2015 Middle East respiratory syndrome_ An emerging coronavirus infection tracked by the crowd

2015·8.83 MB·English

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ContentslistsavailableatScienceDirect

Virus Research

journal homepage: www.elsevier.com/locate/virusres

Middle East respiratory syndrome: An emerging coronavirus infection

tracked by the crowd

IanM.Mackay∗,KatherineE.Arden

QueenslandPaediatricInfectiousDiseasesLaboratory,QueenslandChildren’sMedicalResearchInstitute,TheUniversityofQueensland,Brisbane,Australia

a r t i c l e i n f o a b s t r a c t

Articlehistory: In2012inJordan,infectionbyanovelcoronavirus(CoV)causedthefirstknowncasesofMiddleEast
Availab leonlinexxx re spirat ory syndro me(MERS ).M E RS-Co Vsequences haves incebee nfo und inabat andth ev irusapp ears

tobeenzooticamongdromedarycamelsacrosstheArabianPeninsulaandinpartsofAfrica.Themajority

Keywords: ofhumancaseshaveoccurredintheKingdomofSaudiArabia(KSA).Inhumans,theetiologicagent,
MERS-CoV M ERS-CoV ,hasb eend etectedin se vere ,mildand in fluenz a-likei llnessa nd inthosew ith outanyo bvious
MERS signsorsym pto msof disease.M E RSisof tena lowe rrespiratoryt ractdis ease as sociat edwithf ever ,cough,
Camel
breathingdifficulties,pneumoniathatcanprogresstoacuterespiratorydistresssyndrome,multiorgan
Zoonosis
failureanddeathamongmorethanathirdofthoseinfected.Severediseaseisusuallyfoundinoldermales
Healthcareworker
Emerging in fectious disease aranpdi dcloymtoorrbesidpiitriaetso aryref afirleuqrueeanntdlya cpureteseknidt niney ciansjeusr yo,fi sMmERoSre. Cooftmenpoarbesde rtvoe dSAaRsSs,e MveEreRSd ipsreoagsereisnspesa tmieonrtes

withunderlyingillnessesandismoreoftenfatal.MERS-CoVhasabroadertropismthanSARS-CoV,rapidly

triggerscellulardamage,employsadifferentreceptorandinducesadelayedproinflammatoryresponse

incells.Mosthumancaseshavebeenlinkedtolapsesininfectionpreventionandcontrolinhealthcare

settings,withafifthofvirusdetectionsreportedamonghealthcareworkers.Thisreviewsetsoutwhatis

currentlyknownaboutMERSandtheMERS-CoV,summarisesthenewphenomenonofcrowd-sourced

epidemiologyandlistssomeofthemanyquestionsthatremainunanswered,nearlythreeyearsafterthe

firstreportedcase.

©2015ElsevierB.V.Allrightsreserved.

1. Briefhistoryofthelocalisedepidemic. (n=351, 37%; data from public sources including the WHO and

MinistriesofHealth).Firstknownasnovelcoronavirus(nCoV),the

The world was made aware of a newly discovered coronavi- followingtwotothreeyearswereaslowdiscoveryprocessrevea-

rusviaanemailfromDr.AliMohamedZaki,anEgyptianvirologist lingavirusthatappearswellestablishedamongdromedarycamels

working at the Dr. Soliman Fakeeh Hospital in Jeddah in The (DC;Camelusdromedarius)acrosstheArabianPeninsulaandparts

KingdomofSaudiArabia(KSA).Theemailwaspublishedonthe ofAfrica.FrominfectedDCs,thevirusisthoughttoinfrequently

websiteoftheprofessionalemergingdiseases(ProMED)network infectexposedhumans.Concernwasraisedearlyonthatpatenting

on20-September-2014(ProMED,2014).Thatfirstcasewasa60 ofthefirstviralisolatewouldleadtorestrictedaccesstothevirus

year old man from Bisha in the KSA and, thanks to the email, and to viral diagnostics (Sciencemag, 2014). However, sensitive,

the rapid discovery of a second case of the virus, this time in validated reverse transcriptase real-time polymerase chain reac-

anillpatientfromQatar,wastransferredtotheUnitedKingdom tion(RT-rtPCR)-baseddiagnosticswereavailable(Abdel-Moneim,

for care (Fig. 1) (Bermingham et al., 2012). As of 20th January 2014) almost immediately. Virus was also made freely available

2015,therehavebeen969detectionsofviralRNAorvirus-specific subjecttoroutinebiosafetyconsiderations,supportingmanyofthe

antibodiesreportedpublicly,955confirmedbytheWorldHealth research findings described herein. In search of an animal host,

Organization(WHO),withoverathirdofthepositivepeopledying bats were implicated in August 2013 (Memish et al., 2013a) but

inthatsamemonthaDClinkwasreported(Reuskenetal.,2013c)

andthatlinkhasmaturedintoaverifiableassociation.Inhumans,

overtdiseasewasfinallygiventhenameMiddleEastrespiratory
∗Correspondingauthorat:Level7,SASVRC,BuildingC18,BackRoadoffBramston
syndromeandtheacronymMERS.Fromtheseanimal-to-human
Terrace,RoyalBrisbaneandWomen’sHospital,HerstonQ4029,Australia.
spilloverevents,theMERScoronavirus(MERS-CoV;seeSection3
Tel.:E +-6m1a 7il a3d6d3r6e s1s6:[email protected](I.M.Mackay). forvariat ioninna min g)spr eadsporadic allyamongpe opl e,causin g

http://dx.doi.org/10.1016/j.virusres.2015.01.021
0168-1702/©2015ElsevierB.V.Allrightsreserved.

