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Epidemiological update: Middle East respiratory syndrome coronavirus (MERS-CoV)

06 May 2014

​As of 6 May 2014, 495 cases of MERS-CoV have been reported globally, including 141 deaths. All cases have either occurred in the Middle East or have direct links to a primary case infected in the Middle East.

Middle East:
Saudi Arabia: 411 cases / 115 deaths
United Arab Emirates: 49 cases / 9 deaths
Qatar: 7 cases / 4 deaths
Jordan: 6 cases / 3 deaths
Oman: 2 cases / 2 deaths
Kuwait: 3 cases / 1 death
Egypt: 1 case/ 0 deaths

Europe:
UK: 4 cases / 3 deaths
Germany: 2 cases / 1 death
France: 2 cases / 1 death
Italy: 1 case / 0 deaths
Greece: 1 case/ 0 deaths
 
Africa:
Tunisia: 3 cases / 1 death
 
Asia:
Malaysia: 1 case / 1 death
Philippines: 1 case / 0 deaths
 
Americas:
United States of America: 1 case/ 0 deaths
 
The primary case for each chain was infected in the Middle East, and local secondary transmission following importation was reported from the United Kingdom, France, and Tunisia.
 
The number of reported cases increased markedly in April 2014 (Figure 1) with 261 cases. Between March 2013 and March 2014 the monthly average number of reported cases was 15.

Figure 1:

In April 2014, four countries (Philippines, Greece, Malaysia and Egypt) notified imported cases from Arabian Peninsula and in May the US reported the first imported case (Figure 2).
 
Figure 2:


As of 6 May 2014, the case-fatality ratio is 28,5 %. The male to female ratio is 2:1. Among the 490 cases with known age, the mean age is 49 years. Median age was 50 (range 1-94 years) and 465 (95%) were older than 19 years. Out of the 420 cases for whom age and sex is known, 206 (49%) have been males aged 40 years and above.
 
Figure 3:


* 14 case s has been excluded due to missing data on age or sex
** 61 case s have been excluded due to missing data on age or sex
 
Since 1 April 2014, 288 cases were reported, as compared to the 207 cases reported from the beginning of the outbreak (March 2012) to 31 March 2014. Among these 288 cases, 248 (86%)  were reported by Saudi Arabia, 32 cases (11%) by the United Arab Emirates, 2 cases were reported by Jordan and one case each by Egypt, Greece, Malaysia, Philippines and the United States of America (Figure 4).
 
Figure 4:


Healthcare workers have been more frequently reported during the month of April 2014 than previously. Since April 2012, 96 cases have been healthcare workers, of whom 63 (65%) were reported in April 2014 compared to 35% before. Seventy (74%) of the healthcare workers were reported from Saudi Arabia, twenty-three (24%) from the United Arab Emirates, and one each from Philippines, Jordan and United States of America.
 
The cause of the rapid increase in cases in April is unknown. The Rapid Risk Assessment of 24 April considers the possible scenarios that might explain this, notably:

• More sensitive case detection through more active case finding and contact tracing or changes in testing algorithms,
• Increased zoonotic transmission with subsequent transmission in healthcare settings,
• Breakdown in infection control measures or otherwise increased transmission in the local healthcare setting,
• Change in the virus resulting in more effective human-to-human transmission, resulting in both nosocomial clusters, and increased numbers of asymptomatic community acquired cases, or
• False positive lab results.
 
ECDC continues to monitor information on the situation on MERS-CoV worldwide. In earlier Rapid Risk Assessments, ECDC concluded that the risk of importation of MERS-CoV to the EU was expected to continue and the risk of secondary transmission in the EU remains low. The assessment provided in the ECDC Rapid Risk Assessment on the 24 April 2014 remains valid.
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