Updated Rapid Risk Assessment: Severe respiratory disease associated with Middle East Respiratory Syndrome Coronavirus (MERS-CoV)

Risk assessment

As of 17 June 2013, 64 cases of MERS-CoV had been reported worldwide, including 38 deaths. All cases remain associated (including indirect association following secondary person-to-person transmission in the UK, Italy, Tunisia and France) with transmission in the Middle East. The age of cases ranges from two years to 94 years (N=60 cases, information on age not available for four cases), with a median of 56 years. Overall 70% (43/61) of cases are males.
The reports of new infections in Saudi Arabia over the past few weeks indicate that there is an ongoing source of infection and low risk of transmission to humans in the Middle East.
The first French case raises the possibility that presentations may not initially include respiratory symptoms, especially in those with immunosuppression or underlying chronic conditions. This also needs to be taken into account when revising case detection strategies.
The confirmed infection in France of a patient who shared a hospital room with an index patient returning from the United Arab Emirates corroborates the risk of nosocomial transmission. The incubation period for this patient is calculated to have been 9─12 days, which is longer than previously estimated. One case in the Jordan cluster has an incubation period of 13 days. Therefore until further evidence emerges, the incubation period is being extended from 10 to 14 days, in accordance with the WHO decision.
These conclusions should be viewed in the light of the many uncertainties surrounding the investigation of cases in the Middle East. It is unusual to have such a degree of uncertainty at this stage in an outbreak.

Executive summary

The update of ECDC Rapid Risk Assessment on Middle East respiratory syndrome coronavirus (MERS-CoV) addresses:

  • Epidemiological situation since publication of the previous Rapid Risk Assessment on 17 May
  • Guidance on contact tracing, including aircraft contact tracing
  • Extension of the incubation period to 14 days, in line with WHO decision
  • Guidance to EU travellers to the Middle East.

As of 17 June 2013, 64 cases of MERS-CoV have been reported worldwide, including 38 deaths. All cases remain associated with transmission in the Arabian Peninsula and Jordan. This includes indirect association following secondary person-to-person transmission in the UK, Italy, Tunisia and France.

The reports of new infections in Saudi Arabia over the past few weeks indicate that there is an ongoing source of infection and low risk of transmission to humans in the Middle East. The source of infection and the routes of transmission have not yet been determined.

EU citizens travelling to the Middle East need to be aware of the presence of MERS-CoV in this area and of the small risk of infection. EU Member States may consider active information efforts for travellers to risk areas. Travellers who develop symptoms during travel or up to 14 days after their return are encouraged to seek medical attention, sharing their history of travel.

For any confirmed cases of MERS-CoV, close contacts must be monitored for symptoms for 14 days after the last exposure. Countries should trace contacts of confirmed MERS-CoV cases on aircraft.

The five person-to-person transmissions that have been documented in Europe, two of which are nosocomial, indicate that the risk of onward transmissions in Europe is significant, in particular in healthcare settings. 

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