Pleasecitethisarticleinpressas:Mackay,I.M.,Arden,K.E.,MiddleEastrespiratorysyndrome:Anemergingcoronavirusinfection

trackedbythecrowd.VirusRes.(2015),http://dx.doi.org/10.1016/j.virusres.2015.01.021
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Fig.1. Atimelineofkeyscientificmilestones,casesofinterestandmassgatheringsofrelevancetothepotentialspreadofMERS-CoVamonghumansandfromanimalsto

humans.Ayellowcircleindicateswhenacountryreportedalaboratoryconfirmeddetectionandanorangecircledenotesensuinglocaltransmission.MentionofDCcontact

priortodiseaseismarkedbyablackcamelicon.

moreseverediseaseamongoldermaleswithunderlyingdiseases. researchandtoengagewithpublichealthentities,thepublicthem-

Theproportionofinfectedpeoplewhoareconfirmedtohavedied selvesandthemainstreammedia.Thisdegreeofengagementwas

from MERS-CoV infection is much higher than for severe acute notpossiblein2002/2003whentheSARSglobaloutbreakbegan

respiratorysyndrome(SARS)-CoV,influenzavirusormanyother itsriseto8100humancasesincluding770deaths(proportionof

pathogens.ThespreadofMERS-CoVamonghumanshasoftenbeen fatalcases,orPFC,of9.5%).Theubiquityofsocialmediaappearsto

associatedwithoutbreaksinhospitals,whichin2012–2014usu- havechangedwhatthepublicexpectsfromaStatewhenitcom-

allycommencedinMarch(Mackay,2014;MaltezouandTsiodras, municatesaboutneworexistinginfectiousdiseaseoutbreaksand

2014).Thisspreadmaybelinkedtosomeseasonalenvironmen- epidemics,andhowquicklytheyexpectthattooccur.

talchanges,changeinhostanimalbehaviour,orperhapssimple

coincidence between season and successive hospital outbreaks. 2. MiddleEastrespiratorysyndrome(MERS)

Approximately a fifth of all cases to date have involved health-

careworkers(HCWs),spikingalongsideperiodsofincreasedtotal PatientswithMERSoftenpresentthemselvestoahospitalwith

casenumbers.Socialmedia,blogsandthemainstreammediahave systemicandlowerrespiratorytract(LRT)signsandsymptomsof

kept close tabs on the spread of MERS-CoV to 23 countries in disease which usually include fever, chills or rigors, dry or pro-

Europe,AsiaandtheUnitedStatesofAmerica(USA;Fig.2),mostly ductive cough, shortness of breath (dyspnea) and one or more

withanoriginintheKSAfromwhere88%ofviraldetectionshave comorbidities including diabetes (prevalent in the KSA), chronic

occurred.Twitterinparticularhasprovidedaglobalforumthrough kidney disease including renal failure, chronic heart disease and
specifich ashtags lik e#MERS and theArab ic hasht ag#AF 4FD?or heart f ailure, re cent surg ery, h yperten sion, chr onic l ung dise ase,

#Coruna.Anengagedworldhashelpedunderstandhowthevirus asthma,obesity,smoking,malignantdiseaseorsteroiduse(Arabi

hasaffectedtheKSAanditsneighbouringcountriesandallowed et al., 2014; Assiri et al., 2013a; Hijawi et al., 2013; Zaki et al.,

outsiderstoviewsciencemusingstakeshape,collaborationsform, 2012).MERS-CoVmaybeidentifiedinpatientswithseverehypox-

local news and commentary trend and new results be discussed aemic respiratory failure and extrapulmonary organ dysfunction

inrealtime.Socialmediaprovidesnewavenuesforscientiststo whichcanprecededeathinoverathirdofinfections(Arabietal.,

expressexperiencedopinion,tomorewidelycommunicatetheir 2014; Assiri et al., 2013a; Hijawi et al., 2013; Zaki et al., 2012).

Fig.2. The23countriesinwhichMERS-CoVhasbeenidentifiedandaguideastothenumberofcasesateachlocation.Localtransmissionishighlighted(bluestar)asare

countrieswithDCsthatcontainantibodiesreactivewithMERS-CoV,viralRNAorinfectiousvirus(camelicon).Correctasofthe20thJanuary,2015.

Pleasecitethisarticleinpressas:Mackay,I.M.,Arden,K.E.,MiddleEastrespiratorysyndrome:Anemergingcoronavirusinfection

trackedbythecrowd.VirusRes.(2015),http://dx.doi.org/10.1016/j.virusres.2015.01.021
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Extrapulmonarydiseasemanifestationsincludecirculatory,renal, symptomonsetamongMERSpatients,comparedtoamedianof

hepaticandhematologicdysfunction.Gastrointestinalsymptoms 20 days for SARS patients (Chu et al., 2005; Eckerle et al., 2013;

have been seen in 20–33% of cases (Assiri et al., 2013a; Mailles Zakietal.,2012).Thismaybeduetodirectinfectionofrenaltissue

etal.,2013;Memishetal.,2013b;ZumlaandMemish,2014),mani- byMERS-CoV(Arabietal.,2014;Zakietal.,2012).Haematologic

festingasdiarrhea,vomitingandabdominalpain.Gastrointestinal changes in MERS cases include thrombocytopenia (Assiri et al.,

symptomswerenotseenatallinonefamilycluster(Omranietal., 2013a;Drostenetal.,2013;Omranietal.,2013)andlymphocytosis

2013)noramongsymptomaticchildreninanother(Memishetal., (Assirietal.,2013a)orlymphopenia(Assirietal.,2013a;Omrani

2014a).Onoccasion,feverandgastrointestinalupsetmayforma etal.,2013)onadmission(Assirietal.,2013a).Monocytenumbers

prodrome,afterwhichsymptomsdeclinetobearelaterfollowedby are often normal (Assiri et al., 2013a) while neutrophils may be

moreseveresystemicandrespiratorysignsandsymptoms(Kraaij- raised(Zakietal.,2012)ornormal(Assirietal.,2013a).

Dirkzwageretal.,2014;Maillesetal.,2013).Rarely,MERS-CoVhas As a group, children have rarely been reported to be positive

been detected in a person with fever but no respiratory or gas- for the virus. Between 1st September 2012 and 2nd December

trointestinalsymptoms(Memishetal.,2014a).Theextenttowhich 2013, 11 paediatric cases (2–16 years of age; median 13-years)

infectionbyothergastrointestinalpathogensaffectthisvariability were identified in total; nine were asymptomatic (72%) and one

isunknown. died(Memishetal.,2014a).InAmman,Jordan,1005samplesfrom

ChestradiographyofMERSpatients,asdistinctfromMERS-CoV hospitalised children under the age of 2-years with fever and/or

positivepeoplewithasubclinicalinfection,revealinfiltratescon- respiratorysignsandsymptomsweretestedbutnonewereposi-

sistentwithacuteviralpneumonia(Assirietal.,2013a;Devietal., tiveforMERS-CoVRNA,despitebeingcollectedatasimilartimeto

