The World Health Organization (WHO) said yesterday that two probable Middle East respiratory syndrome coronavirus (MERS-CoV) cases reported by Spain in November were never confirmed, which means that no confirmed cases have been linked to the 2013 Hajj.
Meanwhile, Saudi Arabia has reported a fatal case in a healthcare worker in Riyadh, apparently confirming a previous media report that a Bangladeshi doctor in that city succumbed to the disease.
In a MERS-CoV summary and literature update, the WHO said follow-up testing was unable to confirm the infection in two women, ages 61 and 50, who had traveled together from Spain to Saudi Arabia for the Hajj in October. Both women experienced febrile respiratory illnesses with evidence of pneumonia and were hospitalized, but both recovered.
At a Spanish laboratory, polymerase chain reaction (PCR) assays targeting one segment of the MERS-CoV genome were positive for both patients, but PCR tests targeting other segments were negative, the WHO said. An outside reference lab ran additional tests, including serologic ones, all of which were negative.
As the WHO noted, the two apparent cases raised worries about possible MERS cases related to the Hajj, which drew more than a million visitors to Saudi Arabia.
"However, other than these two unconfirmed cases, there were no other reports of Hajj-related MERS-CoV patients, despite extensive testing in nearly every country from which Hajj pilgrims originated," the WHO said. "At this point, it is clear that neither significant transmission nor exportation of MERS-CoV occurred in association with the Hajj."
The non-confirmation means that France, Germany, Italy, and the United Kingdom are the only European countries that have had confirmed MERS cases, all of them with links to the Middle East.
Saudi case announcement
The announcement of the Saudi case came in a machine-translated statement from the Ministry of Health (MOH), posted on FluTrackers, an infectious-disease monitoring site. It said only that a 54-year-old health practitioner who was working in the Riyadh region died of MERS-CoV.
The notice appeared to confirm a Jan 17 story in Arab News, a Saudi Arabian English-language newspaper, which said that a 55-year-old Bangladeshi surgeon named Mohammed Humayun Kabeer, 55, had died of MERS. The story said he had worked at Prince Salman Hospital and died after 9 days of hospitalization.
The MOH had not posted an English-language statement about the case at this writing, but the ministry has increased its posted MERS-CoV case count by 1, to 142 cases and 58 deaths.
21 cases in 2 months
The WHO summary said 21 MERS cases have been confirmed since the agency's last summary 2 months ago, on Nov 22. Of the 21 cases, 14, with 4 deaths, were in Saudi Arabia; 6 cases, with 2 deaths, were in the United Arab Emirates (UAE); and 1 fatal case was in Oman.
The WHO's overall MERS-CoV count is 178 confirmed cases, including 76 deaths, for a case-fatality ratio of 42.7%. In its previous update, the WHO reported 157 confirmed and 19 probable cases, for a total of 176, but today's update lists only confirmed cases.
The overall median age of case-patients is 52 years, compared with 51 as of the previous update in November. For primary cases—those with no links to other human cases—the median age is 58, whereas for secondary cases (with links to other cases), the median is 44 years.
The gender pattern also differs between primary and secondary cases, the WHO reported. Overall, 62% of patients have been male (versus 65.3% in November). For primary cases the share of males is 76% (the same as it was in November), while for secondary cases it is 53% (versus 58% in November).
More than half of secondary cases have been associated with healthcare settings, the WHO reported, which is similar to the situation 2 months ago. Cases have involved healthcare workers who treated MERS patients, other patients who were treated for other conditions, and people visiting MERS patients.
As it has said before, the WHO observed that most primary case-patients had no history of exposure to animals, despite the confirmation of MERS-CoV or a very similar virus in camels in Qatar and recent evidence that a MERS-CoV-like virus has circulated in camels in the UAE since 2003.
"More work is needed to determine the route of transmission to humans and the types of exposures that result in infection," the agency said.
It cautioned that people who have risk factors for severe MERS-CoV infections, such as chronic illnesses like diabetes or chronic lung disease, should take precautions when visiting farms in affected countries.
Jan 20 WHO summary and literature update
Jan 21 FluTrackers translation of Saudi MOH statement
Saudi MOH MERS-CoV page
Jan 17 CIDRAP News item about MERS case in Riyadh
Nov 22, 2013, WHO summary and literature update
Related Nov 22, 2013, CIDRAP News story