WHO does not advise special screening at points of entry with regard to this event nor does it recommend that any travel or trade restrictions be applied.
The WHO continues to closely monitor the situation.
--
Communicated by:
ProMED-mail
<promed@promedmail.org>
******
[2] Saudi Arabia - new case
Date: 23 Mar 2013
Source: CTV (Canadian TV) [edited]
http://www.ctvnews.ca/politics/new-coro ... -1.1208249
The World Health Organization says there has been another infection with the new coronavirus, this time in someone who was a contact of an earlier case. But the Geneva-based global health agency says it doesn't have enough information to estimate whether the new infection was the result of person-to-person spread. The case is from Saudi Arabia, the 9th from that country.
Globally there have now been 16 confirmed infections from the new virus -- which is from the same family as SARS -- with at least 9 deaths.
The WHO statement says the newest case was a contact of a 39-year-old Saudi man who died from the infection on [2 Mar 2013]. The newest case is a person who had mild illness only; the person has recovered and has been released from hospital. The WHO says currently it doesn't know enough to gauge whether the new case was infected by the 39-year-old man, or contracted the virus from the same source as he did. In fact, it appears that the WHO may know very little about the new case.
The press release from the agency does not reveal the individual's gender or age. Nor does it say when the person fell ill, was hospitalized and released from hospital.
WHO press releases announcing infections with the new coronavirus -- which it calls NCoV -- generally contain those kinds of details when the health agency has them.
If it turns out this is a case of person-to-person spread, it would not be the 1st time that has been seen. There have been at least 3 instances where human-to-human spread is suspected, and in one of those cases it is assumed to have happened. That instance involved a cluster of cases in Britain, started by a man who returned home ill after a trip to Pakistan and Saudi Arabia. The man's son, who had cancer, became infected and died. Another member of their extended family was infected, but she had only mild illness. As the son and the 3rd case in that cluster had not travelled outside Britain before becoming ill, it is believed they contracted the virus from the man who had travelled.
A British newspaper, the Birmingham Mail, reported Saturday [23 Mar 2013] that the 1st case in that cluster succumbed to his illness this week. But the WHO's statement Saturday [23 Mar 2013] does not reflect an additional death caused by the coronavirus.
The new virus was 1st spotted last June [2012] after a man from the Saudi capital, Riyadh, died from an infection for which a cause could not initially be discovered.
Subsequently it was recognized that earlier cases had occurred in Jordan, where 11 people fell ill last April [2012] in a cluster of mysterious infections in a hospital. Stored samples from the 2 fatal cases in that cluster later revealed they had been infected with the coronavirus.
When a blood test to determine past infection becomes available, it may be possible to determine if others in that cluster were also infected. But to date laboratories working to develop a blood test that picks up these cases has proved difficult to develop.
To date 4 countries have recorded infections: Saudi Arabia, with 9 cases and 6 deaths; Qatar, with 2 cases; Britain, with 3 cases and one (or 2) deaths; and Jordan, with 2 fatal cases.
--
Communicated by:
ProMED-mail
<promed@promedmail.org>
******
[3] UK - fatality
Date: 23 Mar 2013
Source: Birmingham Mail [edited]
http://www.birminghammail.co.uk/lifesty ... ks-1877516
Birmingham grandad is UK's 2nd Coronavirus victim
-------------------
[The Birmingham resident], of Winson Green, lost a battle against a SARS-like bug in hospital on Tuesday [19 Mar 2013]. [The Birmingham resident] has become the UK's 2nd victim to the new SARS-like bug Coronavirus. The tragedy comes as his wife and daughter were in Pakistan after burying his [38-year-old son], who had also fallen victim to the killer disease.
The dad-of-2, in his 60s, of Winson Green, was being treated at Wythenshawe Hospital, in Manchester, and seemed to be improving. But he took a turn for the worse and lost his battle on Tuesday [19 Mar 2013]. His funeral was held at a mosque in Small Heath, on Wednesday [20 Mar 2013] and his body has now been taken to Pakistan for burial.
[The 60 year old man] had contracted the disease after a trip to Saudi Arabia with his daughter. He complained of a temperature and chest problems upon his return at the end of January [2013] and within a few days he was admitted to City Hospital, in Birmingham.
It's thought during this period that his [38-year-old] son, dad-of-2, suffering from cancer, picked up the bug from his father. [The son] was undergoing chemotherapy at the Queen Elizabeth Hospital, in Edgbaston. He continued to be treated there for both conditions and died on [17 Feb 2013].
The 1st patients infected with the coronavirus fell ill in Jordan, Qatar and Saudi Arabia last year [2012], but the source of the infection remains unknown, despite missions by the World Health Organisation and other international groups. As with SARS, the virus has most likely jumped from bats into other animals, in this case perhaps goats or other livestock, which have gone on to infect humans.
It has infected at least 15 people since it emerged in the Middle East last year [2013] - more than half of whom have died of pneumonia and multiple organ failure, symptoms that were common in SARS patients.
A Wythenshawe Hospital spokesman confirmed [that the patient] had died on Tuesday [19 Mar 2013].
[Byline: Anuji Varma]
--
Communicated by:
ProMED-mail
<promed@promedmail.org>
[As stated above, the total number of confirmed cases of illness associated with infection with the novel coronavirus (nCoV) is now 16, of which 10 had a fatal outcome, a case fatality rate (CFR) of 62.5 per cent. As mentioned in an earlier report, the total number of confirmed cases to date is small (16), the observed CFR of 62.5 may be a reflection of non-confirmation of milder illness associated with infection with this nCoV. The newswire in [3] seems to confirm the report of the death of the index case in the UK cluster of nCoV infections. As a reminder, the index case had a history of travel to Pakistan and Saudi Arabia during the incubation period for nCoV infection.
The breakdown of cases (and deaths) by country of report is:
- Saudi Arabia: 9 (6 deaths)
- Jordan: 2 (2 deaths)
- UK: 4 (1 patient from Qatar -- under treatment, 3 patients from UK -- one with history of travel to Saudi Arabia and Pakistan prior to illness; one recovered, 2 deaths)
- Germany: one (patient from Qatar -- discharged).
As mentioned in the newswire in report [2] above, at present, retrospective identification of cases with milder clinical illness infected with this nCoV has not been successful to date. One suspects that the report of the cluster of ICU staff in Jordan did have more cases than were confirmed, but in the absence of laboratory confirmation it is difficult to definitively state they were infected with the nCoV.
The absence of more information on the newly reported case in Saudi Arabia makes any interpretation/discussion of the possible route of transmission difficult at this time. This moderator attempted a search of the Arabic language media [using an online translation tool] to see if there were any local reports on this case that might shed more information. Unfortunately the only articles found were summaries of the current WHO announcement. More information from knowledgeable sources in the region would be greatly appreciated.