2014;Tsiodrasetal.,2014;Zakietal.,2012).Onlyonrareocca- thefirstknownoutbreakofMERS-CoVintheneighbouringtown

sions have studies described upper respiratory tract (URT) signs ofAl-Zarqa(Khuri-Bulosetal.,2013).Asecondtrimesterstillbirth

and symptoms. In one example, approximately 15–25% of cases occurredinapregnantwomanduringanacuterespiratoryillness

presented with rhinorrhoea and/or sore throat (2014e; Memish andwhilenotRT-rtPCRpositive,themothersubsequentlydevel-

etal.,2013b;Payneetal.,2014;ZumlaandMemish,2014).Todate, opedantibodiestoMERS-CoV,suggestiveofrecentinfection(Payne

MERS has been an opportunistic disease. Severe MERS has been etal.,2014).HerexposurehistorytoaMERS-CoVRT-rtPCRpositive

defined by admission to an intensive care unit; use of extracor- relativeandanantibody-reactivehusband,herincubationperiod

porealmembraneoxygenation(ECMO),mechanicalventilationor andhersymptomhistorymettheWHOcriteriaforbeingaprobable

vasopressors;casesbeingreportedascriticalorsevere;afatalout- MERS-CoVcase(Payneetal.,2014).

come(Arabietal.,2014).Therelativespeedofdiseaseprogression

mayrelatetoMERS-CoVreachingearlierpeakviralloadsandinfect-
3. TheMiddleEastrespiratorysyndromecoronavirus
ingdifferentcellsthantheSARS-CoV(Drosten,2013).Nonetheless,
(MERS-CoV)
itisalsoapparentthatMERSisnotrestrictedtothosewithcomor-

bidities.Withincreasedlaboratorytesting,particularlyofcontacts
ThevirusassociatedwithMERSwasinitiallyidentifiedasthe
ofconfirmedMERScases,anumberofMERS-CoVpositiveindivid-
“novelcoronavirus”ornCOV;aproblematicchoicegiventhatother
ualswithoutcomorbiditieshavebeendetectedwhoexperiencea
novelcoronavirusescouldbediscoveredandwerebeingdiscovered
mildillnessornosymptomsatall(Al-TawfiqandMemish,2014).
withregularitypriortoandsincetheidentificationofMERS-CoV.
ThisdemonstratesthatMERS,likemostrespiratoryviruses,isasso-
Whenthefirstgenomeofahumanvariantwassequenceditwas
ciatedwithawidespectrumofsymptomsanddegreesofseverity.
namedhumanbetacoronavirus2cEMC(subsequentlyreferredto
The mean incubation period in a study of 47 cases was 5.2
here as EMC/2012), with the implication that it was a human
days,with95%ofcaseshavingshownsymptomswithin12.4days
notanimalcoronavirus.TherewerealsovariantsnamedEngland-
(Assirietal.,2013a).Inasmallerstudytheincubationperiodranged
Qatar, Jordan-N3 and England 1. Ten months after its discovery,
betweenoneandninedays,with13–14daysbetweenwhenillness
thecoronavirusstudygroupassembledaninternationalconsensus
beganinonepersonandsubsequentlyspreadtoanother(Memish
andtheviruswasrenamedandgiventheacronymofMERS-CoV
etal.,2013b).Thelengthandnatureoftheprodromeisundefined
(deGrootetal.,2013).
todate.ThefirstWHOcasedefinition(WorldHealthOrganization,

2014a)definedprobablecasesofMERSbasedonthepresenceof

febrile illness, cough, requirement for hospitalization with sus- 3.1. Theviralgenome

picion of LRT involvement and included roles for contact with a

probable or confirmed case or for travel or residence within the MERS-CoV is a putative member of a new species (van

Arabianpeninsula.Ifstrictlyadheredto,onlytheseveresyndrome Boheemenetal.,2012)withintheorderNidovirales,familyCoron-

wouldmeetthecasedefinitionandbesubjecttolaboratorytest- aviridae,subfamilyCoronavirinae,genusBetacoronavirus,subgroup

ing,whichwastheparadigmearlyon(Assirietal.,2013a).From 2c (Raj et al., 2014b). The first full sequence defined a single-

July 2013, the revised WHO case definition included the impor- stranded, positive sense, 30,119 nucleotide (nt) long genome

tanceofseekingoutandunderstandingtheroleofasymptomatic (Fig. 3) (van Boheemen et al., 2012; Zaki et al., 2012). Based on

cases(WorldHealthOrganization,2014d).Apartfromreportsfrom analysis of 42 complete sequences, the genome is predicted to
theW HOand KSAM inistryofHea lth,asym ptom atico rsubcli nical be evolv ing at 1.12×10 −3 substitu tions per site ( Cotten et al.,

cases of MERS-CoV infection have also been documented in the 2014).Thispermittedapredictivecalculationofthetimetomost

scientificliterature(Drostenetal.,2014b;Memishetal.,2014b). recent viral ancestor (tMRCA) for most of the variants, which

Inonesuchcase,aHCWshedvirusfor42daysintheabsenceof suggested MERS-CoV first appeared around March 2012 (ran-

disease(Al-Gethamyetal.,2014). ging from December 2011 to July 2012) (Cotten et al., 2014).

MERScanprogresstoanacuterespiratorydistresssyndrome Comparison of the first open reading frame’s (ORF 1ab) amino

(ARDS)requiringexternalventilationandthentomultiorganfail- acid sequence to that from its closest betacoronavirus relatives,

ure(Devietal.,2014;Reussetal.,2014;Zakietal.,2012)similar Tylonycteris bat HKU4 and Pipistrellus bat HKU5, found there

tosevereinfluenzaandSARScases(Zakietal.,2012).Acuterenal was less than 80% identity which supported the conclusion that

failure can occur in MERS patients, doing so sooner than it did MERS-CoV was a novel and distinct virus. This genomic region

amongSARSpatients(Eckerleetal.,2013).Progressiveimpairment is a key taxonomic identifier of CoV species. MERS-CoV is pre-

ofrenalfunctionandacutekidneyinjurycanstart9–12daysafter dicted to encode at least ten open reading frames bracketed by

Pleasecitethisarticleinpressas:Mackay,I.M.,Arden,K.E.,MiddleEastrespiratorysyndrome:Anemergingcoronavirusinfection

trackedbythecrowd.VirusRes.(2015),http://dx.doi.org/10.1016/j.virusres.2015.01.021
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1 2,000 4,000 6,000 8,000 10,000 12,000 14,000 16,000 18,000 20,000 22,000 24,000 26,000 28,000 30,119
3 4b E 8b
FS
UTR ORF 1a ORF 1b 4a 5 M N UTR
L
Fig.3. SchematicofMERS-CoVgenome(EMC/2012variantisolatedfromsputumofa60-yearoldmanfromBisha,KSA).Openreadingframesareindicatedasyellow
rect an glesbracket ed bytermina luntrans latedregion s(UTR; greyrect angles ).The5(cid:3) UT R includes the predi ctedl eader( L)tran script ion-regu latorys eque nce.FS-fr am e-shift.
Predictedp apain-like pr oteinase cleavagesites areind icated with orangearro wsr esultin gin∼16 cle avagenon -struct ura lproteinproducts(based on(vanB oheemenetal.,

2012)).ThegenomeisdrawntoscaleusingGeneiousv6.1.6andannotatedusingAdobeIllustrator.MERS-CoVEMC/2012sequenceGenBankaccessionnumberJX869059

(Zakietal.,2012).

