Middle East respiratory syndrome coronavirus

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LogoWarningBox4.pngAs of 3rd September 2015 WHO notes[1]:
  • Insufficient awareness about the urgent dangers posed by this virus
  • Insufficient engagement by all relevant sectors
  • Insufficient implementation of scalable infection control measures, especially in health care settings such as emergency departments
Web Resources for Middle East respiratory syndrome coronavirus
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MERS-CoV, nCoV. Caused by a coronavirus. Hard to distinguish from severe influenza clinically, but infectious, with a high mortality and to date associated with exposure to camels. Can present with diarrhoea in immunosuppressed well before the severe pneumonia that may get the case recognised.

In September 2012 some cases of a novel coronavirus (nCoV) raised concerns that another emerging disease causing severe respiratory illness might be emerging. The outbreak of what was subsequently named Middle East respiratory syndrome coronavirus (MERS-CoV) does not seem to reflect better technical ability to identify novel viruses. There could be a significant threat to public health if a viral strain develops high rates of transmission either by respiratory aerosol or stool spread. While as of 2013 there have been no major outbreak or pandemic problems, however clusters controlled by high standard isolation precautions do prove that there is human to human transmission with high mortality. The earliest case occurred in retrospect in late March 2012. Further cases occurred in April 2013 in Saudi Arabia [2]. Clusters occur amongst healthcare workers, as with SARS, with both asymptomatic cases and outbreaks only recognised in retrospect occurring. As of March 2014 the case fatality rate of those presenting with SARI is about 45%. As of February 2015 an epidemic curve reveals that a significant outbreak did occur in April/May 2014[3]. As of May 2015 the serology positive fatality rate is 38% and over 1100 cases have been confirmed. An outbreak in South Korea was associated with delayed recognition and breaking of quarantine. The virus genome has similarities to a coronavirus found in bats and binds to CD26. Deep bronchial lavage specimens may be needed for diagnosis.


Infective agent

  • Coronavirus[4]
    • Binds to dipeptidyl peptase 4-receptor
    • Member of genus β
    • Single positive-stranded RNA genome 30,119 nucleotides long and contains 11 open reading frames (ORFs)
      • The 5' end has two overlapping ORFs, ORF1a and ORF1b
        • Translated to two large polyproteins, polyprotein 1a (pp1a) and polyprotein 1ab (pp1ab)
        • Cleaved into 16 functional nonstructural proteins (nsps) by papain-like protease (PLpro) and 3C-like protease (3CLpro) that self-cleave from pp1ab
          • These are responsible for viral RNA-dependent RNA polymerase activity (nsp12), RNA helicase activity (nsp13), exoribonuclease activity (nsp14), endoribonuclease activity (nsp15) and methyltransferase activity (nsp16)
          • nsp14 is essential, as it is involved in proofreading by monitoring the mutation rate, a unique feature for an RNA virus
      • The other ORFs encode:
        • Structural proteins:
          • Spike (S)
          • Envelope (E)
          • Membrane (M)
          • Nucleocapsid (N)
        • Accessory proteins
          • Encoded by ORF3, ORF4a, ORF4b, ORF5 and ORF8b are unique and may help evade host immune response


  • No positive human serology before 2012 reported.
  • Antibodies that cross react with MERS corononavirus have been found in dromedary camels. Some primary cases are associated with recent camel exposure.
  • Dromedary camels from Nigeria through to the Middle East have been exposed to a similar virus since at least 2003[5] and possibly for decades.
  • All cases of human to human contact can be explained by transmission from symptomatic patients
  • Super-spreaders exist as with SARS
  • Incubation time 2-14 days (not infectious)
  • Seasonal incidence appears highest April to May
  • Risk association includes diabetes
  • Mortality rate as of July 2013 was 56% but later studies found asymptomatic and minimal symptomatic infection especially after secondary human human transmission very common.
  • Patients can shed the virus after resolution of symptoms, but the duration of infectivity is unknown. No evidence as of April 2014 that asymptomatic cases are contagious.

Clinical Presentation

  • URTI (definite transmission mechanism)
  • Diarrhoea (probable transmission mechanism)
  • Pneumonia


  • Probably sub strain dependent
  • Highest mortality is associated with pre-existing renal failure and diabetes mellitus

Diagnostic criteria

Infection control precautions

  • Droplet precautions when providing care to all patients with symptoms of acute respiratory infection.
  • Contact precautions and eye protection should be added when caring for probable or confirmed cases of MERS-CoV infection.
  • Airborne precautions should be applied when performing aerosol generating procedures.

Possible treatments

Treatments are to date unproven and there is little commercial incentive to develop new agents due to market size[4]

More information about the novel virus and concerns about it (external links)