Comparative Study on the Immunogenicity and Efficacy of Different Post-exposure Intramuscular Rabies Vaccination Regimens in China.

Objective: This study aimed to compare the current Essen rabies post-exposure immunization schedule (0-3-7-14-28) in China and the simple 4-dose schedule (0-3-7-14) newly recommended by the World Health Organization in terms of their safety, efficacy, and protection. Methods: Mice were vaccinated according to different immunization schedules, and blood was collected for detection of rabies virus neutralizing antibodies (RVNAs) on days 14, 21, 28, 35, and 120 after the first immunization. Additionally, different groups of mice were injected with lethal doses of the CVS-11 virus on day 0, subjected to different rabies immunization schedules, and assessed for morbidity and death status. In a clinical trial, 185 rabies-exposed individuals were selected for post-exposure vaccination according to the Essen schedule, and blood was collected for RVNAs detection on days 28 and 42 after the first immunization. Results: A statistically significant difference in RVNAs between mice in the Essen and 0-3-7-14 schedule groups was observed on the 35th day ( P < 0.05). The groups 0-3-7-14, 0-3-7-21, and 0-3-7-28 showed no statistically significant difference ( P > 0.05) in RVNAs levels at any time point. The post-exposure immune protective test showed that the survival rate of mice in the control group was 20%, whereas that in the immunization groups was 40%. In the clinical trial, the RVNAs positive conversion rates on days 28 (14 days after 4 doses) and 42 (14 days after 5 doses) were both 100%, and no significant difference in RVNAs levels was observed ( P > 0.05). Conclusion: The simple 4-dose schedule can produce sufficient RVNAs levels, with no significant effect of a delayed fourth vaccine dose (14-28 d) on the immunization potential.

Prevalence of severe fever with thrombocytopenia syndrome virus in animals in Henan Province, China.

Severe fever with thrombocytopenia syndrome (SFTS) is an emerging infectious disease caused by severe fever with thrombocytopenia syndrome virus (SFTSV). SFTSV has been found in humans, ticks and animals, and SFTS has high mortality and increasing prevalence in East Asia. In the study, the samples (heart, liver, lung, kidney, spleen, brain tissue and serum) were collected from 374 domestic animals and 241 wild animals in Pingqiao District and Xinxian County of Xinyang in Henan Province, China. 275 (44.72%, 275/615) animals were positive for anti-SFTSV antibodies, the anti-SFTSV antibodies positive ratios of domestic and wild animals were 43.58% (163/374) and 46.47% (112/241), respectively. There was no significant difference in domestic and wild animals, but significant differences were detected among different species of animals (χ2 = 112.59, P < 0.0001). Among 615 animals, 105 (17.07%, 105/615) animals were positive for SFTSV RNA, and only one SFTSV strain was isolated from heart tissue of a yellow weasel. The phylogenetic analysis shows that the sequence from animals belonged to the same group with viral sequences obtained from humans. The animals maybe play a reservoir host in maintaining the life cycle of SFTSV in nature.

Distribution of Avian Influenza A Viruses in Poultry-Related Environment and Its Association with Human Infection in Henan, 2016 to 2017.

OBJECTIVE: To survey avian influenza A viruses (AIVs) in the environment and explore the reasons for the surge in human H7N9 cases. METHODS: A total of 1,045 samples were collected from routine surveillance on poultry-related environments and 307 samples from human H7N9 cases-exposed environments in Henan from 2016 to 2017. The nucleic acids of influenza A (Flu A), H5, H7, and H9 subtypes were detected by real-time polymerase chain reaction. RESULTS: A total of 27 H7N9 cases were confirmed in Henan from 2016 to 2017, 24 had a history of live poultry exposure, and 15 had H7N9 virus detected in the related live poultry markets (LPMs). About 96% (264/275) Flu A positive-environmental samples were from LPMs. H9 was the main AIV subtype (10.05%) from routine surveillance sites with only 1 H7-positive sample, whereas 21.17% samples were H7-positive in H7N9 cases-exposed environments. Samples from H7N9 cases-exposed LPMs (47.56%) had much higher AIVs positive rates than those from routine surveillance sites (12.34%). The H7+H9 combination of mixed infection was 78.18% (43/55) of H7-positive samples and 41.34% (43/104) of H9-positive samples. CONCLUSION: The contamination status of AIVs in poultry-related environments is closely associated with the incidence of human infection caused by AIVs. Therefore, systematic surveillance of AIVs in LPMs in China is essential for the detection of novel reassortant viruses and their potential for interspecies transmission.