For the HealthMap/ProMED map of the middle eastern region showing Saudi Arabia and surrounding countries, see http://healthmap.org/r/1HAJ. - Mod.MPP]
-
Birgitt
- Moderator
- Beiträge: 35341
- Registriert: Di 2. Aug 2005, 22:52
- Wohnort: NRW / Südl. Rheinland
- Kontaktdaten:
Neuartiger Corona-Virus - Deutschland ex VAE
NOVEL CORONAVIRUS - EASTERN MEDITERRANEAN (13): GERMANY ex UAE
**************************************************************
A ProMED-mail post
http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases
http://www.isid.org
In this report:
[1] Germany ex UAE - RKI report
[2] Germany ex UAE, Saudi Arabia - CIDRAP
[3] Germany ex UAE - German newswire
[4] Summary table of nCoV cases to date - RKI
******
[1]Germany ex UAE - RKI
Date: 25 Mar 2013
Source: Robert Koch Institute (RKI) [machine trans. edited]
http://www.rki.de/DE/Content/InfAZ/C/Co ... 662#Inhalt
Coronavirus infections
Update on Robert Koch Institute (RKI) risk assessment on disease from the novel coronavirus (HCoV-EMC)
---------------
2nd case imported to Germany:
A patient hospitalized in Munich since [19 Mar 2013] was confirmed as having an infection with the novel coronavirus [nCoV] on [23 Mar 2013]. The man had been in a hospital in Abu Dhabi, United Arab Emirates, and was [transferred] to Germany. The patient is being treated in intensive care. The contact investigation is being conducted by the health department in Munich, and all contacts have been informed. This is the 2nd case of disease [caused by the nCoV] imported to Germany. The 1st patient was transferred to Germany on [24 Oct 2012] for treatment and has recovered (see further information of the City of Munich for the 2nd imported case into Germany).
Information on all confirmed cases are summarized in a table (see below)
On the background of a possible human-to-human transmission:
The 1st possible cluster of cases was reported in a family in Saudi Arabia in 2012. In this family, 2 males were infected, there was a short period of unprotected contact involved in the care of the 1st patient which may be considered as a possible source of transmission.
In February 2013 the last 3 reported cases from the UK had been confirmed. This affected a patient ["the index case"] who prior to his illness had visited Saudi Arabia, and 2 family members of the index patient. One of the family members died, the other was diagnosed with milder respiratory symptoms and recovered quickly.
Risk assessment:
There is still no evidence of continuous human-to-human transmission. In Germany, there have been only 2 imported cases of [nCoV associated illness]. There is no increased risk of disease in the general population.
The care of probable cases in the hospital shall continue to include strict measures according to recommendations for diseases caused by the SARS CoV, because of the severe course of these diseases. This recommendation also is for individuals to avoid contact with sick persons with a history of travel to the Arabian Peninsula.
The Robert Koch Institute has differential diagnostic laboratory tests (see case definition of the RKI of [12 Dec 2012]). The specific diagnosis of novel coronavirus has been established at the Robert Koch Institute and the Institute of Virology at the University of Bonn (see also notes the RKI for laboratory diagnostics).
For more information [there are links to these documents at the source URL provided above]:
City of Munich on the 2nd imported into Germany case
Table of confirmed cases of infection with the new coronavirus (HCoV-EMC) (see below)
Recommendations of the Robert Koch Institute for Hygiene and infection control in patients with severe acute respiratory infection (SARI)
Case definition of the RKI for severe respiratory disease associated with a novel coronavirus (12/12/2012)
Notes for the laboratory diagnosis of suspected severe acute respiratory syndrome due to infection with a new human beta 2c EMC/2012 coronavirus (HCoV-EMC)
--
Communicated by:
Daniel Lucey
<daniel.lucey8@gmail.com
******
[2] Germany ex UAE, Saudi Arabia - CIDRAP
Date: 25 Mar 2013
Source: CIDRAP
http://www.cidrap.umn.edu/cidrap/conten ... orona.html
Germany, Saudi Arabia report new novel coronavirus cases
-----------------
The German media and Saudi Arabia's health ministry have reported 2 new novel coronavirus (NCoV) cases, one in a patient hospitalized in Munich and the other a mild illness in a Saudi Arabian resident.
According to an early report today [25 Mar 2013] in German from Abendzeitung, a news source based in Munich, the German patient arrived in Germany from the Middle East by medical transport. It says the patient is in isolation in the intensive care unit (ICU) at Munich Municipal Hospital.
The patient is a 73-year-old man from the United Arab Emirates who was 1st treated in an Abu Dhabi hospital on [19 Mar 2013], another German news source, TZ Online, reported today [25 Mar 2013]. It said medical authorities are monitoring about 50 people who had contact with the patient.
The case appears to be Germany's 2nd NCoV case. In October [2012] a Qatari man was hospitalized and treated in Germany but has since recovered. The man's NCoV infection wasn't detected until almost a month after he was hospitalized, and so far no evidence of infection has been found in any of that case-patient's German contacts.
Saudi Arabia's health ministry said its new case is a contact of a 39-year-old man who died in early March [2013] from the disease in that country, according to a [23 Mar 2013] World Health Organization (WHO) statement [see prior ProMED-mail report on this case Novel coronavirus - Eastern Mediterranean (12): KSA, UK fatality, RFI 20130323.1600113]. The patient had a mild illness, recovered, and has been discharged from the hospital. It said there isn't enough information to allow a conclusive assessment of the mode and source of transmission.
The WHO provided no other details about the patient's NCoV infection. However, Ziad Al-Memish, undersecretary with the health ministry, said the patient is from Riyadh, Arab News, an English-language newspaper based in Jeddah, reported yesterday [24 Mar 2013]. He added that the ministry has taken prevention measures and is monitoring the disease.
The latest infection in Saudi Arabia appears to represent yet another instance of a mild illness in a person who had contact with another infected patient. Though the disease has been fatal for many patients infected with NCoV, the emergence of mild cases has raised questions about surveillance for the disease and whether people with asymptomatic or mild disease could be playing a role in the spread of the virus.
In a related development, the index patient in a recent 3-case British family cluster has died, according to a [23 Mar 2013] Birmingham Mail report. The man died at Wythenshawe Hospital in Manchester on [19 Mar 2013], and his body has been taken to Pakistan for burial. The 60-year-old man got sick at the end of January [2012] after traveling to Pakistan and Saudi Arabia and has remained hospitalized.
The Saudi Arabian case pushes the number of WHO-confirmed NCoV cases to 16, and the UK death raises the fatality count to 10. That count does not include Germany's new case.
The 2nd patient sickened in the UK family cluster was a 38-year-old male household contact who died on [17 Feb 2013]. The Birmingham Mail report said he was the older man's son. The 3rd patient is a 30-year-old woman from a different household who got sick with a mild NCoV infection after visiting the older man 3 times in the hospital.
Two other clusters have been reported among the NCoV cases, but few details are known. One involved 3 members of one Saudi family and the other included 2 Jordanian deaths that were part of a cluster linked to a hospital ICU.
