WHO cites 7th coronavirus case, gives surveillance guidance

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Nov 29, 2012 (CIDRAP News) – A third case in a family cluster of novel coronavirus infections has been confirmed, raising the global case count to seven, and the fourth illness in the family is now listed as a probable case, the World Health Organization (WHO) has announced.

In a statement dated yesterday, the WHO also indicated that only one death has been attributed to the novel virus so far, contradicting a Nov 23 announcement that reported two deaths among the first six cases.

The WHO also offered new surveillance recommendations for the novel virus. The agency called for testing of patients in any cluster of severe, unexplained respiratory infections, regardless of location or travel history, and testing of healthcare workers who suffer unexplained pneumonia after caring for patients with severe respiratory infections.

And in a related development, the Saudi Medical Journal reported that the person who had the third known novel coronavirus case is a 45-year-old gym teacher who visited a farm 3 days before he got sick and who survived his severe illness despite having preexisting health problems and only one kidney.

Update on cases
In reporting on cases 3 through 6 on Nov 23, the WHO said two of the confirmed patients belonged to the same family and household in Saudi Arabia and that two more members of the same family were sick, but their cases had not been confirmed. The latest statement said three of the confirmed case-patients and the person with the probable case all belong to the same family.

The statement did not specify whether the family members are thought to have passed the virus to one another or caught it from another source. "The source of the virus is unknown, as is the mode of transmission," the statement says.

The cases occurred in the Jeddha and Riyadh areas of Saudi Arabia, which are bout 850 kilometers apart, and in Doha, Qatar, the WHO noted.

The new announcement notes only one death from the novel coronavirus so far, a change from last week's statement noting two deaths among the first six cases. The WHO did not respond to a query about this point this afternoon.

The statement says all seven patients had an acute respiratory infection with signs and symptoms of pneumonia. Four patients had renal failure, and one of these died. "The remaining three patients had pneumonia that required intensive support, without renal failure, and recovered," it adds.

The WHO gave no update on the second case-patient, a Qatari man who was flown to London for treatment in September and has been hospitalized there since then.

Surveillance advice
The WHO's updated surveillance guidance follows up on comments the agency made last week about a need to broaden testing for the novel coronavirus. At that point the agency said the virus might be more widely distributed than just Saudi Arabia and Qatar, and suggested that health authorities consider testing patients with unexplained pneumonias even if they had no history of travel to the two countries.

The updated guidance recommends investigation for four categories of people:

  • Those with an unexplained acute respiratory infection, suspected pneumonia, and residence in or travel to the Arabian Peninsula or neighboring countries within 10 days before onset of illness
  • People with an acute respiratory illness who were in close contact with a confirmed or probable novel coronavirus case-patient within 10 days before getting sick
  • Any cluster of severe acute respiratory infections, regardless of location or travel history, and especially if patients need intensive care
  • Healthcare workers who care for patients with severe acute respiratory infections and fall ill with unexplained pneumonia, regardless of location or travel history

In addition, the WHO said countries that have the capacity may want to consider testing any patient who has unexplained, severe pneumonia. Also, the agency suggested the possibility of retrospective testing of stored respiratory specimens from patients who had unexplained pneumonia.

Details on third case
A team of Saudi and British authors provided details on the third novel coronavirus case, which was first announced by Saudi authorities Nov 4. The 45-year-old patient was hospitalized for 22 days and needed breathing support and hemodialysis before his eventual recovery, according to the report.

The article describes the patient as a heavy smoker who has type 2 diabetes, a history of ischemic heart disease, and only one functioning kidney.

Three days before his illness onset, the man visited a farm near his home and had brief contact with farm animals. The report does not mention any illness among the animals. The man had not traveled outside Riyadh before his illness, but he had been in contact with one of his children, who had a mild cold.

The patient fell ill on Oct 9, was seriously ill by Oct 12, and was moved to an intensive care unit (ICU) the next day. He needed breathing assistance for several days, and he received dialysis treatments for renal failure from Oct 15 to 23. He was finally released from the hospital Nov 4.

The man tested negative for a wide range of viruses and bacterial pathogens. But respiratory specimens tested positive for the novel coronavirus upE gene in two labs, a Saudi Arabian health ministry lab in Jeddah and the UK Health Protection Agency lab in Birmingham. The virus was not found in the patient's stool, plasma, or serum specimens.

The authors sequenced small pieces of two of the coronavirus genes from this case and the first case, which involved a Saudi Arabian man who died in June. They found that the sequences were identical to one another and to the same gene fragments from the second novel coronavirus case (the Qatari patient in London).

The authors comment that exposure to farm animals was identified as a risk factor in the first novel coronavirus case, but add that such exposures appear to be "an insignificant risk factor for cases 2 and 3."

"However, all cases would have been exposed to recurring dust storms through an arid summer, and possibly aerosolized virus as well," they write. "Investigations of possible animal reservoirs are currently in progress."

The report also raises the possibility—which has been mentioned before—that a cluster of unexplained respiratory illnesses in a Jordanian hospital ICU in April of this year might have been related to the novel virus.

"Still to be identified is the agent responsible for 11 cases of severe respiratory disease at an ICU in Zarqa, Jordan," it says. "The report by the Jordanian Minister of Health on April 17, 2012, noted that 8 cases were members of the healthcare staff."

In a report in May, the European Centre for Disease Prevention and Control (ECDC) said one nurse died in the Jordanian outbreak and that all the patients had high fever and lower respiratory symptoms. Jordanian health officials thought the outbreak was caused by a virus, but no lab results were available at the time.

British officials mentioned the Jordanian outbreak in an Oct 4 Eurosurveillance report on the Qatari patient treated in London for a coronavirus infection, but they said only that more information was needed.

In response to a CIDRAP News query today, a WHO spokesperson said the agency had no new information on the Jordanian outbreak but was hoping to get something soon.

See also:

Nov 28 WHO statement

Nov 26 CIDRAP News story on WHO call for more surveillance

May 4 ECDC report on unexplained respiratory cases in Jordan

Oct 4 CIDRAP News story mentioning possible Jordanian illness cluster

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