Chinese guidelines for the diagnosis and treatment of hand, foot and mouth disease (2018 edition).

BACKGROUND: Hand, foot, and mouth disease (HFMD) is a common infectious disease in childhood caused by an enterovirus (EV), and which is principally seen in children under 5 years of age. To promote diagnostic awareness and effective treatments, to further standardize and strengthen the clinical management and to reduce the mortality of HFMD, the guidelines for diagnosis and treatment have been developed. METHODS: National Health Commission of China assembled an expert committee for a revision of the guidelines. The committee included 33 members who are specialized in diagnosis and treatment of HFMD. RESULTS: Early recognition of severe cases is utmost important in diagnosis and treatment of patients with HFMD. The key to diagnosis and treatment of severe cases lies in the timely and accurate recognition of stages 2 and 3 of HFMD, in order to stop progression to stage 4. Clinicians should particularly pay attention to those EV-A71 cases in children aged less than 3 years, and those with disease duration less than 3 days. The following indicators should alert the clinician of possible deterioration and impending critical disease: (1) persistent hyperthermia; (2) involvement of nervous system; (3) worsening respiratory rate and rhythm; (4) circulatory dysfunction; (5) elevated peripheral WBC count; (6) elevated blood glucose and (7) elevated blood lactic acid. For treatment, most mild cases can be treated as outpatients. Patients should be isolated to avoid cross-infection. Intense treatment modalities should be given for those severe cases. CONCLUSION: The guidelines can provide systematic guidance on the diagnosis and management of HFMD.

Species-specific profiles and risk assessment of perfluoroalkyl substances in coral reef fishes from the South China Sea.

The contamination profiles of sixteen perfluoroalkyl substances (PFAS) were examined in coral reef fish samples collected from the South China Sea (SCS) where no information about this topic was available in the literature. The results revealed that six PFAS were found in coral reef fish samples from the SCS. Perfluorooctane sulfonate (PFOS) was the most predominant PFAS contaminant detected in most of the samples, with the highest concentration value of 27.05 ng/g wet weight (ww) observed in Cephalopholis urodelus. Perfluoroundecanoic acid (PFUnDA) and Perfluorotridecanoic acid (PFTrDA) were the second and third dominant PFAS, respectively. Mean PFOS concentrations in muscle of seven coral reef fish varied from 0.29 ng/g ww in Lethrinus olivaceus to 10.78 ng/g ww in Cephalopholis urodelus. No significant linear relationship was observed between PFOS levels and coral reef fish traits (length, weight) collected in this region. Average daily intake of PFOS for the seven coral reef fishes ranged from 0.79 ng/kg/d for Lethrinus olivaceus to 29.53 ng/kg/d for Cephalopholis urodelus. The hazard ratio (HR) values for human consumption of PFOS-contaminated coral reef fishes ranged from 0.04 to 1.48, with Cephalopholis urodelus having the highest HR value of 1.18 (higher than 1) among the species, indicating frequent consumption of Cephalopholis urodelus might pose potential health risk to local population. The present work have provided the first hand data of PFAS in coral reef fishes in the SCS and indirectly demonstrated the existence of low level PFAS pollution in the SCS in China.

Bites from the same dog, different outcomes for two patients: a case report.

BACKGROUND: Rabies is a serious reemerging zoonosis in China. At present human rabies cases are primarily diagnosed based on clinical presentation. CASE PRESENTATION: In August 2012, a woman and her son were attacked by a stray dog in Henan, China. The son received rabies postexposure prophylaxis (wound treatment followed by vaccine, no immunoglobulin), however, the mother did not. Rabies infection was subsequently laboratory confirmed in the mother and she died in December; her son is alive and healthy after 2 years of follow-up. CONCLUSION: This report documents that the timely utilization of postexposure prophylaxis is a required measure in preventing rabies after exposure to an animal bite.

A large outbreak of acute gastroenteritis caused by the human norovirus GII.17 strain at a university in Henan Province, China.

