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MERS-CoV May Become a Pandemic Threat, Experts Warn

Laurie Barclay, MD

January 27, 2014

Experts recommend an urgent collaborative study of treatment options for the Middle East respiratory syndrome coronavirus (MERS-CoV), which has the potential to become a worldwide public health threat, according to a case series published online January 27 in the Annals of Internal Medicine. "In September 2012, a new coronavirus was isolated for the first time from a patient in Saudi Arabia, who presented with acute pneumonia and renal failure," write Yaseen M. Arabi, MD, from the Intensive Care Department, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Kingdom of Saudi Arabia, and colleagues. "Since then, 170 laboratory-confirmed cases of infection with MERS-CoV have been reported to the World Health Organization, including 72 deaths. The disease has a high fatality rate and has several clinical features that resemble the infection caused by the severe acute respiratory syndrome coronavirus (SARS-CoV)." Despite concern that MERS-CoV has the potential to cause a pandemic, data on critically ill patients with MERSCoV infection are limited. The goal of this case series was to describe the critical illness associated with MERS-CoV. At 3 intensive care units (ICUs) at 2 tertiary care hospitals in Saudi Arabia, the investigators tested 114 patients between December 2012 and August 2013 and identified 12 with confirmed or probable MERS-CoV infection. They collected data on patients' initial symptoms, comorbidities, pulmonary and extrapulmonary findings, illness severity, organ failure, ICU course, and outcome. The investigators also reported surveillance results of healthcare workers (HCWs) and patients with potential exposure. MERS-CoV Infection Has High Mortality Eleven patients (10%) met criteria for confirmed or probable cases, and 3 of these patients were part of a healthcareassociated cluster that included 3 HCWs. The 12th patient in this case series was one of the HCWs who became critically ill. All 12 patients presented with acute severe hypoxemic respiratory failure and had underlying comorbid conditions. The median Acute Physiology and Chronic Health Evaluation II score was 28 (range, 16 to 36). Most (92%) of the case-patients experienced shock, acute kidney injury, thrombocytopenia, or other extrapulmonary manifestations. At day 90, only 5 patients (42%) survived. The investigators suggest that patients with chronic comorbid conditions are susceptible hosts for MERS-CoV. Although only 4 (1%) of the 520 exposed HCWs tested positive for MERS-CoV, this did suggest human-to-human transmission. "MERS-CoV causes severe acute hypoxemic respiratory failure and considerable extrapulmonary organ dysfunction and is associated with high mortality," the authors write. "Community-acquired and healthcare-associated MERSCoV infection occurs in patients with chronic comorbid conditions. The healthcare-associated cluster suggests that human-to-human transmission does occur with unprotected exposure." Limitations of this study include the case series design and small sample size. Lessons Learned From SARS-CoV In an accompanying editorial, Trish M. Perl, MD, from Johns Hopkins University School of Medicine and Bloomberg School of Public Health in Baltimore, Maryland, and colleagues point out that lessons learned from SARS-CoV may

apply to MERS-CoV, given many similarities in clinical presentation. However, they note, preexisting chronic illness is more common in patients with severe MERS-CoVassociated pneumonia than in those with SARS. Rates of diabetes, renal disease, and heart disease are 68%, 49%, and 28%, respectively, in patients with MERS compared with 24%, 2.6%, and 10%, respectively, among those with SARS. Case-control studies could help clinicians identify pertinent exposures and develop preventive strategies. Given the high mortality, researchers will need to develop a range of effective treatments, such as antivirals, convalescent serum therapy, and therapeutic drug options. "Analysis to date suggests that MERS-CoV does not yet have pandemic potential," the editorialists write. "However, we must keep in mind both the rapid evolution that occurred with SARS and the fact that it emerged in a much more densely populated region. Given the right environment and a crowded part of the world, MERS-CoV might propagate more readily." It is still unknown whether MERS-CoV infection results from repeated introductions from an animal reservoir with subsequent limited transmission in humans or from sustained human-to-human transmission, with most cases being subclinical disease. The editorialists note both the need for infection control practices and the paucity of data regarding virus transmission. In fact, the Centers for Disease Control and Prevention and the World Health Organization disagree on the need for airborne isolation, the editorialists write. "Health careassociated MERS-CoV transmission to patients, workers, and visitors remains significant but is underplayed," the editorialists conclude. "Focus on the health care setting may prevent continued human-to-human transmission among at-risk patients. We applaud these brave authors for providing independent data and enhancing the scientific collaborations that MERS-CoV has created. Globalization and emerging viruses combine to demand new levels of scientific transparency and collaboration to effectively protect populations, a change we must all strive to achieve." This study received no primary funding. Full conflict-of-interest information is available on the journal's Web site for both the article and the editorial. Ann Intern Med. Published online January 27, 2014. Abstract Editorial Medscape Medical News 2014 WebMD, LLC Send comments and news tips to news@medscape.net.
Cite this article: MERS-CoV May Become a Pandemic Threat, Experts Warn. Medscape. Jan 27, 2014.