In other coronavirus developments, though NCoV doesn't appear to spread easily from person-to-person so far, some infectious disease experts aren't ruling out the possibility that "superspreaders" could contract the virus and contribute to a more global outbreak, much the way SARS (severe acute respiratory syndrome) spread 10 years ago, the Canadian Press (CP) reported today. [for the full article discussing the possibility of "superspreaders", see the article by Helen Branswell, available at http://ca.news.yahoo.com/superspreaders ... 19467.html. - Mod.MPP]
Ron Fouchier, PhD, told the CP that the current transmission patter could change quickly if an NCoV superspreader were hospitalized in a facility that didn't recognize the disease and take precautions. The CP story noted that during the SARS epidemic only a few people infected a fair number more, which uncovered the disease and sparked global panic.
Donald Low, MD, a microbiologist from Toronto who played a key role in Canada's response to SARS, told the CP that it's impossible to predict the spread of NCoV, because coronaviruses are RNA viruses, which are known for mutating rapidly.
[Byline: Lisa Schnirring]
--
Communicated by:
ProMED-mail Rapporteur Mary Marshall
******
[3] Germany ex UAE - German newswire
Date: 25 Mar 2013
Source: TZ Online [machine trans. edited]
http://www.tz-online.de/aktuelles/muenc ... 20137.html
In the Schwabing [Hospital] isolation ward, doctors fight for the life of an Arab, who is seriously ill with the dangerous coronavirus. 50 people [in Munich], who had contact with him are now being observed.
The virus appears not to be extremely contagious - but is extremely deadly: Worldwide only 16 infections with the new coronavirus are known, [of which] 9 patients died [there was a 10th death that occurred last week. - Mod.MPP]. Now a man in Munich is in danger. The health authorities are monitoring around 50 people in the city, who had contact with the patient. For the population no risk of infection had passed.
The patient lies in the Schwabing Hospital in an isolation room in the ICU. "The condition is clinically critical," said the chief of infectious diseases Clemens Wendtner. The patient is on a ventilator [assisted breathing].
Not much information is available on the patient due to privacy concerns. The 73-year-old comes from the United Arab Emirates, so far all of the cases of nCoV have occurred on the [Arabian] Peninsula. [Of the 16 confirmed cases, there were 2 in Jordan and 2 cases in the UK. These latter 2 cases were contacts of a 3rd case in the UK who had traveled to Pakistan and Saudi Arabia during the incubation period for the infection. - Mod.MPP] This current case was admitted to a hospital in Abu Dhabi on [10 Mar 2013]. Last Tuesday [19 Mar 2013], he arrived in Germany by private jet for treatment. At the time of arrival, the etiology of his illness was not known and he was on mechanical ventilation. He was taken by an intensive care ambulance to Schwabing. The doctors quickly classified this as a serious infection and placed him in isolation. On Saturday [24 Mar 2013] the laboratory sent an alarm: the novel human coronavirus Beta 2c EMC/2012 was identified.
At present, while little is known of this pathogen, the World Health Organization has warned over the past 6 months that the virus belongs to the same family as the SARS virus. "The risk of infection is not the same but," says Prof. Wendtner, patients are therefore not in the highest category as for Ebola and SARS isolation, but in the 2nd highest. "But the mortality rate is very high among those affected."
According to recent studies, the disease could transmitted in the Middle East from animals to humans -- possibly via contact with dust particles contaminated with dried bat excrement, or through direct contact with it.
Whether and how the virus is transmitted from person to person is not clear: In the 1st case in Germany in the fall of 2012 there was no further infection [among contacts]. A 45-year-old from Qatar had been treated from Qatar [in Germany] and recovered. Recently, however, a Briton was infected in Pakistan or Saudi Arabia. After returning 2 younger family members were infected [through presumed contact with this patient] and his 38-year-old son died.
Therefore, the Munich city health department has approximately 50 people in Munich under observation - especially relatives [of the patient] and hospital staff. To date, these contacts have not been isolated and are not considered to be a great risk. they can move around freely and clinical staff are on duty. They all have to give a blood sample and report daily to the authorities announcing if they experience symptoms. [This is being done as] "A precautionary measure", reassured Prof. Wendtner. The circle [of observation] has been drawn very large on purpose. "So far, no one is showing symptoms."
--
Communicated by:
ProMED-mail
<promed@promedmail.org>
******
[4] Summary table of nCoV cases to date - RKI
Date: 25 Mar 2013
Source: Robert Koch Institute (RKI)
<http://www.rki.de/DE/Content/InfAZ/C/Co ... cationFile
Confirmed cases of coronavirus (hnCoV-EMC)
Case No: date of onset / age / gender (M/F) / most likely location of infection / date of report / date of death / ? cluster / date of hospitalization
1: 1 Apr 2012 / 45 / F / Jordan / 30 Nov 2012 / April 2012 / Yes - Hospital A / yes [NA]
2: 1 Apr 2012 / 25 / M / Jordan / 30 Nov 2012 / April 2012 / Yes - Hospital A / yes [NA]
3: 13 Jun 2012 / 60 / M / KSA / 20 Sep 2012 / 20 Jun 2012 / - / 13 Jun 2012
4: 3 Sep 2012 / 49 / M / Qatar, Saudi Arabia / 23 Sep 2012 / No / - / 3 Sep 2012
5: 10 Oct 2012 / 45 / M / KSA / 7 Nov 2012 / No / - / 12 Oct 2012
6: 5 Oct 2012 / 45 / M / Qatar / 23 Nov 2012 / No / - / 12 Oct 2012; 24 Oct 2012 trans to Germany
7: 3-5 Nov 2012 / 31 / M / KSA / 20 Nov 2012 / No / Yes - Family A / NA
8: 28 Oct 2012 / 39 / M / KSA / 23 Nov 2012 / 1 Nov 2012 / Yes - Family A / 28 Oct 2011
9: October 2012 / 70 / M / KSA / 28 Nov 2012 / 24 Oct 2012 / Yes - Family A / NA
10: 24 Jan 2013 60 / M / Pakistan, KSA / 11 Feb 2013 / [19 Mar 2013] / Yes - Family B / Yes [31 Jan 2013]
11: 6 Feb 2013 / 38 / M / UK / 12 Feb 2013 / [17 Feb 2013] / Yes - Family B / Yes [9 Feb 2013]
12: 5 Feb 2013 / 30 / F / UK / 13 Feb 2013 / No / Yes - Family B / No
13: NA / NA / NA / KSA / 21 Feb 2013 / 10 Feb 2013 / - / 29 Jan 2013
14: NA / 69 / M / KSA / 6 Mar 2013 / 19 Feb 2013 / - / 10 Feb 2013
15: NA / 39 / M / KSA / 12 Mar 2013 / 2 Mar 2013 / Yes - with Case 16 / 28 Feb 2013
16: NA / NA / NA / KSA / 23 Mar 2013 / No / Yes - with Case 15 / Yes, already discharged
17: NA / 73 / M / UAE / 24 Mar 2013 / No / - / 10 Mar 2013; 19 Mar 2013 transferred to Germany
--
Communicated by:
Daniel Lucey
<daniel.lucey8@gmail.com>
[The latest case represents the 17th confirmed case of respiratory illness associated with infection with the nCoV. As with previous cases, there is a linkage to presence in the Middle East (or contact with an individual who had been in the Middle East) prior to onset of illness. In this case, the patient was hospitalized in Abu Dhabi, in the United Arab Emirates (UAE) prior to transfer to Germany. Information on travel history of this patient prior to onset of illness is not available at present.