BACKGROUND: Human noroviruses are a major cause of viral gastroenteritis and are the main etiological agents of acute gastroenteritis outbreaks. An increasing number of outbreaks and sporadic cases of norovirus have been reported in China in recent years. There was a large acute gastroenteritis outbreak at a university in Henan Province, China in the past five years. We want to identify the source, transmission routes of the outbreak by epidemiological investigation and laboratory testing in order to provide the effective control measures. METHODS: The clinical cases were investigated, and analysed by descriptive epidemiological methods according to factors such as time, department, grade and so on. Samples were collected from clinical cases, healthy persons, the environment, water, and food at the university. These samples were tested for potential bacteria and viruses. The samples that tested positive for norovirus were selected for whole genome sequencing and the sequences were then analysed. RESULTS: From 4 March to 3 April 2015, a total of 753 acute diarrhoea cases were reported at the university; the attack rate was 3.29%. The epidemic curve showed two peaks, with the main peak occurring between 10 and 20 March, accounting for 85.26% of reported cases. The rates of norovirus detection in samples from confirmed cases, people without symptoms, and environmental samples were 32.72%, 17.39%, and 9.17%, respectively. The phylogenetic analysis showed that the norovirus belonged to the genotype GII.17. CONCLUSIONS: This is the largest and most severe outbreak caused by genotype GII.17 norovirus in recent years in China. The GII.17 viruses displayed high epidemic activity and have become a dominant strain in China since the winter of 2014, having replaced the previously dominant GII.4 Sydney 2012 strain.

Fast Differential Analysis of Propolis Using Surface Desorption Atmospheric Pressure Chemical Ionization Mass Spectrometry.

Mass spectral fingerprints of 24 raw propolis samples, including 23 from China and one from the United States, were directly obtained using surface desorption atmospheric pressure chemical ionization mass spectrometry (SDAPCI-MS) without sample pretreatment. Under the optimized experimental conditions, the most abundant signals were detected in the mass ranges of 70 to 500 m/z and 200 to 350 m/z, respectively. Principal component analyses (PCA) for the two mass ranges showed similarities in that the colors had a significant correlation with the first two PCs; in contrast there was no correlation with the climatic zones from which the samples originated. Analytes such as chrysin, pinocembrin, and quercetin were detected and identified using multiple stage mass spectrometry within 3 min. Therefore, SDAPCI-MS can be used for rapid and reliable high-throughput analysis of propolis.

Outbreak of dengue Fever in central China, 2013.

In 2013, the first dengue fever (DF) outbreak in central China was reported in the central of Henan province, northern temperate regions, although they have been sequentially recorded in Southern China. 106 suspected DF cases were reported and 73 patients were confirmed dengue virus type 3 (DEN-3) infections. 62/392 (15.8%) local health persons showed DEN antibodies positive. To this day Henan is the northernmost province in China which has been reported about outbreak of DF and what is important is that it warns us the endemic range of DF has been expanded geographically in China.

Detection of new bunyavirus RNA by reverse transcription-loop-mediated isothermal amplification.

Severe fever with thrombocytopenia syndrome (SFTS) is a newly emerging and epidemic infectious disease in central and northeast China. It is caused by New Bunyavirus and carries an average 12% case fatality rate. Early and rapid detection is critical for prevention and control of New Bunyavirus infection, since no vaccine or antiviral drugs are currently available, and prevention requires careful attention to control of the suspected tick vector. In this study, a simple and sensitive reverse transcription-loop-mediated isothermal amplification (RT-LAMP) assay was developed for rapid detection of New Bunyavirus. The detection limit of the RT-LAMP assay was approximately 10(3) 50% tissue culture infective doses/ml of New Bunyavirus in culture supernatants, and no cross-reactive amplification of other viruses known to cause similar clinical manifestations was observed. The assay was further evaluated using 138 specimens from clinically suspected SFTS and 40 laboratory-proven hantavirus infection with fever and renal syndrome patients, and the assay exhibited 97% agreement compared to real-time RT-PCR and conventional RT-PCR. Using real-time RT-PCR as the diagnostic gold standard, RT-LAMP was 99% sensitive and 100% specific. The RT-LAMP assay could become a useful alternative in clinical diagnosis of SFTS caused by New Bunyavirus, especially in resource-limited hospitals or rural clinics of China.

[Hand-foot-mouth disease pathogen separation and EV71 VP1 gene analysis in Sanmenxia City, Henan Province, China].