5(cid:3)and3(cid:3)untranslatedregions(Rajetal.,2014b).Structuralproteins comparisonoftrimmedgenomes(EMC/2012vs.Bisha1)revealed

includethespike(S),envelope(E),membrane(M)andnucleocap- 115nucleotidedifferences(0.38%difference)resolvingBisha1into

sid(N)(vanBoheemenetal.,2012).Nonstructuralproteins(nsps) Clade B (Cotten et al., 2013b). This is unusual because when a

fromtheproductsofORF1aandORF1bhavebeenpredicted,fol- Jordan-N3 virus was intentionally serially passed through Vero

lowingidentificationofconserveddomainsandaftercomparative orMRC5cellculture(Jordan-N3/2012MG167),only2ntchanges

analysiswithothercoronaviralproteins.Thenspsincludeapapain- occurredwithintheentirecodingregionoftheresultantsequence,

likeprotease(PLpro;nsp4(Kilianskietal.,2013;Linetal.,2014) despite eight passages (Frey et al., 2014). For comparison, after

transmembranedomains(nsp4,nsp6),a3C-likeprotease(3CLpro; threepassagesthroughVerocellculture,nogeneticchangeswere

nsp5(Kilianskietal.,2013)),anRNA-dependentRNApolymerase foundinaDCMERS-CoVvariantofQatar22014(Rajetal.,2014a).

(RdRp;nsp12),ahelicase(nsp13)andanexonuclease(nsp14)(van A very divergent MERS-CoV variant originated from an

Boheemenetal.,2012). EgyptianDClikelyimportedfromSudanwasidentifiedasNRCE-
Comple te gen omedeductionusingdeepsequencingmethods HKU205| Nile |2013 . It constr ucts a linea ge o utside th e c urrent

has been the predominant tool for genome analysis during the clades,perhapscomprisingthefirstoccupantofCladeC(Corman

emergenceofMERS-CoV(Cottenetal.,2013a,b,2014)thefirsttime et al., 2014a; Cotten et al., 2013b; Smits et al., 2015). This lin-

it’susehasbeensopervasiveforthestudyofaviraloutbreakwith eage may represent additional diversity of MERS-CoV variants

globalreach.Whiletheerrorratecanbehigherthanfortraditional remainingtobediscoveredinDCfromoutsidetheArabianpenin-

Sangersequencing,thenear-completegenomiclengthcoveredby sula.AvirussequencedfromaNeoromiciacapensisbatwasmore

just a single run (e.g. 90% of the MERS-CoV EMC/2012 genome) closelyrelatedtoMERS-CoVthanpreviousbatsequenceshadbeen,

and the depth of coverage at each nucleotide is such that deep providingalinkbetweenhuman,camelandbatvirusesasmem-

sequencingcorrectsforerroneousnucleotide(Rajetal.,2014a;van bersofthesameCoVspecies(Cormanetal.,2014a).Despiteusually
Boheemene tal.,201 2). Subgenom icsequenci ng,a m ain stayofv iral com pri sing ≤1% ofth etotalg enome,in si lico compar isonsho wsthat

genotyping and molecular epidemiology to this point, has been viralgeneticchangesamongvariantspermitgeographictrackingof

used rarely for MERS-CoV identification or confirmation, despite thespreadofvariantsandidentificationthatRiyadh,inparticular,

assayshavingbeensuggestedearlyonCormanetal.(2012b).Such harboursawiderangeofMERS-CoVvariants(Fig.4)(Cottenetal.,

anapproachissimpler,moreaccessibletoawiderrangeoflabo- 2013b). This process of molecular epidemiology can also imply

ratoriesandfaster.It’sutilityhassincebeendemonstratedusing somephysicaldirectiontothemovementofMERS-CoVaroundthe

molecularassaystoamplifyandsequencea615nucleotidelong regionandovertime(Cottenetal.,2014).

fragmentofthespikeS2domaingenefragment(Smitsetal.,2015). WhencomparedtoBisha12012,mostsinglenucleotidediffer-

Thisassayagreedwiththeresultsgeneratedbythesequencingof encesamongvariantswerelocatedinthelastthirdofthegenome,

fullgenomesanddefinedadditionalsequencegroupingswithinan encompassingtheSprotein(Fig.5)andaccessoryproteins(Cotten

existingMERS-CoVclade.Withtheadditionofmoregenomesover etal.,2013b).AtleastnineMERS-CoVgenomesharbouraminoacid

time from both humans and from DCs, two clades have become substitutionsintheribosomebindingdomain(RBD)ofthespike

apparent;AandB.CladeAcontainsonlyhuman-derivedMERS-CoV proteinandcodons158(N-terminalregion),460(RBD),1020(in

genomes(Fig.4)(Cottenetal.,2013b). heptadrepeat1),1202and1208bearinvestigationasmarkersof

adaptivechange(Cottenetal.,2014;Rajetal.,2014a).Studiesare

neededtodeterminewhetherthereanyfunctionaloutcomeson
3.2. Genomicvariabilityandmolecularepidemiology virusre plic ationandt ransmiss iondu eto theseandfu turechan ges