The table available on the RKI website (see section [4] above) is a good summary of the state of knowledge to date on the epidemiology of this disease -- there are many "holes" in the information available on the cases. Of the 17 cases, 14 were in males, 2 in females and one presently not known. 10 cases have died.
The nCoV is most closely related to a previously identified bat coronavirus. The mechanism for the species jump from bat to human has not been defined as yet. Some speculation is that there has been intermediate infection of domestic farm animals in the Middle East, which then in turn infected the humans. Results of studies conducted on bats and animals in the Middle East are still pending.
More information on the epidemiology of these cases to date would be greatly appreciated.
For the HealthMap/ProMED-mail map of the Middle East/Arabian Peninsula, see http://healthmap.org/r/1HAJ.
For a map of the United Arab Emirates, see http://emiratesvoyage.com/i/maps/uae/uae_map_3.gif. - Mod.MPP]
**************************************************************
A ProMED-mail post
http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases
http://www.isid.org
In this report:
[1] Germany ex UAE - RKI report
[2] Germany ex UAE, Saudi Arabia - CIDRAP
[3] Germany ex UAE - German newswire
[4] Summary table of nCoV cases to date - RKI
******
[1]Germany ex UAE - RKI
Date: 25 Mar 2013
Source: Robert Koch Institute (RKI) [machine trans. edited]
http://www.rki.de/DE/Content/InfAZ/C/Co ... 662#Inhalt
Coronavirus infections
Update on Robert Koch Institute (RKI) risk assessment on disease from the novel coronavirus (HCoV-EMC)
---------------
2nd case imported to Germany:
A patient hospitalized in Munich since [19 Mar 2013] was confirmed as having an infection with the novel coronavirus [nCoV] on [23 Mar 2013]. The man had been in a hospital in Abu Dhabi, United Arab Emirates, and was [transferred] to Germany. The patient is being treated in intensive care. The contact investigation is being conducted by the health department in Munich, and all contacts have been informed. This is the 2nd case of disease [caused by the nCoV] imported to Germany. The 1st patient was transferred to Germany on [24 Oct 2012] for treatment and has recovered (see further information of the City of Munich for the 2nd imported case into Germany).
Information on all confirmed cases are summarized in a table (see below)
On the background of a possible human-to-human transmission:
The 1st possible cluster of cases was reported in a family in Saudi Arabia in 2012. In this family, 2 males were infected, there was a short period of unprotected contact involved in the care of the 1st patient which may be considered as a possible source of transmission.
In February 2013 the last 3 reported cases from the UK had been confirmed. This affected a patient ["the index case"] who prior to his illness had visited Saudi Arabia, and 2 family members of the index patient. One of the family members died, the other was diagnosed with milder respiratory symptoms and recovered quickly.
Risk assessment:
There is still no evidence of continuous human-to-human transmission. In Germany, there have been only 2 imported cases of [nCoV associated illness]. There is no increased risk of disease in the general population.
The care of probable cases in the hospital shall continue to include strict measures according to recommendations for diseases caused by the SARS CoV, because of the severe course of these diseases. This recommendation also is for individuals to avoid contact with sick persons with a history of travel to the Arabian Peninsula.
The Robert Koch Institute has differential diagnostic laboratory tests (see case definition of the RKI of [12 Dec 2012]). The specific diagnosis of novel coronavirus has been established at the Robert Koch Institute and the Institute of Virology at the University of Bonn (see also notes the RKI for laboratory diagnostics).
For more information [there are links to these documents at the source URL provided above]:
City of Munich on the 2nd imported into Germany case
Table of confirmed cases of infection with the new coronavirus (HCoV-EMC) (see below)
Recommendations of the Robert Koch Institute for Hygiene and infection control in patients with severe acute respiratory infection (SARI)
Case definition of the RKI for severe respiratory disease associated with a novel coronavirus (12/12/2012)
Notes for the laboratory diagnosis of suspected severe acute respiratory syndrome due to infection with a new human beta 2c EMC/2012 coronavirus (HCoV-EMC)
--
Communicated by:
Daniel Lucey
<daniel.lucey8@gmail.com
******
[2] Germany ex UAE, Saudi Arabia - CIDRAP
Date: 25 Mar 2013
Source: CIDRAP
http://www.cidrap.umn.edu/cidrap/conten ... orona.html
Germany, Saudi Arabia report new novel coronavirus cases
-----------------
The German media and Saudi Arabia's health ministry have reported 2 new novel coronavirus (NCoV) cases, one in a patient hospitalized in Munich and the other a mild illness in a Saudi Arabian resident.
According to an early report today [25 Mar 2013] in German from Abendzeitung, a news source based in Munich, the German patient arrived in Germany from the Middle East by medical transport. It says the patient is in isolation in the intensive care unit (ICU) at Munich Municipal Hospital.
The patient is a 73-year-old man from the United Arab Emirates who was 1st treated in an Abu Dhabi hospital on [19 Mar 2013], another German news source, TZ Online, reported today [25 Mar 2013]. It said medical authorities are monitoring about 50 people who had contact with the patient.
The case appears to be Germany's 2nd NCoV case. In October [2012] a Qatari man was hospitalized and treated in Germany but has since recovered. The man's NCoV infection wasn't detected until almost a month after he was hospitalized, and so far no evidence of infection has been found in any of that case-patient's German contacts.
Saudi Arabia's health ministry said its new case is a contact of a 39-year-old man who died in early March [2013] from the disease in that country, according to a [23 Mar 2013] World Health Organization (WHO) statement [see prior ProMED-mail report on this case Novel coronavirus - Eastern Mediterranean (12): KSA, UK fatality, RFI 20130323.1600113]. The patient had a mild illness, recovered, and has been discharged from the hospital. It said there isn't enough information to allow a conclusive assessment of the mode and source of transmission.
The WHO provided no other details about the patient's NCoV infection. However, Ziad Al-Memish, undersecretary with the health ministry, said the patient is from Riyadh, Arab News, an English-language newspaper based in Jeddah, reported yesterday [24 Mar 2013]. He added that the ministry has taken prevention measures and is monitoring the disease.
The latest infection in Saudi Arabia appears to represent yet another instance of a mild illness in a person who had contact with another infected patient. Though the disease has been fatal for many patients infected with NCoV, the emergence of mild cases has raised questions about surveillance for the disease and whether people with asymptomatic or mild disease could be playing a role in the spread of the virus.
In a related development, the index patient in a recent 3-case British family cluster has died, according to a [23 Mar 2013] Birmingham Mail report. The man died at Wythenshawe Hospital in Manchester on [19 Mar 2013], and his body has been taken to Pakistan for burial. The 60-year-old man got sick at the end of January [2012] after traveling to Pakistan and Saudi Arabia and has remained hospitalized.
The Saudi Arabian case pushes the number of WHO-confirmed NCoV cases to 16, and the UK death raises the fatality count to 10. That count does not include Germany's new case.