The aim of this study was to understand the enterovirus types and biological features of pediatric cases of HFMD in Sanmenxia City during 2011, and compare the latter to a cohort of healthy children. Stool samples of 55 cases of HFMD and 60 healthy children were collected for the isolation and identification of enteroviruses using RNA extraction and real-time RT-PCR assays. EV71 and CA16 were identified by nucleotide sequencing using virus-specific VP1 primers; for the other enteroviruses, 012/011 and 008/013 primers were used for amplification and sequencing. The results were analysed by sequence alignment with known sequences, and the characteristics of the EV71 VP1 gene were also analyzed. The detection rates for enteroviruses in cases of HFMD and healthy children were 52.73% (29/55) and 18.33% (11/60), respectively. Among these, there were 22 cases of EV71, four cases of CA16 and three cases of other enteroviruses in the cases with HFMD. Eleven healthy children had intestinal viruses, of which nine were Coxsackie B virus strains (81.82%, 9/11). Gene sequencing of the 19 EV71 strains illustrated that they were all subgenotype C4a, but the evolutionary tree showed an obvious clustering between cases from Lingbao City and Lushi County. This study demonstrates that the EV71 subgenotype C4a and CA16 strains were the most common cause of HFMD in Sanmenxia City in 2011, and that Coxsackie B strains were prevalent in healthy children. This finding may indicate that there is a widespread source of recessive infection in the community.

Arabidopsis RPG1 is important for primexine deposition and functions redundantly with RPG2 for plant fertility at the late reproductive stage.

Arabidopsis Ruptured Pollen Grain-1 (RPG1/Sweet8) is a member of the MtN3/saliva protein family that functions as a sugar transporter. The rpg1 mutant shows defective exine pattern formation. In this study, transmission electron microscopy (TEM) observations showed that much less primexine was deposited in rpg1 tetrads. Furthermore, microspore membrane undulation was abnormal, and sporopollenin accumulation was also defective. This suggests that a reduced primexine deposition in rpg1 leads to abnormal membrane undulation that affects exine pattern formation. Chemical staining revealed thinning of the callose wall of rpg1, as well as significantly reduced expression of Callose synthase-5 (CalS5) in rpg1. The fertility of the rpg1 mutant could be partly restored at late reproductive stages, potentially complemented in part by RPG2, another member of the MtN3/saliva family, which is expressed in the anther during microsporogenesis. The double mutant, rpg1rpg2, was almost sterile and was not restored during late reproduction. These results suggest that RPG1 and RPG2 are involved in primexine deposition and therefore pollen wall pattern formation.

AUXIN RESPONSE FACTOR17 is essential for pollen wall pattern formation in Arabidopsis.

In angiosperms, pollen wall pattern formation is determined by primexine deposition on the microspores. Here, we show that AUXIN RESPONSE FACTOR17 (ARF17) is essential for primexine formation and pollen development in Arabidopsis (Arabidopsis thaliana). The arf17 mutant exhibited a male-sterile phenotype with normal vegetative growth. ARF17 was expressed in microsporocytes and microgametophytes from meiosis to the bicellular microspore stage. Transmission electron microscopy analysis showed that primexine was absent in the arf17 mutant, which leads to pollen wall-patterning defects and pollen degradation. Callose deposition was also significantly reduced in the arf17 mutant, and the expression of CALLOSE SYNTHASE5 (CalS5), the major gene for callose biosynthesis, was approximately 10% that of the wild type. Chromatin immunoprecipitation and electrophoretic mobility shift assays showed that ARF17 can directly bind to the CalS5 promoter. As indicated by the expression of DR5-driven green fluorescent protein, which is an synthetic auxin response reporter, auxin signaling appeared to be specifically impaired in arf17 anthers. Taken together, our results suggest that ARF17 is essential for pollen wall patterning in Arabidopsis by modulating primexine formation at least partially through direct regulation of CalS5 gene expression.

CYCLIN-DEPENDENT KINASE G1 is associated with the spliceosome to regulate CALLOSE SYNTHASE5 splicing and pollen wall formation in Arabidopsis.

