MERS-CoV Replicates in the Upper

Respiratory Tracts of Camels

Mary E. Wilson, MD reviewing Adney DR et al. Emerg Infect Dis 2014 Dec.
Large amounts of Middle East respiratory syndrome coronavirus were shed by camels inoculated
with a human viral isolate.
Camels have been implicated as one source of human infection with Middle East respiratory
syndrome coronavirus (MERS-CoV; NEJM JW Infect Dis Apr 25 2014). To assess whether
camels are reservoirs for MERS-CoV, investigators inoculated three adult male camels (age 2, 3,
and 5 years) with MERS-CoV at three sites: intratracheal, intranasal in each nostril, and
conjunctival. Before inoculation, all three camels had tested negative for MERS-CoV and bovine
coronavirus neutralizing antibodies.
All three camels developed rhinorrhea (lasting up to 2 weeks) and mildly elevated temperature.
In nasal discharge, infectious virus was documented through day 7 postinoculation, and viral
RNA was detected through day 35. Viral RNA was not detected in fecal or urine samples; neither
infectious virus nor viral RNA was detected in serum or blood samples. Exhaled breath was
positive for MERS-CoV RNA on polymerase chain reaction testing.
From the camel euthanized on day 5 postinoculation, infectious virus was found in multiple
tissues in the upper respiratory tract, the trachea and lung, and the lymph nodes. The respiratory
epithelium in the nasal turbinates was the main site of replication. No pathologic changes or viral
antigens were detected in the tissues of the camel euthanized on day 42 postinoculation. The two
camels alive at 14 days postinoculation showed robust MERS-CoVspecific antibody responses.

Reaction:
The authors note that given the large quantities of MERS-CoV shed in nasal secretions, camelto-camel and camel-to-human transmission could occur through direct contact and large-droplet
transmission. Fomites also might play a role in transmission. In this study, the amount of virus
given as inoculation was similar to the amount shed by camels, suggesting that transmission in
natural settings is plausible. In previous studies, infection and shedding in natural settings
occurred primarily in young camels.

Healthcare-Associated MERS-CoV Outbreak

Larry M. Baddour, MD reviewing Oboho IK et al. N Engl J Med 2015 Feb 26.
Healthcare exposure was the predominant factor driving the 2014 Middle East respiratory
syndrome coronavirus outbreak in Jeddah, Saudi Arabia.
Because of its high mortality rate, Middle East respiratory syndrome coronavirus (MERS-CoV)
infection has received much attention since its identification in 2012. Extensive investigations
into the epidemiology of this illness have yielded evidence of transmission from dromedary
camels to humans (NEJM JW Infect Dis Jan 2015 and Emerg Infect Dis 2014; 20:1999) and of
secondary human-to-human spread in households and healthcare facilities. Now, Saudi Arabian
Ministry of Health and CDC researchers have investigated a MERS-CoV outbreak in early 2014
in Jeddah. All laboratory-confirmed cases were included.
Overall, 255 patients were identified (median age, 45 years; interquartile range, 3059). Despite
this relatively young age, 37% were admitted to an intensive care unit, and 37% died. Among the
191 symptomatic patients, 21% were healthcare employees. Of the remaining symptomatic
patients who did not work in healthcare and who had information available (n=112), 97%
reported recent contact with a healthcare facility or with a person who had confirmed MERSCoV infection or a severe respiratory illness of unknown cause.
Of the 64 patients with reportedly asymptomatic infection, 64% were healthcare personnel.
Among the 33 patients who could be contacted for additional information, 79% reported at least
one symptom consistent with MERS-CoV infection; 36% had manifested signs and symptoms
that prompted laboratory screening for MERS-CoV and were apparently misclassified as
asymptomatic.

Reaction:
The findings demonstrate the importance of healthcare exposure in transmitting this potentially
lethal illness. As noted by the authors, they underscore the need to strengthen infection
prevention and control practices in healthcare facilities and to promptly recognize early or
mild MERS-CoV infection in an effort to limit spread.