(Cottenetal.,2014).Anearlyinvitroanalysisdidnotfinddiffer-
Todate,theMERS-CoVgenomescollectedfromsamplesspan- ences in s hed ding, r epli cation o r imm une esc ape amo ng v iruses
ningj usttw oy earsarege neticallyv erysimil arto eachoth er.An isolate d up to May 2014 (Dros ten et al., 2 015). Th e locat ion and
align men tof 56com ple teornear- comp leteME RS -CoV genom es crystals truc tu reof theRB Dwasde scr ibe dinsev eral reportsf rom
sampledfr om 20 12to2014 dif feredby0–0.38 %.Forcomp arison,an mid-20 13(Chen et al.,2 013 ;Du etal.,2013 b; Lueta l.,2013; Mou
alignmen tof3 1com p leteH CoV-NL 63 genomes fro msamplesc ol- etal.,2013 ;Wan ge tal .,2013 ).
lectedbetw e en 1983and 2009shows theydive rgeb y0.5%at the

nucleotidelevel(datanotshown;theoreticallyequatesto145nt

fora27,553ntgenome).Thereisasyetnostudywhichattaches 4. MoleculardetectionofMERS-CoVinfection

clinicalrelevancetothecladesorsmallergroupingsofMERS-CoV

nor any of the genomic variation noted to date (Drosten et al., EarlydiagnosticmethodsappearedwithindaysoftheProMED

2015).ItisinterestingthatCladeAcontainsonlytheAfricangreen email announcing the first MERS case. These included Vero and

monkeykidney(Vero;innateimmunedeficientcells)cell-culture LLC-MK2cellcultureandseveralin-houseRT-rtPCRassays(Fig.6)

passagedEMC/2012variantandtwovariantsoftheJordan-N3vari- (Corman et al., 2012a,b; Zaki et al., 2012). Antibody testing of

antfrom2012,butnocamel-derivedMERS-CoVgenomes(Cotten humanseraremainsrare.

et al., 2013b). When the MERS-CoV genome of the variant from RT-rtPCR assays validated by Corman et al. were quickly rec-

Bishawasre-sequenceddirectlyfromtheoriginalURTsample,the ommended by the WHO having been shown to be sensitive

Pleasecitethisarticleinpressas:Mackay,I.M.,Arden,K.E.,MiddleEastrespiratorysyndrome:Anemergingcoronavirusinfection

trackedbythecrowd.VirusRes.(2015),http://dx.doi.org/10.1016/j.virusres.2015.01.021
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NRCE-HKU205 CAMEL KJ477102
Munich 2013 KF192507
58.6 Eng land 12012 NC_019843
Riyadh 4 2013 KJ156952
Riyadh 3 2013 KF600613
Wadi Ad Dawasir 1 2013 KJ156881
Riyadh 5 2013 KJ156944
Taif 1 2013 KJ156949
Jeddah 1 2013 KJ556336
MERS CoV Jeddah HUMAN 1 2013 KF958702
MERS CoV Jeddah CAMEL 1 2013 KF917527
KSA CAMEL 363 2013 KJ713298
KSA CAMEL 503 2013 KJ713297
KSA CAMEL 378 2013 KJ713296
KSA CAMEL 505 2013 KJ713295
100 Qatar 2 2014 KJ650098
MERS-CoV/Jeddah 2014 C8826
M MMMFlEoEEE RrMRRRiSdSSS-Ea---CRCCC/oSUoooV-VVVSC////AJoMJJe Vee2ddda/ dKJkddeaSkaadhAahhd h2 222a 002h0011011 2441440 4C KCC1 7JC497859 012C635497955937 5 67 50 April/May 2014 Healthcare Cluster
Bisha 1 2012 KF600620
Riyadh 1 2012 KF600612
Indiana/USA 1 KSA 2014 KJ813439
Riyadh 8b 2013 KJ156942 mmunity
72.6 79 M aQ Qdaai tnRtaaairyhr4a3 3d 22bh00 211104331 2KK30FF K991J663111 K522J622192151 669 34 September 2013 CorCluste
Buraidah 1 2013 KF600630
KSA CAMEL 376 2013 KJ713299
FRA/UAE 2013 KF745068
KSA CAMEL KFU-HKU13 2013 KJ650295
KSA CAMEL KFU-HKU1 2013 KJ650297
KSA CAMEL KFU-HKU19Dam 2013 KJ650296
HPA HPABetacoronavirusEngland2...
Riyadh 9 2013 KJ156869
Al Hasa 3 2013 KF186565
Al Hasa 21 2013 KF600634
Al Hasa 18 2013 KF600651
Al Hasa 25 2013 KJ156866
Al Hasa 15 2013 KF600645
Al Hasa 4 2013 KF186564
A AA A lA l lA H lHH lH laH aaHsassaasaaas as 1 a12 a1 212 126 90270 2 102 120310301 31K 1K3 3FK3 F1K 1FK K8F68F66F06660500500660606726664 73 44 27 April/May 2013 Healthcare Cluster B
EMC/2012 2012 JC869059
74 Jordan-N3/2012 bronchial wash KC776174 A
8.0E-4
Fig.4. Thegeneticrelationshipbetweenallnear-completeandcompleteMERS-CoVgenomenucleotidesequences(downloadedfromGenBankusingthelistedaccession

numbers;England2wasobtainedfromhttp://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/MERSCoV/respPartialgeneticsequenceofnovelcoronavirus/%5D).This

neighbourjoiningtreewascreatedinMEGAv6usinganalignmentofhumanandDC-derivedMERS-CoVsequences(Geneiousv6).ThetreewasrootedusingNRCE-HKU205

CAMELKJ477102.Cladesareindicatednexttodark(CladeA)orpale(CladeB)blueverticalbars.CameliconsdenotegenomesfromDC.MERS-CoVsequencesdescribedas

originatingfromthesamepatienteitherbefore(Bisha1)orafter(EMC/2012)passageincellculture(Cottenetal.,2013b)arestarred(red).Identicalgenomesfromahuman

andoneofhisillcamelsfromJeddah(Azharetal.,2014a),theKSAarealsostarred(yellow).Healthcareorcommunityoutbreaksareboxed(blue,green,pink)andlabelled.