Arabidopsis thaliana CYCLIN-DEPEDENT KINASE G1 (CDKG1) belongs to the family of cyclin-dependent protein kinases that were originally characterized as cell cycle regulators in eukaryotes. Here, we report that CDKG1 regulates pre-mRNA splicing of CALLOSE SYNTHASE5 (CalS5) and, therefore, pollen wall formation. The knockout mutant cdkg1 exhibits reduced male fertility with impaired callose synthesis and abnormal pollen wall formation. The sixth intron in CalS5 pre-mRNA, a rare type of intron with a GC 5' splice site, is abnormally spliced in cdkg1. RNA immunoprecipitation analysis suggests that CDKG1 is associated with this intron. CDKG1 contains N-terminal Ser/Arg (RS) motifs and interacts with splicing factor Arginine/Serine-Rich Zinc Knuckle-Containing Protein33 (RSZ33) through its RS region to regulate proper splicing. CDKG1 and RS-containing Zinc Finger Protein22 (SRZ22), a splicing factor interacting with RSZ33 and U1 small nuclear ribonucleoprotein particle (snRNP) component U1-70k, colocalize in nuclear speckles and reside in the same complex. We propose that CDKG1 is recruited to U1 snRNP through RSZ33 to facilitate the splicing of the sixth intron of CalS5.

[Genome sequences of coxsackievirus B5 isolated from viral encephalitis patients in Henan province, 2011].

OBJECTIVE: To analyze the complete genome sequences of two coxsackievirus B5 (CVB5) isolated in Henan province, 2011. METHODS: Specimens were collected from viral encephalitis patients and followed by viral isolation on them. RNA were extracted from positive isolates and the amplified products were sequenced. The full-length genomes of them were acquired by assembling the fragments, using DNAStar 5.01 software while phylogenetic analysis were performed with Mega 5.05 and other software. RESULTS: The genomes RNA of 03001N and 17Y showed 7408 bp and 7404 bp long, and the 5'- and 3'-untranslated regions were 747 bp, 743 bp and 103 bp, 103 bp, respectively. BLAST analysis of these two isolates, based on the complete genome, showed 97% identity, with both of them having the highest similarity(98%, 99%)to the CVB5 strain isolated from Henan in 2010 rather than other CVB5 strains. Coding regions of both isolates were 6558 bp, code for a polyprotein of 2185 amino acids (aa) and both of them showed 99% amino acid identity. Phylogenetic tree in VP1 region showed that the two isolates belonged to the same clade with other strains isolated from all over the country in the past years, except for some CVB5 strains isolated from Henan and Shandong province in 2009 that formed the other cluster. CONCLUSION: It seemed that more than one group of CVB5 were circulating in Henan province and these two isolates appeared the main epidemic strains circulating in the past years.

[Survey on ticks and detection of new bunyavirus in some vect in the endemic areas of fever, thrombocytopenia and leukopenia syndrome (FTLS) in Henan province].

OBJECTIVE: To investigate the distribution, species, seasonal fluctuation of ticks and detect new bunyavirus in some hematophagus in the endemic areas of fever thrombocytopenia and leukopenia syndrome (FTLS) in Henan province. METHODS: From March to December 2011, the free ticks were collected manually with white cloth from the grassland and the parasitic ticks were collected from the host skin by hand searching in Xinyang and Jiyuan. The density and seasonal fluctuation of ticks were analyzed after classification of the specimen. The hematophagus were collected including gadfly (38 in 16 groups), cattle lice (224 in 16 groups), mosquitoes (238 in 17 groups) and ticks (825 in 77 groups), then RNA of new bunyavirus were detected by RT-PCR. RESULTS: A total of 12 388 ticks were collected in Xinyang and Jiyuan, consisting of 2 families, 5 geniuses and 6 species. In Xinyang city, 622 ticks were identified, consisting of 2 families, 3 geniuses and 3 species, including 2 (0.32%) Ornithodoros lahorensis, 451 (72.51%) Haemaphysalis longicornis and 117 (18.81%) Boophilus microplus. In Jiyuan city, 11 766 ticks were identified, consisting of 1 family, 4 geniuses and 5 species, including 7718 (65.60%) Haemaphysalis longicornis, 164 (1.39%) H.anatolicum anatolicum and 710 (6.03%) other ticks such as H. detritum, Boophilus microplus and Rhipicephalus sanguineus. Haemaphysalis longicornis were found in both districts as the predominant species in Henan province. Ticks were active from March to October. The average density was 160 per person hour and the peak was from May to July with density 278, 209 and 542 per person hour respectively. The results was positive in RNA detection of new bunyavirus in 11 groups of tick and 3 groups of gadfly by RT-PCR. The results were negative in all other hematophagus. CONCLUSION: Ornithodoros lahorensis, Haemaphysalis longicornis, Boophilus microplus, H.anatolicum anatolicum, Rhipicephalus sanguineus and H. detritum were found in Henan province. Haemaphysalis longicornis was the predominant species. The density of ticks varied with the seasons. The detection of new bunyavirus by PCR was positive in some ticks and gadflies.

