First US MERS patient worked in Saudi Arabia healthcare

A person who recently worked in healthcare in Saudi Arabia and fell ill after flying to the United States on Apr 24 has the first confirmed US case of MERS-CoV (Middle East respiratory syndrome coronavirus), federal health officials announced today while asserting that there is very little risk to the public.

The patient, who was not identified, was admitted to Community Hospital in Munster, Ind., on Apr 28, tested positive for MERS this afternoon, and is in stable condition, the Centers for Disease Control and Prevention (CDC) announced. To protect the patient's family, the CDC did not reveal the person's gender, age, or whether he or she is a US or Saudi resident.

"The first importation of MERS-CoV infection represents a very low risk to the general public," said Anne Schuchat, MD, director of the CDC's National Center for Immunization and Respiratory Diseases, at a press teleconference this afternoon. "The virus has not shown an ability to spread easily."

The case comes amid a major increase in MERS illnesses in Saudi Arabia over the past several weeks, including many in healthcare workers (HCWs). Riyadh is one of the cities that have had many recent cases, along with Jeddah.

"We do not have any reports of any other patients ill with MERS-CoV in this investigation. But it's a very active investigation and very early," said Schuchat.

From Riyadh to London to Chicago

The patient flew on Apr 24 from Riyadh to London and on to Chicago, then took a bus from Chicago to Indiana, CDC officials and the Indiana State Department of Health (IDPH) said.

He or she got sick with a cough, shortness of breath, and fever on Apr 27, the IDPH said in a statement. The person went to the Munster hospital's emergency department the next day and was admitted.

In view of the pateint's symptoms and travel history, physicians decided a MERS test was in order, the IDPH said.

The patient is receiving oxygen but is "generally stable" and does not require a ventilator at this point, Schuchcat said.

The hospital has contacted "all high-risk individuals" about the case, the IDPH said. It said anyone who visited the hospital's emergency department between 6:30 and 9:30 p.m. on Apr 28 should contact their healthcare provider if they experience symptoms.

Out of "an abundance of caution," the CDC and its partners are contacting those who traveled with the patient by airliner and bus so they can be alert for any possible MERS symptoms, officials said. The agency did not disclose the airline flights or the bus line involved.

Schuchat said the agency is working with the Department of Homeland Security and the airline industry to contact passengers. "We don't anticipate issuing a broader alert at this time," she said.

Officials said they didn't know yet how the person caught the virus, but they acknowledged that the exposure "may have occurred" in Saudi Arabia. Schuchat said it was unknown whether the patient had any contact with camels, which are known to carry the virus and are suspected of passing it to humans.

The CDC is "very concerned that this virus has spread in healthcare facilities," Schuchat stated, but she also said, "With healthcare facilities with good infection control practices we don't expect substantial transmission of this virus. We don't have a sense now that this is very easy to spread, but out of an abundance of caution we're focusing on close contacts and healthcare contacts."

She said the agency is taking the case "very seriously," given that the disease is fatal in about a third of people who have symptoms.

Precautions recommended

In a press release the CDC said, "While experts do not yet know exactly how this virus is spread, CDC advises Americans to help protect themselves from respiratory illnesses by washing hands often, avoiding close contact with people who are sick, avoid touching their eyes, nose and/or mouth with unwashed hands, and disinfecting frequently touched surfaces."

Schuchat said the agency is not recommending that people change their travel plans because of MERS. But anyone who experiences symptoms within 14 days after travel in or near the Arabian Peninsula should contact a healthcare provider, she added.

Imported cases of MERS have occurred in several other countries, including the United Kingdom, Germany, France, Italy, Greece, Tunisia, Malaysia, and the Philippines. In a few instances those cases led to one or two additional cases, but no sustained transmission has been reported.

Schuchat said the incubation period for MERS-CoV is generally about 5 days, but it may run as long as 14 days. "Most patients who have a clear-cut exposure have become ill within 5 days," she commented.

Transmission possible before symptoms?

Other experts said a key question raised by the case is whether an infected but not-yet-sick patient can pass the virus to others. They said it's not likely, but no one knows for sure.

"The risk overall is low for all cases we've seen where the patients was not symptomatic. I don't think its absolute zero. But at this point I think it's exceedingly low risk," said Michael T. Osterholm, PhD, MPH, director of the Center for Infectious Disease Research and Policy, which publishes CIDRAP News.

Connie Savor Price, MD, chief of infectious diseases at Denver Health and Hospital, commented, "Many viruses are quite able to spread the day of or the day before symptoms start. . . . It reassures me that the patient wasn't symptomatic during travel, but I can't tell for certain there wasn't potential for spread.

"Were also hearing more about patients who are asymptomatic," she added. "Given that there are still so many questions about the epidemiology, we have to take seriously the possibilities here." Price is also an associate professor of medicine at the University of Colorado, Denver.

In other comments, Price questioned the CDC decision not to publicly identify the airline and bus line on which the MERS patient traveled. She suggested the agency might find the patient's potential contacts faster if it went public with the information.

"I worry that sometimes we're more concerned about causing panic than about halting transmission," she said. "We have to do both, but maybe at this point we should be more concerned about halting transmission."

Osterholm, however, called the CDC's approach reasonable: "I don't think there's any need to make it public. I think it's exceedingly low-risk, the patient being asymptomatic at the time."

Another expert, Matthew Frieman, PhD, of the University of Maryland School of Medicine's Department of Microbiology and Immunology, commented that the case shows again how easily diseases can spread around the world.

"This case demonstrates that for MERS and other emerging diseases, we are only a plane ride away from spreading them from one side of the world to the other," he commented by e-mail. "It shows why we should be investing in our infectious disease research and infrastructure to detect and treat these diseases at home, even if they seem far away at the moment. It also reiterates the necessity of proper quarantine and infection control at all hospital levels."

Schuchat put it this way at the press conference: "While centered in the Arabian Peninsula, MERS-CoV is now in our heartland."

Besides those already mentioned, Middle Eastern countries that have had MERS cases are the UAE, Qatar, Jordan, Oman, Kuwait, and Egypt.

See also:

May 2 CDC press release

May 2 IDPH press release


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