S2
S1 membrane fusion
receptor-binding subunit
SP NTD RBD RBM HR1 HR2 TM
1 18 353 367 484 567 606 992 1054 1252 1286 1296 1318 1353
Fig.5. SchematicrepresentationoftheMERS-CoVSprotein.SP-signalpeptide;NTD,N-terminaldomain;RBD,receptorbindingdomain;RBM,receptorbindingmotif;HR,

heptadrepeat;TM,transmembranedomain;S1/S2,SSpikeproteinsubunitsseparatedafterproteasecleavage.NumberingfromLuetal.(2013)andDuetal.(2013a).

and specific (Corman et al., 2012a,b). The target sequences of RT-rtPCRontheupstreamEregion(upE;Fig.6)oftheMERS-

the recommended screening assays remained conserved among CoVgenomewasusedtoscreen5235nasopharyngealswabsfrom

genomes until at least mid-2014 when last checked by IMM 3210 incoming (29th September to 9th October 2013) and 2025

(Fig.6). outgoing(14thOctoberto26thOctober2013)adultpilgrimswho

Pleasecitethisarticleinpressas:Mackay,I.M.,Arden,K.E.,MiddleEastrespiratorysyndrome:Anemergingcoronavirusinfection

trackedbythecrowd.VirusRes.(2015),http://dx.doi.org/10.1016/j.virusres.2015.01.021
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Orf1a Orf1ab S E M N
18,266−18,347 27,458−27,550
ORF1b upE
1st reported assays
11,197−11,280 15,049−15,290 29,549−29,860
ORF1a RdRpSeq NSeq
2nd reported assays
WHO recommended
f or screening
WHO recommended
for sequencing
Fig.6. Aschematicdepictingthelocationofprimers(bluearrowsindicatedirection)andoligoprobes(greenrectangles)fortheearliestRT-rtPCRscreeningassaysand

conventional,semi-nested(threeprimers)RT-PCRconfirmatorysequencingassays(Cormanetal.,2012a,b).Publicationorderisnotedbyfirst[27thSeptember2012;red]

andsecond[6thDecember2012;orange]colouredrectangles,bothbyCormanetal.ThoseassaysrecommendedbytheWHO(WorldHealthOrganization,2013b)are

highlightedunderneathbyyellowdots.

performedtheHajjin2013,withnocasesbeingidentified(Memish InvestigationTeam,2013;Memishetal.,2014b,d)and,ifnoted,for

etal.,2014d).ThismayreflecttheabsenceofMERS-CoV,noLRT othersmallerinvestigativeMERS-CoVtesting(Kraaij-Dirkzwager

testing(Memishetal.,2014d)orthat61%ofpilgrimswerearriving etal.,2014;Memishetal.,2013b).Inamacaquemonkeymodel,

from countries without any known MERS-CoV circulation. Simi- MERS-CoVRNAwasshedfromboththeURTandLRT(deWitetal.,

larly,noMERS-CoVwasidentifiedduringthe2012inHajjamong 2013).Inahumancase,throatswabswerepositiveforsixdays,and

the nasal swabs from 154 pilgrims tested by RT-rtPCR (Corman againafteragap(Kraaij-Dirkzwageretal.,2014).Inanothercase,a

etal.,2012a)beforeleavingforanddepartingfrom,theKSAnor 40-yearoldfemaleHCWshedMERS-CoVRNAfromtheURT(Ziad

from114swabbedpilgrimswithinfluenza-likeillnessintheKSA A.Memish,personalcommunication)foratleast42-daysbetween

duringtheHajjin2013(Barasheedetal.,2014;Gautretetal.,2013). AprilandJune2014(Al-Gethamyetal.,2014).Shedidnotshow

Acrossaperiodofrapidcaseaccumulationandintensescreeningin signsofdiseaseduringhertimesheddingvirus.InastudyofMERS

JeddahduringMarchtoJuly2014(calledtheJeddah-2014outbreak casesinanintensivecaresetting,threeof12patientsshedvirusfor
hereaft er),∼5 000sam p les were tested ina monthyield ing∼140 12–22 d ays (Arabiet al.,2 014).E lsewh ere ,v iralRNA was detec ted
MERS-CoV detect ions (∼3 % pre valence ) (M ERS, 2 014g). A mong inhum ano ronasa lsw ab sfor1 6days(Dro stene tal., 201 3)andin

5065individualssampledandtestedacrosstheKSAbetween1st pharyngealorendotrachealaspiratesfor24days(Spanakisetal.,

October 2012 and 30th September 2013, 108 (2.1%) detections 2014).OverthreequartersofMERScasesshedviralRNAintheir

weremadeusingtheupEandORF1aassays.Thiswasahospital- lowerrespiratorytractspecimens(trachealaspiratesandsputum)

centric population which included hospitalised cases (n=2908), foratleast30dayswhileonly30%ofcontactswerestillshedding

their families (n=462) and associated HCWs (n=1695) (Memish RNAintheirupperrespiratoryspecimens(Memishetal.,2014e).

etal.,2014b).Amongthedetections,19wereHCWsand10were TheLRTisaWHO-recommendedsamplingsiteforMERS-CoV

familycontacts(Memishetal.,2014b).DuringtimesofhighMERS- RT-rtPCR testing, especially when collection of samples will be

CoVactivity,its2–3%prevalenceisnotverydifferentfromamore delayed by a week or more after symptom onset (World Health

hospital-basedprevalenceforotherHCoVs(Mackayetal.,2012). Organization, 2013b). Samples to test include bronchoalveolar

GiventheproportionofdeathsamongthoseinfectedwithMERS- lavage(BAL),tracheal/tracheobronchialaspirate,pleuralfluidand

CoV,itisnotavirusthatshouldreasonablybedescribedasa“storm sputum (CDC, 2014; World Health Organization, 2013b). Fresh

in a teacup”, however to date it has been given many “oppor- samplesyieldbetterdiagnosticresultsthanrefrigeratedmaterial
tu ni ties” for worldwid e s pread a nd i t has not ye t taken any of (Drosten et al ., 2013 ) and if de lays of ≥72 h are likely, samples
them. (except f or bloo d) sho uld be frozen at −70 ◦C (CD C, 201 4). Lung

biopsy or autopsy tissues can also be tested if available (World

HealthOrganization,2013b).FromtheURT,whichisalessinvasive
4.1. Specimentypesandlengthofviralshedding andcon venientsamp lingsite ,acom bin edno seand th r oats wabora