The 2nd patient sickened in the UK family cluster was a 38-year-old male household contact who died on [17 Feb 2013]. The Birmingham Mail report said he was the older man's son. The 3rd patient is a 30-year-old woman from a different household who got sick with a mild NCoV infection after visiting the older man 3 times in the hospital.
Two other clusters have been reported among the NCoV cases, but few details are known. One involved 3 members of one Saudi family and the other included 2 Jordanian deaths that were part of a cluster linked to a hospital ICU.
In other coronavirus developments, though NCoV doesn't appear to spread easily from person-to-person so far, some infectious disease experts aren't ruling out the possibility that "superspreaders" could contract the virus and contribute to a more global outbreak, much the way SARS (severe acute respiratory syndrome) spread 10 years ago, the Canadian Press (CP) reported today. [for the full article discussing the possibility of "superspreaders", see the article by Helen Branswell, available at http://ca.news.yahoo.com/superspreaders ... 19467.html. - Mod.MPP]
Ron Fouchier, PhD, told the CP that the current transmission patter could change quickly if an NCoV superspreader were hospitalized in a facility that didn't recognize the disease and take precautions. The CP story noted that during the SARS epidemic only a few people infected a fair number more, which uncovered the disease and sparked global panic.
Donald Low, MD, a microbiologist from Toronto who played a key role in Canada's response to SARS, told the CP that it's impossible to predict the spread of NCoV, because coronaviruses are RNA viruses, which are known for mutating rapidly.
[Byline: Lisa Schnirring]
--
Communicated by:
ProMED-mail Rapporteur Mary Marshall
******
[3] Germany ex UAE - German newswire
Date: 25 Mar 2013
Source: TZ Online [machine trans. edited]
http://www.tz-online.de/aktuelles/muenc ... 20137.html
In the Schwabing [Hospital] isolation ward, doctors fight for the life of an Arab, who is seriously ill with the dangerous coronavirus. 50 people [in Munich], who had contact with him are now being observed.
The virus appears not to be extremely contagious - but is extremely deadly: Worldwide only 16 infections with the new coronavirus are known, [of which] 9 patients died [there was a 10th death that occurred last week. - Mod.MPP]. Now a man in Munich is in danger. The health authorities are monitoring around 50 people in the city, who had contact with the patient. For the population no risk of infection had passed.
The patient lies in the Schwabing Hospital in an isolation room in the ICU. "The condition is clinically critical," said the chief of infectious diseases Clemens Wendtner. The patient is on a ventilator [assisted breathing].
Not much information is available on the patient due to privacy concerns. The 73-year-old comes from the United Arab Emirates, so far all of the cases of nCoV have occurred on the [Arabian] Peninsula. [Of the 16 confirmed cases, there were 2 in Jordan and 2 cases in the UK. These latter 2 cases were contacts of a 3rd case in the UK who had traveled to Pakistan and Saudi Arabia during the incubation period for the infection. - Mod.MPP] This current case was admitted to a hospital in Abu Dhabi on [10 Mar 2013]. Last Tuesday [19 Mar 2013], he arrived in Germany by private jet for treatment. At the time of arrival, the etiology of his illness was not known and he was on mechanical ventilation. He was taken by an intensive care ambulance to Schwabing. The doctors quickly classified this as a serious infection and placed him in isolation. On Saturday [24 Mar 2013] the laboratory sent an alarm: the novel human coronavirus Beta 2c EMC/2012 was identified.
At present, while little is known of this pathogen, the World Health Organization has warned over the past 6 months that the virus belongs to the same family as the SARS virus. "The risk of infection is not the same but," says Prof. Wendtner, patients are therefore not in the highest category as for Ebola and SARS isolation, but in the 2nd highest. "But the mortality rate is very high among those affected."
According to recent studies, the disease could transmitted in the Middle East from animals to humans -- possibly via contact with dust particles contaminated with dried bat excrement, or through direct contact with it.
Whether and how the virus is transmitted from person to person is not clear: In the 1st case in Germany in the fall of 2012 there was no further infection [among contacts]. A 45-year-old from Qatar had been treated from Qatar [in Germany] and recovered. Recently, however, a Briton was infected in Pakistan or Saudi Arabia. After returning 2 younger family members were infected [through presumed contact with this patient] and his 38-year-old son died.
Therefore, the Munich city health department has approximately 50 people in Munich under observation - especially relatives [of the patient] and hospital staff. To date, these contacts have not been isolated and are not considered to be a great risk. they can move around freely and clinical staff are on duty. They all have to give a blood sample and report daily to the authorities announcing if they experience symptoms. [This is being done as] "A precautionary measure", reassured Prof. Wendtner. The circle [of observation] has been drawn very large on purpose. "So far, no one is showing symptoms."
--
Communicated by:
ProMED-mail
<promed@promedmail.org>
******
[4] Summary table of nCoV cases to date - RKI
Date: 25 Mar 2013
Source: Robert Koch Institute (RKI)
<http://www.rki.de/DE/Content/InfAZ/C/Co ... cationFile
Confirmed cases of coronavirus (hnCoV-EMC)
Case No: date of onset / age / gender (M/F) / most likely location of infection / date of report / date of death / ? cluster / date of hospitalization
1: 1 Apr 2012 / 45 / F / Jordan / 30 Nov 2012 / April 2012 / Yes - Hospital A / yes [NA]
2: 1 Apr 2012 / 25 / M / Jordan / 30 Nov 2012 / April 2012 / Yes - Hospital A / yes [NA]
3: 13 Jun 2012 / 60 / M / KSA / 20 Sep 2012 / 20 Jun 2012 / - / 13 Jun 2012
4: 3 Sep 2012 / 49 / M / Qatar, Saudi Arabia / 23 Sep 2012 / No / - / 3 Sep 2012
5: 10 Oct 2012 / 45 / M / KSA / 7 Nov 2012 / No / - / 12 Oct 2012
6: 5 Oct 2012 / 45 / M / Qatar / 23 Nov 2012 / No / - / 12 Oct 2012; 24 Oct 2012 trans to Germany
7: 3-5 Nov 2012 / 31 / M / KSA / 20 Nov 2012 / No / Yes - Family A / NA
8: 28 Oct 2012 / 39 / M / KSA / 23 Nov 2012 / 1 Nov 2012 / Yes - Family A / 28 Oct 2011
9: October 2012 / 70 / M / KSA / 28 Nov 2012 / 24 Oct 2012 / Yes - Family A / NA
10: 24 Jan 2013 60 / M / Pakistan, KSA / 11 Feb 2013 / [19 Mar 2013] / Yes - Family B / Yes [31 Jan 2013]
11: 6 Feb 2013 / 38 / M / UK / 12 Feb 2013 / [17 Feb 2013] / Yes - Family B / Yes [9 Feb 2013]
12: 5 Feb 2013 / 30 / F / UK / 13 Feb 2013 / No / Yes - Family B / No
13: NA / NA / NA / KSA / 21 Feb 2013 / 10 Feb 2013 / - / 29 Jan 2013
14: NA / 69 / M / KSA / 6 Mar 2013 / 19 Feb 2013 / - / 10 Feb 2013
15: NA / 39 / M / KSA / 12 Mar 2013 / 2 Mar 2013 / Yes - with Case 16 / 28 Feb 2013
16: NA / NA / NA / KSA / 23 Mar 2013 / No / Yes - with Case 15 / Yes, already discharged
17: NA / 73 / M / UAE / 24 Mar 2013 / No / - / 10 Mar 2013; 19 Mar 2013 transferred to Germany
--
Communicated by:
Daniel Lucey
<daniel.lucey8@gmail.com>
[The latest case represents the 17th confirmed case of respiratory illness associated with infection with the nCoV. As with previous cases, there is a linkage to presence in the Middle East (or contact with an individual who had been in the Middle East) prior to onset of illness. In this case, the patient was hospitalized in Abu Dhabi, in the United Arab Emirates (UAE) prior to transfer to Germany. Information on travel history of this patient prior to onset of illness is not available at present.
