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11 Feb 2013
Epidemiological update: case of severe lower respiratory tract disease associated with a novel coronavirus

On 11 February 2013, the UK Health Protection Agency (HPA) announced that an additional case of the novel coronavirus (NCoV) infection has been confirmed in a UK resident. The patient, a 60 year old male, became ill on 24 January 2013 and was admitted to hospital in England, with a severe lower respiratory tract disease on 31 January.

In the 10 days before his illness onset, the patient had visited both Pakistan (from 16 December 2012 to 20 January 2013) and Saudi Arabia (from 20 to 28 January 2013). After hospital admission, his condition deteriorated and he was transferred for extracorporeal membrane oxygenation (ECMO) treatment on 5 February. He remains severely ill in intensive care.

Laboratory investigations of respiratory specimens from 1 February have confirmed both an influenza A H1N1pdm09 infection and a NCoV infection. Because of the latter, the UK posted an alert through the EU Early Warning and Response System and the International Health Regulations.The HPA is coordinating the response to and further investigation of the potential contacts. Infection control measures have been instituted around the case. Contacts are being followed up and investigated if they develop relevant symptoms following the nationally recommended protocol.

Disease background information

As of 7 December 2012, nine laboratory-confirmed cases of severe pneumonia caused by the novel coronavirus (NCoV) had been reported to WHO. This is the 10th confirmed case.

Five of the nine cases were fatal. Onset of disease was from April to October 2012; all cases were resident in Saudi Arabia, Qatar or Jordan during the preceding days however it cannot at this stage be assumed that the viruses are only to be found in those countries.

The novel virus is distinctly different from the coronavirus which caused the SARS outbreaks in 2003 and genetically related to bat coronaviruses. No animal reservoir or mode of zoonotic transmission has yet been identified for the novel coronavirus though it is noted that similar viruses are known to be endemic in bats in many parts of the world.

The two fatal cases in Jordan were part of a cluster of 11 patients with respiratory symptoms linked to a hospital, but the limited information as yet available does not allow confirmation or refutation of their having been human-to-human transmission either in Jordan or in a family cluster in the Kingdom of Saudi Arabia.

After careful and intensive investigation of those exposed to the infections in the previous two cases in Europe, in the UK and Germany, there were no proven secondary infections.
ECDC, jointly with WHO, has mapped the capacity of virology reference laboratories in EU/EEA Member States with regard to the novel coronavirus (RT-PCR/sequencing assay). So far, approximately 250 people have been tested for the novel coronavirus in the EU since the first case was reported. Except for the two confirmed cases, which were referred to the UK and Germany, none of the tests were positive. The results of this survey were published in Eurosurveillance on 6 December 2012.



An additional case of NCov was identified. The patient fell ill 4 days after entering Saudi Arabia, but the  exposure could have happened while in Pakistan or in Saudi Arabia. All nine previous cases identified were reported as having some link with the Arabian Peninsula: Kingdom of Saudi Arabia (5), Qatar (2) and Jordan (2). However the virus reservoir and routes of transmission remain unknown and it should not be excluded that these novel viruses can be found in other parts of the world.

The wide geographical distribution, the long intervals between cases and clusters, and the absence of evidence for mild or asymptomatic human infections which could maintain a chain of transmission between outbreaks, point to intermittent zoonotic transmission or an environmental source. Zoonotic transmission does not exclude human-to-human transmission from an index case but there is only limited evidence to date that this has occurred.

WHO recognizes that the emergence of a new coronavirus capable of causing severe disease raises concerns because of experience with SARS. Although this novel coronavirus is distantly related to the SARS CoV, they are different. Based on current information, it does not appear to transmit easily or sustainably between people, unlike the SARS virus.

The occurrence of such sporadic cases is to be expected in the context of the enhanced surveillance for cases and clusters implemented in the Arabian Peninsula and worldwide.

ECDC notes the WHO advice encouraging Member States to maintain surveillance for severe acute respiratory infections and to carefully review any unusual patterns of infection. Testing for the new coronavirus in patients with unexplained pneumonias, or patients with severe, progressive or complicated illness not responding to treatment, should be considered along with investigations for more likely infections.

This event does not affect the conclusions of the rapid risk assessment published by ECDC on 7 December 2012. However, ECDC will be reviewing and updating its risk assessment in the light of this additional case and other developments in the last 2 months.

Update 18 February 2013:

See updated Table of confirmed cases of novel coronavirus infection, in order of onset of disease.

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