nasopharyngealaspirateisrecommended(CDC,2014).Pairedsera,
DatahaveshownoneormoreRT-rtPCRnegativeURTsamples collectedtwoto threew e eksapartarep refera blefor serolo gical
fromclin ically suspe ctM ERS cases maybec ontradict edb yfurther testingw hile as ingles ample ispre ferr edifcollec ted twoweeks
URT sampling orthep referr eduse ofL RT samples(Be rmi ngham afteron setof di sease( WorldH ea lthOrgan iza tion,201 3b).
etal .,2012;Om ra nie tal.,2013) .Hig he rvira lloadso ccurintheLRT Ur ineha sb eenfou ndtoco ntainM ERS-CoVRNA 12and13days
co mp aredto theUR T,e sp ecially withinc reas ingtim efrom o nse tof after sym pto m on set an d stool sa mples wer e RT- rtP CR pos itive
symptoms (C DC, 2014 ;Drosten etal., 2013;Mem ish etal., 2013b ). upto 16daysa fteron set( Droste netal., 2013; Kraaij-Dir kzwager
Sincethem ajorit yofdi seasesym p tom sappe artohav e bee nmani- eta l., 20 14);b oths ample typessho ul db econs idered(CDC,2014;
festin g as systemi c a nd LRT disease, th is may n ot be surp rising W orld Health Orga nization ,2013 b).Int wo casesthata rrived inthe
(Assiri eta l.,2013a) .Ho weve ratwrit ing, nohu man da taexistto Nether lands, urinewasRT- rtPCRne ga tive butf aece swasw ea kly
define wh eth erthev irusreplic ate ssolely int heLRT, theU RT,h as positivewhil esera wer eRT-rtPC Rpositive for fived ayso rmore
aprefe rencefor on eover theother ,orre pli cate sino the rhum an (Kraaij-D irkzw ager etal., 2014).ME RS-CoV vira lRN Adet ect ionin
ti ssues in viv o. S amp ling of t he UR T h as been f req uently noted serum has proven a u sef ul retro spective so urce of P CR templa te
fromth el arges thumanM ER S-C oVin vest igativ estudies(G autret whenr espi ratorys am plesw erenotavaila ble(Hi jaw iet al.,2013).
etal., 201 3;Heal thProte ctionAgenc y(HPA)UKN ovelCor onavirus RNAae miamayal socorrel atew ithd iseasese verity;s ign so fvirus

Pleasecitethisarticleinpressas:Mackay,I.M.,Arden,K.E.,MiddleEastrespiratorysyndrome:Anemergingcoronavirusinfection

trackedbythecrowd.VirusRes.(2015),http://dx.doi.org/10.1016/j.virusres.2015.01.021
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I.M.Mackay,K.E.Arden/VirusResearchxxx(2015)xxx–xxx 7

clearedfromseruminonerecoveredhumancasewhilelingering communityexposurestoMERS-CoVamongcountriesintheAra-

untilthedeathofanother(Faureetal.,2014). bian Peninsula. Early sero-surveys of humans used conventional

Inastudyofdifferentsampletypes(64nasopharyngeal[NPA], immunofluorescentassays(IFA)inwhichantibodies,ifpresentin

30trachealaspirates,13sputaand3BAL),trachealaspiratesand patient sera, attach to MERS-CoV infected cell cultures to iden-

BALreturnedthebestviralloadvaluesfollowedbyNPAandspu- tify the presence of IgG, IgM or neutralising antibodies (Corman

tum, which generally equated with whole genome sequencing et al., 2012b; Drosten et al., 2013; Zaki et al., 2012). No sign of

success(Memishetal.,2014c).Thisrepresentstheonlystudyof MERS-CoVantibodywasfoundamong2400serafrompatientsvis-

theeffectofsampletypeonmolecularanalysisanditconfirmed iting the Dr. Soliman Fakeeh Hospital in Jeddah, KSA from 2010

boththeimportanceofLRTsamplingforwholegenomesequenc- through 2012 (Zaki et al., 2012), and no sign of prior MERS-CoV

ing,whilenotingthat57%ofsamplesfrom112distinctpatientsin infectionwasfoundamong130healthyblooddonorsscreenedat

theKSAinfactoriginatedfromtheURT(Memishetal.,2014c). KingAbdulazizUniversityHospitalinJeddah(collectedbetween

JanuaryandDecember2012).Eightof226slaughterhousework-

4.2. MERS-CoVandothervirusesandbacteria erswerepositivebyIFA,butthoseresultscouldnotbeconfirmed

byneutralization(NT)test.ThestudyindicatedthatHCoV-HKU1

Manystudiesmakenomentionofadditionaltestingforendemic was a likely source of cross-reactive antigen by IFA (Aburizaiza

humanrespiratoryvirusesorbacteria(Assirietal.,2013a,b;Devi etal.,2014).AnabsenceofMERS-CoVantibodiesamongslaughter-

etal.,2014).Whenvirusesaresought,theyincludesomeofthefol- houseworkersmayreflectthekillingofolderDCswhichareless

lowing:humanherpesvirus(HHV),rhinovirus(HRV),enterovirus oftenMERS-CoVpositive(seeTable1),therarityofinfectedani-

(EV), respiratory syncytial virus (RSV), parainfluenzavirus types mals,alimitedtransmissionriskassociatedwithslaughteringDCs

1, 2 and 3 (PIVs), influenzaviruses (IFVs), endemic HCoVs, aden- (Aburizaizaetal.,2014),aweakimmuneresponsebyhumanswho

oviruses (AdVs) and metapneumovirus (MPV) and co-detections donotgetsevereMERS,oranoveralllowriskofMERS-CoVtrans-

withMERS-CoVdooccur(Berminghametal.,2012;Drostenetal., mission by contact. IFA also suffered from some cross-reactivity

2013; Health Protection Agency (HPA) UK Novel Coronavirus withconvalescentSARSpatientserawhichcouldnotberesolvedby

InvestigationTeam,2013;Memishetal.,2013b).Whenincluded, anNTtest(Chanetal.,2013b).Theneedforwell-validatedassays

othervirusesareoftenabsentinthesamplespositiveforMERS-CoV was further emphasised when publicly released MERS-CoV anti-

(Al-Tawfiqetal.,2014;Berminghametal.,2012;Kraaij-Dirkzwager bodytestresultsindicatedthatahandshakeandtwoface-to-face

et al., 2014; Omrani et al., 2013) but have been found in sam- meetingsweresufficientforMERS-CoVtransmissionbetweentwo

plesnegativeforMERS-CoVduringsuchrareMERSinvestigations peopleintheUSA(CDCNewsroom,2014;Sampathkumar,2014).