The table available on the RKI website (see section [4] above) is a good summary of the state of knowledge to date on the epidemiology of this disease -- there are many "holes" in the information available on the cases. Of the 17 cases, 14 were in males, 2 in females and one presently not known. 10 cases have died.
The nCoV is most closely related to a previously identified bat coronavirus. The mechanism for the species jump from bat to human has not been defined as yet. Some speculation is that there has been intermediate infection of domestic farm animals in the Middle East, which then in turn infected the humans. Results of studies conducted on bats and animals in the Middle East are still pending.
More information on the epidemiology of these cases to date would be greatly appreciated.
For the HealthMap/ProMED-mail map of the Middle East/Arabian Peninsula, see http://healthmap.org/r/1HAJ.
For a map of the United Arab Emirates, see http://emiratesvoyage.com/i/maps/uae/uae_map_3.gif. - Mod.MPP]
-
Birgitt
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Neuartiger Corona-Virus - WHO update
NOVEL CORONAVIRUS - EASTERN MEDITERRANEAN (14): GERMANY ex UAE, WHO, FATAL
**************************************************************************
A ProMED-mail post
http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases
http://www.isid.org
Date: 26 Mar 2013
Source: WHO Global Alert and Response (GAR)
http://www.who.int/csr/don/2013_03_26/en/index.html
Novel coronavirus infection - update [26 Mar 2013]
---------------
The Robert Koch Institute [RKI] informed the World Health Organization (WHO) of a new confirmed case of infection with the novel coronavirus (nCoV). The patient was a 73-year-old male from United Arab Emirates [UAE], who was transferred from a hospital in Abu Dhabi to Munich by air ambulance on [19 Mar 2013]. He died on [26 Mar 2013].
In the United Kingdom, the index patient in the family cluster reported on [11 Feb 2013] with travel history to Pakistan and Saudi Arabia prior to his illness, has died.
To date, the WHO has been informed of a global total of 17 confirmed cases of human infection with nCoV, including 11 deaths.
Based on the current situation and available information, the WHO encourages all Member States (MS) to continue their surveillance for severe acute respiratory infections (SARI) and to carefully review any unusual patterns. The WHO is currently working with international experts and countries where cases have been reported to assess the situation and review recommendations for surveillance and monitoring.
All MS are reminded to promptly assess and notify the WHO of any new case of infection with nCoV, along with information about potential exposures that may have resulted in infection and a description of the clinical course.
The WHO does not advise special screening at points of entry with regard to this event nor does it recommend that any travel or trade restrictions be applied. The WHO continues to closely monitor the situation.
--
Communicated by:
ProMED-mail Rapporteur Marianne Hopp
[The above mentioned cases were reported in earlier ProMED-mail posts, including a media report announcing the death of the case in the UK (see Novel coronavirus - Eastern Mediterranean (13): Germany ex UAE 20130326.1603038 and Novel coronavirus - Eastern Mediterranean (12): KSA, UK fatality, RFI 20130323.1600113).
As of today, 26 Mar 2013, the breakdown of cases (and deaths) by country of report is:
- Saudi Arabia: 9 (6 deaths)
- Jordan: 2 (2 deaths)
- UK: 4 (one patient from Qatar -- under treatment, 3 patients from UK -- one with history of travel to Saudi Arabia and Pakistan prior to illness; one recovered, 2 deaths)
- Germany: 2 (one patient from Qatar -- discharged, one patient from the UAE - one death).
As mentioned in the above WHO release, the total number of confirmed nCoV cases is now 17 with 11 deaths, bringing the case fatality ratio to 64.7 percent. Caution in interpretation of this figure as the numbers of cases is still very low and the ability to detect prior mild infections with this specific coronavirus is presently absent. Given the histories of other respiratory illnesses in contacts of cases that were relatively mild and associated with full recovery, but tested negative for infection with the nCoV, the possibility that there are more infections associated with milder disease is there.
In the report of the Jordanian cluster, there were a total of 11 individuals reported to have had respiratory illnesses, with confirmation of nCoV infection in specimens from the 2 fatal cases only (see prior ProMED-mail reports: Novel coronavirus - Eastern Mediterranean: WHO, Jordan, conf., RFI 20121130.1432498 and Novel coronavirus - Saudi Arabia (04): RFI, Jordan, April 2012 20120925.1308001).
More information on the epidemiologic investigations of this newest case would be greatly appreciated.
For the HealthMap/ProMED map showing the UAE, see http://healthmap.org/r/1HAK. - Mod.MPP]
**************************************************************************
A ProMED-mail post
http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases
http://www.isid.org
Date: 26 Mar 2013
Source: WHO Global Alert and Response (GAR)
http://www.who.int/csr/don/2013_03_26/en/index.html
Novel coronavirus infection - update [26 Mar 2013]
---------------
The Robert Koch Institute [RKI] informed the World Health Organization (WHO) of a new confirmed case of infection with the novel coronavirus (nCoV). The patient was a 73-year-old male from United Arab Emirates [UAE], who was transferred from a hospital in Abu Dhabi to Munich by air ambulance on [19 Mar 2013]. He died on [26 Mar 2013].
In the United Kingdom, the index patient in the family cluster reported on [11 Feb 2013] with travel history to Pakistan and Saudi Arabia prior to his illness, has died.
To date, the WHO has been informed of a global total of 17 confirmed cases of human infection with nCoV, including 11 deaths.
Based on the current situation and available information, the WHO encourages all Member States (MS) to continue their surveillance for severe acute respiratory infections (SARI) and to carefully review any unusual patterns. The WHO is currently working with international experts and countries where cases have been reported to assess the situation and review recommendations for surveillance and monitoring.
All MS are reminded to promptly assess and notify the WHO of any new case of infection with nCoV, along with information about potential exposures that may have resulted in infection and a description of the clinical course.
The WHO does not advise special screening at points of entry with regard to this event nor does it recommend that any travel or trade restrictions be applied. The WHO continues to closely monitor the situation.
--
Communicated by:
ProMED-mail Rapporteur Marianne Hopp
[The above mentioned cases were reported in earlier ProMED-mail posts, including a media report announcing the death of the case in the UK (see Novel coronavirus - Eastern Mediterranean (13): Germany ex UAE 20130326.1603038 and Novel coronavirus - Eastern Mediterranean (12): KSA, UK fatality, RFI 20130323.1600113).