[Molecular epidemiological analysis of species B enteroviruses isolated from Henan Province of China during the six months in 2010].

This report presents an overview of human enterovirus B species in Henan Province. A total of 14 isolates of HEV-B species isolated under HFMD surveillance network during the six months in 2010 were examined. Based on molecular typing results targeting VP1 region, 14 isolates were classified into 6 serotypes of HEV-B. Furthermore, comparison of these 14 isolates with reference strains and strains in mainland China was conducted. The phylogenetic analysis revealed that E25, E11 and E6 showed homology with those from Shandong Province which adjoins Henan Province. E1 and E13 showed homology with those from Yunnan Province, and E30 showed homology with Henan strain isolated in 2008. Cocirculation of two lineages of echovirus 6 was observed.

[Genomic characteristics of coxsakievirus A16 isolated in Henan Province].

To reveal the genomic sequence characteristics of coxsackievirus A16 (CoxA16) strain isolated from patients with hand-foot-mouth disease (HFMD) in Henan province. A total of 406 samples were detected by reverse-transcription polymerase chain reaction (RT-PCR) and cell-culture-based isolation of coxsackievirus A16. The whole genome of CoxA16 isolate was amplified using 10 pairs of primers, the sequences were analyzed and phylogenetic tree was generated by bioinformatics software. The full length of HN1162/HN/CHN/2010 genome was 7411bp. Compared with the other CoxA16 strains released in GenBank, the nucleotide similarities were 87.0-97.9%, 77.0%-95.4%, 80.3%-96.9%, 77.9% 96.2%, 80.5-100% in 5'UTR, P1, P2, P3, 3'UTR region, respectively; The similarities of nucleotide and amino acid sequences in VP1 region were 91.4%-96.4% and 99.3%-99.7%, respectively. Phylogenetic tree analysis showed that CoxA16 strains isolated from Henan, Shenzhen, Guangzhou and Fujian belonged to the same cluster. The newly isolated CoxA16 from Henan province belonged to subgenotype C2/B-2. These results will have great significance in monitoring CoxA16 and for prevention and control of hand-foot-mouth disease.

[Analysis of the epidemic characteristics of fever and thrombocytopenia syndrome in Henan province, 2007 - 2011].

OBJECTIVE: To analyze the epidemiological characteristics of fever thrombocytopenia and leukopenia syndrome (FTLS) in Henan province, China in 2007 - 2011. METHODS: Data from specific surveillance system for FTLS in Henan and Information Management System of Chinese Center for Disease Control and Prevention were used to collect the information of the cases.Descriptive epidemiological methods were used to analyze the surveillance data during 2007 - 2011. Patients' sera were collected to detect new bunyavirus using fluorescent RT-PCR and virus isolation. RESULTS: During 2007 - 2011, 1021 FTLS cases were reported in Henan province. The fatality rate was 2.25%with 23 deaths. The cases reported in Xinyang city were 1007, accounting for 98.75%.Cases were mainly occurred between April and October, accounting for 96.47% (985/1021). Epidemic peak was May to July, accounting for 59.16% (604/1021). The second peak occurred in September, accounting for 12.05% (123/1021). The age of the cases ranged from 1 to 88 years old with the median age of 59. Sex ratio (male:female) was 1:1.50 (408:613). In all cases, 93.73% (957/1021) were farmers. In 465 patients' sera, the positive rate of new bunyavirus was 69.25% (322/465) using fluorescent RT-PCR. In 164 patients' sera, 67 strains of new bunyavirus were isolated with isolation rate of 40.85% (67/164). CONCLUSION: FTLS in Henan province is caused mainly by the new bunyavirus and has certain regional and seasonal characteristics. Most cases are female older farmers.