(Reussetal.,2014).TestsonthefirsthumancaseintheKSAuseda These results were subsequently retracted because they did not

LRTsampletoisolateMERS-CoVinculture,conductimmunofluo- withstand further confirmatory analysis with the less rapid, but

rescenceforsomeviruses(negativeforIFV,PIVs,RSVandAdVs) highlyspecific,NTassay(CDCNewsroom,2014).

and RT-PCR for other viruses (negative for AdV, EVs, MPV and A more biologically safe IFA was developed that did not

HHVs)(Zakietal.,2012).RT-PCRalsodetectedMERS-CoV.Acase requireinfectiousvirusbutwasinsteadbasedontransfectedcells

exportedtoGreeceinApril-2014wastested(andfoundnegative) expressingrecombinantportionsoftheMERS-CoVNandSgenes

forIFVs,LegionellaandPneumococcus(Tsiodrasetal.,2014).Other (Cormanetal.,2012b;Reussetal.,2014).Recombinantlentiviruses

bacterialtestinghasbeenconductedbuttheimpactofbacterialco- expressingMERS-CoVSproteinandluciferasearealsosaferand

presenceisalsounclear(Al-Tawfiqetal.,2014;Devietal.,2014; simplerdiagnosticalternativestoworkingwithinfectiousMERS-

Memishetal.,2013b;Tsiodrasetal.,2014).TwoMERScasesthat CoV (Perera et al., 2013; Zhao et al., 2013). A pseudo particle

travelledfromtheKSAtotheNetherlandswerenegativeforRSV, neutralization (ppNT) assay has seen widespread use in animal

AdV,bocavirus(BoV),PIVs,HCoVs,HRV,IFVs,RSVandMPV(Kraaij- studiesandisatleastassensitiveasthemicroneutralization(MNT)

Dirkzwageretal.,2014).Testingforotherrespiratorypathogens test(Hemidaetal.,2013,2014a,2015;Pereraetal.,2013;Reusken

isstronglyrecommended(WorldHealthOrganization,2013b)but etal.,2013b).InastudyofseracollectedattheKingFahdHospital,

limited data address the occurrence of co-infections or alterna- EasternregionoftheKSA(158fromchildrenwithLRTinfections

tiveviraldiagnosesamongbothcasesandcontactssuspectedof betweenMay2010andMay2011and110from19to52yearold

MERS-CoVinfection.LittleisknownofothercausesofMERS-like maleblooddonors)noevidenceofMERS-CoVneutralisingantibody

pneumoniaintheKSAorofthegeneralburdenofdiseasedueto couldbefoundusingtheppNTassay(Giereretal.,2013).Similarly,

the known classical respiratory viruses including endemic other inastudyoffourherdsmenincontactwithaninfectedDCherdin

humancoronaviruses. Al-Ahsa,eightpeoplewhohadintermittentcontactwiththeherd,

30veterinarysurgeonsandsupportstaffwhowerenotexposedto

4.3. SerologicalsurveystoidentifypriorMERS-CoVinfection theherd,threeunprotectedabattoirworkersinAl-Ahsaand146

controlswhowerenotexposedtocamelsinanyprofessionalrole,

DespitewidespreaduseinelucidatingtheroleofDCsasasource none had serological evidence of past MERS-CoV infection using

for MERS-CoV, no strategic and widespread sero-surveys have theppNTassay(Hemidaetal.,2015).

beenconductedinhumansusingsamplescollectedpost-2012.The MERS-CoVdoesnotappeartobeeasilytransmittedfromDCs

developmentofrobustserologicalassayshingesontheaccessibil- to humans, or perhaps it does not trigger a detectable immune

ityofareliablepanelofwell-characterisedanimalorhumansera response if only mild disease or asymptomatic infection results.

includingthosepositiveforantibodiesspecifictoMERS-CoVandto Astudyofsuchcasesisanimportantmissinglinkforinterpreta-

likelyagentsofcross-reaction(Meyeretal.,2014a).Obtainingthese tionofthesenegativehumanserologydata.AJordanianoutbreakof

controlmaterialshasbeenproblematicandhasslowedthedevel- acuteLRTdiseaseinahospitalinAl-Zarqain2012,whichpredated

opmentandcommercializationofassaysforhumantesting(Meyer thefirstKSAcaseofMERS,wasretrospectivelyfoundtohavebeen

etal.,2014a).OnecompanyhasproducedanELISAkittodetect associatedwithMERS-CoVinfection,initiallyviaRT-rtPCR,butsub-

IgGincamelsusingarecombinantS1receptor-bindingsubunitof sequently,andonalargerscale,usingpositivitybyELISAandIFAor

MERS-CoV S protein as the antigen and produces a diagnos- MNTtest(Al-Abdallatetal.,2014;Hijawietal.,2013;Payneetal.,

tic reagent for immunofluorescence (Drosten et al., 2014b; 2014).TheELISAusedarecombinantNproteinfromthegroup2

EUROIMMUN Medizinische Labordiagnostika AGf, 2014). Sero- betacoronavirus(Pipistrellus)bat-CoVHKU5toidentifyantibod-

surveys are essential to determine a baseline of animal and ies against the equivalent cross-reactive MERS-CoV protein and

Pleasecitethisarticleinpressas:Mackay,I.M.,Arden,K.E.,MiddleEastrespiratorysyndrome:Anemergingcoronavirusinfection

trackedbythecrowd.VirusRes.(2015),http://dx.doi.org/10.1016/j.virusres.2015.01.021
8 V G
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.101.,M DCd Nasalswabs/18 2013–14 KSA VRTe-rrot PceClRl c(uUlptuEr(eCorman 33% Hemidaetal.(2014a) en/V E
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.2015.01.021espiratorysyn D7D365CC8/Adults/ sNSwearsaaab/l3s a/57n86d conjunctival 22001130– 2011 ONmigearni a epc(RSCat1pT op a-NsrrtluTm.ut,Pb br2aCeu0n Rnm1 ;ie2t iOt cb( arRC)ol oFa.a,1V n2ra)dr0 a A(1OrCb2yRoaarF)m1ban 79%4% KNReooulwosdokzteniney je eatkn a d(l2. (021041)4b) xx(2015)xxx–xxx RESS
d DC Sera/204 2009,2013 Tunisia S1subunit(CoV)Ab 30%of Reuskenetal.(2014b)
ro 204 cap turemi croarr arya juve niles
m
54%ofadults
e:Ane D18C8 Sera/188 2011–2013 Ethiopia cSa1p stuubreu nmiti c(rCooaVr)r aArbya 9j9u37v%%e nooiffl eadsults Reusken et al. (2014b)
m DC Sera 1992–2013 Kenya Recombinantspike(S1) 30% Cormanetal.(2014b)
e
r 774 ELISA(Memishetal., 28%
g
in 2014f) 15%
g Recombinantspike(S1)IFA
coro M(CNorTman et al ., 2012 b)
nav D11C0/Adult Nasal swabs/110 2013 Egypt RetTa-rl.t,P2C0R1 (2Uap),EO (RCFo1raman 40%% Chu et al. (2014)
ir
u Sera/52 (Cormanetal.,2012b))
s
in Culture on RT pos 92%
fec ppNTb
t
io
n