As of today, 26 Mar 2013, the breakdown of cases (and deaths) by country of report is:
- Saudi Arabia: 9 (6 deaths)
- Jordan: 2 (2 deaths)
- UK: 4 (one patient from Qatar -- under treatment, 3 patients from UK -- one with history of travel to Saudi Arabia and Pakistan prior to illness; one recovered, 2 deaths)
- Germany: 2 (one patient from Qatar -- discharged, one patient from the UAE - one death).
As mentioned in the above WHO release, the total number of confirmed nCoV cases is now 17 with 11 deaths, bringing the case fatality ratio to 64.7 percent. Caution in interpretation of this figure as the numbers of cases is still very low and the ability to detect prior mild infections with this specific coronavirus is presently absent. Given the histories of other respiratory illnesses in contacts of cases that were relatively mild and associated with full recovery, but tested negative for infection with the nCoV, the possibility that there are more infections associated with milder disease is there.
In the report of the Jordanian cluster, there were a total of 11 individuals reported to have had respiratory illnesses, with confirmation of nCoV infection in specimens from the 2 fatal cases only (see prior ProMED-mail reports: Novel coronavirus - Eastern Mediterranean: WHO, Jordan, conf., RFI 20121130.1432498 and Novel coronavirus - Saudi Arabia (04): RFI, Jordan, April 2012 20120925.1308001).
More information on the epidemiologic investigations of this newest case would be greatly appreciated.
For the HealthMap/ProMED map showing the UAE, see http://healthmap.org/r/1HAK. - Mod.MPP]
-
Birgitt
- Moderator
- Beiträge: 35341
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Neuartiger Corona-Virus - Deutschland ex VAE
NOVEL CORONAVIRUS - EASTERN MEDITERRANEAN (15): CAMEL EXPOSURE
**************************************************************
A ProMED-mail post
http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases
http://www.isid.org
Date: 4 Apr 2013
Source: ScienceInsider [edited]
http://news.sciencemag.org/scienceinsid ... -came.html
On [26 Mar 2013], a 73-year-old man from Abu Dhabi, the capital of the United Arab Emirates, died at the Klinikum Schwabing, a hospital in Munich [Germany]. He was the 11th known fatality related to infection with the novel coronavirus (nCoV), a pathogen that was 1st reported in September 2012 and is attracting substantial interest from researchers. Overall, officials have reported 17 cases of nCoV infection.
Clemens Wendtner, a professor of medicine and assistant medical director at the University of Cologne, is a physician at the Munich hospital. ScienceInsider asked Wendtner how the case was handled and why he thinks the patient may have been infected by one of his racing camels. Questions and answers have been edited for brevity and clarity.
Q: Why did the patient seek treatment in Germany and why did he come to the Klinikum Schwabing?
C.W.: We are one of 7 reference centers for infectious diseases in Germany; the Klinikum Schwabing has a unit for highly contagious patients, and one of the 1st SARS patients was treated here in 2003. This particular patient was treated in Munich for multiple myeloma, which had been diagnosed in 2009. He flew into Germany on a frequent basis to get chemotherapy and even stem cell transplantation at a private center.
While in Abu Dhabi, his condition deteriorated, and his treating hematologist here in Munich asked to fly him in to get a closer look; the family also wanted him to be transferred. At this point, we only knew he had some pulmonary problems, but we were not aware of any coronavirus testing; this was not done in the United Arab Emirates.
Q: When did you suspect he might have the virus?
C.W.: When we examined his condition and saw his medication list; he had even started on [the influenza drug] Tamiflu, but his condition didn't improve. So we said: "Maybe it's a good idea to check for the coronavirus." So we did a bronchoalveolar lavage, [a procedure to sample fluid from the lungs,] and sent the material to Christian Drosten's lab at the University of Bonn; this is the German reference lab for the new coronavirus. The results came back on [23 Mar 2013]. At this point, the patient's medical condition was quite bad.
Q: Did you take special precautions once you knew he was infected to prevent further infections?
C.W.: That was done from the beginning. We are trained with difficult infectious disease situations, so this is what we do when we don't know what is going on. He was in an intensive care unit and put in special isolation; the staff used special precaution measures, such as 3M masks. We also tested staff for the virus, but nobody was positive.
Q: How many people did you test?
C.W.: We had a group of roughly 60 people, and not only staff members. ... The patient flew in on a private jet, and we screened the crew members as well as 4 relatives who had come with him. But we did PCR testing only for people who had symptoms, such as coughing and flu-like symptoms. There were fewer than 10 of those, and all were negative. The others were put on surveillance screening, but if they didn't develop symptoms, they weren't tested.
Q: Have these precautions ended now?
C.W.: Yes.
Q: Is it worrying that quite a few patients with the new coronavirus have sought medical attention in Germany and the United Kingdom? With SARS, you saw people infecting others on planes or seeding new outbreaks in the countries where they arrived.
C.W.: This virus is not in the same category as SARS in terms of the risk of spread. But one point is very valid: The screening tests, especially in the [Arabian Peninsula], are underdeveloped. So there may be a higher number of undetected cases. I was approached by officials from the U.A.E.; they were worried about this 1st case, because most other cases have been in Saudi Arabia, and they are quite interested in getting testing set up in their country. We will help them, together with professor Drosten in Bonn.
Q: You have said in interviews that he may have become infected through contact with a camel. What is the evidence for that?
C.W.: So far, it's only circumstantial evidence. The patient owned racing camels. One of them got ill and was very weak; the patient was in close contact with that camel, and on the evening the camel got very sick, the patient developed flu-like symptoms. Three days later, he was in a medical unit in Abu Dhabi. There is another family member who also had close contact with the camel; he also got ill, but we could not follow up with that gentleman.
We are really interested to find the missing link, to maybe get some material, some blood, some stool, out of this camel. Professor Drosten may send one of his scientific colleagues to Abu Dhabi. We will also get some help from the U.A.E. consulate in Munich.
Q: So the United Arab Emirates is willing to collaborate on this?
C.W.: Yes, they have understood that it's in their best interest to get a better understanding of how the disease might spread from animals to humans.
Q: Is the camel still alive?
C.W.: Yes, at least it was alive a couple of days ago.
Q: When will this investigation start?
C.W.: As you can imagine, we are very interested insolving this issue, so this would probably have to happen in the next couple of days.
Q: Have you heard about other camels in Abu Dhabi or the United Arab Emirates getting sick?
C.W.: No, I don't have any information on this. Even the consulate could not tell me. But maybe they didn't pay attention before. This just popped up as a problem, so they may have a closer look at this in the future.
[Byline: Martin Enserink]
--
Communicated by:
ProMED-mail
<promed@promedmail.org>
[Of interest in the above report/interview is the history of contact with an ill animal prior to onset of illness. In earlier reports of cases in the Eastern Mediterranean region, there had been reports of contact with farm animals; in one case, there was report of contact with a sick animal prior to onset of illness as well.
