05 Jun 2015

MERS-CoV: Republic of Korea and China

Middle East respiratory syndrome coronavirus (MERS-CoV) update: Republic of Korea and China

On 20 May 2015, the Republic of Korea notified the World Health Organization (WHO) of it's first laboratory confirmed case of Middle East respiratory syndrome coronavirus (MERS-CoV) in a 68 year-old male. He had recently travelled to the Middle East: Bahrain, the United Arab Emirates, the Kingdom of Saudi Arabia and Qatar in April and May 2015 [1].

As of 5 June 2015, a total of 40 cases have been reported, including four deaths[2]. The index case appears to have transmitted infection to close relatives, patients with whom he shared medical facilities, and healthcare workers providing care. These exposures happened before MERS-CoV was suspected or diagnosed [3].

An additional case exposed to MERS-CoV in Republic of Korea flew to Hong Kong, Special Administrative Region, China whilst symptomatic. He then travelled on by bus to Guangdong in mainland China. Chinese authorities have quarantined this traveller and identified contacts in Hong Kong and China [3, 4].

This is the largest nosocomial outbreak reported outside of the Middle East and is also the first time MERS-CoV has been exported to Republic of Korea or China [3].

As of 3 June 2015, a total of 1,179 confirmed cases of human infection with MERS-CoV, in 25 different countries, have been reported to WHO since 2012, including at least 442 deaths.

Cases of MERS-CoV have been identified in the following Middle Eastern countries: Egypt, Iran, Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, United Arab Emirates and Yemen.

Outside the Middle East, cases with links to the Middle East (either imported or in contact with an imported case) have been reported from:

Europe: Austria, France, Germany, Greece, Italy, the Netherlands, Turkey and the United Kingdom.

North Africa: Algeria and Tunisia.

Asia: China, the Republic of Korea, Malaysia and the Philippines.

Americas: United States [3].

As the ongoing outbreak in Republic of Korea started from a single person who travelled to the Middle East, WHO is in contact with health authorities in the relevant countries to investigate potential sources of exposure [3].

MERS-CoV is a zoonotic virus that can lead to limited person to person transmission. Most infections have occurred in the Middle East, with many community-acquired infections thought to be associated with direct or indirect contact with infected camels or camel-related products. Community wide transmission has not been observed in any location. While household human-to-human transmission has been observed in affected countries, most human cases reported currently have resulted from limited human-to-human transmission in healthcare settings [3]. Nosocomial outbreaks have previously been reported from the Middle East. [/expand]

Advice for travellers

The risk of UK residents contracting infection in the UK remains very low. The risk to people travelling to Middle Eastern countries may be slightly higher than within the UK, but is still very low and does not warrant a change in travel advice [5].

Public Health England advises the following measures for travellers:

  • All travellers to the Middle East are advised to avoid any unnecessary contact with camels.
  • Practise good hand and general hygiene such as regular hand washing at all times, especially after visiting farms, barns or market areas.
  • Avoid close contact with sick people and sick animals.
  • Avoid unnecessary contact with camels.
  • Avoid the consumption of raw camel milk, camel products and/or camel products from the Middle East.
  • Avoid the consumption of any type of raw milk, raw milk products and any food that may be contaminated with animal secretions unless peeled/cleaned/thoroughly cooked [5].

Travellers returning from areas affected by the virus, with mild respiratory symptoms, are most likely to have a common respiratory illness such as a cold.

Travellers returning areas affected by the virus with severe, unexplained respiratory symptoms should seek medical advice from their GP or NHS 111 and must mention their travel history, so that appropriate measures and testing can be undertaken.

People who are acutely ill with an infectious disease are advised not to travel [5].

Advice for Health Professionals

There remains a risk of imported cases to the UK, and health professionals should remain vigilant. The current outbreak in Republic of Korea highlights the impact that MERS-CoV can have in healthcare settings if suspected cases are not promptly identified and isolated.  Early identification and implementation of infection control measures for suspected cases is crucial [5].

Health care providers in the UK are reminded to remain vigilant for recent travellers returning from areas affected by the virus who develop a severe unexplained respiratory illness. Clinicians are reminded that MERS-CoV infection should be considered even with atypical signs and symptoms, especially in people with diabetes, renal failure, chronic lung disease, and immunocompromised persons. In addition, unexplained clusters of severe respiratory infection should be investigated, particularly if they occur in healthcare settings [6].  

Public Health England provides guidance for both the general public and healthcare professionals. Information for health professionals includes guidance on risk assessment and case management.

Clinical queries about the management of potential cases of severe respiratory infections in people recently returned from regions reporting outbreaks should be directed in the first instance to the local infectious disease physician or microbiologists. The national Imported Fever Service: Public Health England is available to local infectious disease physicians or microbiologists, should specialist advice be required (0844 778 8990).

Currently there is no change to travel advice, please refer to previous Clinical Updates for more information.

For specific country advice, please see country information pages

For specific outbreak information, please check Outbreak Surveillance database.

Resources

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Polio: Public Health Emergency of International Concern

An update on the polio Public Health Emergency of International Concern (PHEIC) Read more

Hepatitis B vaccine shortage and vaccine prioritisation: advising the traveller

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