ProMED-mail looks forward to reports of additional studies performed in the UAE with respect to this case and the above mentioned possible link with a sick camel.
- Mod.MPP]
[Picture of camel racing in Abu Dhabi:
http://news.bbcimg.co.uk/media/images/5 ... l4_afp.jpg
- Mod.JW
A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/r/1HAJ.]
**************************************************************
A ProMED-mail post
http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases
http://www.isid.org
Date: 4 Apr 2013
Source: ScienceInsider [edited]
http://news.sciencemag.org/scienceinsid ... -came.html
On [26 Mar 2013], a 73-year-old man from Abu Dhabi, the capital of the United Arab Emirates, died at the Klinikum Schwabing, a hospital in Munich [Germany]. He was the 11th known fatality related to infection with the novel coronavirus (nCoV), a pathogen that was 1st reported in September 2012 and is attracting substantial interest from researchers. Overall, officials have reported 17 cases of nCoV infection.
Clemens Wendtner, a professor of medicine and assistant medical director at the University of Cologne, is a physician at the Munich hospital. ScienceInsider asked Wendtner how the case was handled and why he thinks the patient may have been infected by one of his racing camels. Questions and answers have been edited for brevity and clarity.
Q: Why did the patient seek treatment in Germany and why did he come to the Klinikum Schwabing?
C.W.: We are one of 7 reference centers for infectious diseases in Germany; the Klinikum Schwabing has a unit for highly contagious patients, and one of the 1st SARS patients was treated here in 2003. This particular patient was treated in Munich for multiple myeloma, which had been diagnosed in 2009. He flew into Germany on a frequent basis to get chemotherapy and even stem cell transplantation at a private center.
While in Abu Dhabi, his condition deteriorated, and his treating hematologist here in Munich asked to fly him in to get a closer look; the family also wanted him to be transferred. At this point, we only knew he had some pulmonary problems, but we were not aware of any coronavirus testing; this was not done in the United Arab Emirates.
Q: When did you suspect he might have the virus?
C.W.: When we examined his condition and saw his medication list; he had even started on [the influenza drug] Tamiflu, but his condition didn't improve. So we said: "Maybe it's a good idea to check for the coronavirus." So we did a bronchoalveolar lavage, [a procedure to sample fluid from the lungs,] and sent the material to Christian Drosten's lab at the University of Bonn; this is the German reference lab for the new coronavirus. The results came back on [23 Mar 2013]. At this point, the patient's medical condition was quite bad.
Q: Did you take special precautions once you knew he was infected to prevent further infections?
C.W.: That was done from the beginning. We are trained with difficult infectious disease situations, so this is what we do when we don't know what is going on. He was in an intensive care unit and put in special isolation; the staff used special precaution measures, such as 3M masks. We also tested staff for the virus, but nobody was positive.
Q: How many people did you test?
C.W.: We had a group of roughly 60 people, and not only staff members. ... The patient flew in on a private jet, and we screened the crew members as well as 4 relatives who had come with him. But we did PCR testing only for people who had symptoms, such as coughing and flu-like symptoms. There were fewer than 10 of those, and all were negative. The others were put on surveillance screening, but if they didn't develop symptoms, they weren't tested.
Q: Have these precautions ended now?
C.W.: Yes.
Q: Is it worrying that quite a few patients with the new coronavirus have sought medical attention in Germany and the United Kingdom? With SARS, you saw people infecting others on planes or seeding new outbreaks in the countries where they arrived.
C.W.: This virus is not in the same category as SARS in terms of the risk of spread. But one point is very valid: The screening tests, especially in the [Arabian Peninsula], are underdeveloped. So there may be a higher number of undetected cases. I was approached by officials from the U.A.E.; they were worried about this 1st case, because most other cases have been in Saudi Arabia, and they are quite interested in getting testing set up in their country. We will help them, together with professor Drosten in Bonn.
Q: You have said in interviews that he may have become infected through contact with a camel. What is the evidence for that?
C.W.: So far, it's only circumstantial evidence. The patient owned racing camels. One of them got ill and was very weak; the patient was in close contact with that camel, and on the evening the camel got very sick, the patient developed flu-like symptoms. Three days later, he was in a medical unit in Abu Dhabi. There is another family member who also had close contact with the camel; he also got ill, but we could not follow up with that gentleman.
We are really interested to find the missing link, to maybe get some material, some blood, some stool, out of this camel. Professor Drosten may send one of his scientific colleagues to Abu Dhabi. We will also get some help from the U.A.E. consulate in Munich.
Q: So the United Arab Emirates is willing to collaborate on this?
C.W.: Yes, they have understood that it's in their best interest to get a better understanding of how the disease might spread from animals to humans.
Q: Is the camel still alive?
C.W.: Yes, at least it was alive a couple of days ago.
Q: When will this investigation start?
C.W.: As you can imagine, we are very interested insolving this issue, so this would probably have to happen in the next couple of days.
Q: Have you heard about other camels in Abu Dhabi or the United Arab Emirates getting sick?
C.W.: No, I don't have any information on this. Even the consulate could not tell me. But maybe they didn't pay attention before. This just popped up as a problem, so they may have a closer look at this in the future.
[Byline: Martin Enserink]
--
Communicated by:
ProMED-mail
<promed@promedmail.org>
[Of interest in the above report/interview is the history of contact with an ill animal prior to onset of illness. In earlier reports of cases in the Eastern Mediterranean region, there had been reports of contact with farm animals; in one case, there was report of contact with a sick animal prior to onset of illness as well.
ProMED-mail looks forward to reports of additional studies performed in the UAE with respect to this case and the above mentioned possible link with a sick camel.
- Mod.MPP]
[Picture of camel racing in Abu Dhabi:
http://news.bbcimg.co.uk/media/images/5 ... l4_afp.jpg
- Mod.JW
A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/r/1HAJ.]
-
Alexander
- Administrator
- Beiträge: 24253
- Registriert: Sa 30. Jul 2005, 19:12
- Wohnort: Dubai/Vereinigte Arabische Emirate
- Kontaktdaten:
Re: Neuartiger Corona-Virus - WHO warnt vor Lungenkrankheit
In Frankreich gibt es einen zweiten Fall, bei dem ein Mann mit dem gefährlichen Coronavirus angesteckt wurde.
Frankreich: Mann offenbar in Krankenhaus mit Coronavirus infiziert
Das Coronavirus ist ein weiteres Mal in Frankreich aufgetaucht. Bei einem zweiten Mann wurde das hochgefährliche Virus entdeckt. Wie er sich anstecken konnte, ist geklärt. mehr...
Grüsse
Alexander
Frankreich: Mann offenbar in Krankenhaus mit Coronavirus infiziert
Das Coronavirus ist ein weiteres Mal in Frankreich aufgetaucht. Bei einem zweiten Mann wurde das hochgefährliche Virus entdeckt. Wie er sich anstecken konnte, ist geklärt. mehr...
Grüsse
Alexander
The one who follows the crowd will usually go no further than the crowd. Those who walk alone are likely to find themselves in places no one has ever been before.
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