Inclusion of MERS-spike protein ELISA in algorithm to determine serologic evidence of MERS-CoV infection.

The Centers for Disease Control and Prevention (CDC) algorithm for detecting presence of serum antibodies against Middle East Respiratory Syndrome coronavirus (MERS-CoV) in subjects with potential infections with the virus has included screening by indirect ELISA against recombinant nucleocapsid (N) protein and confirmation by immunofluorescent staining of infected monolayers and/or microneutralization titration. Other international groups include indirect ELISA assays using the spike (S) protein, as part of their serological determinations. In the current study, we describe development and validation of an indirect MERS-CoV S ELISA to be used as part of our serological determination for evidence of previous exposure to the virus.

Persistence of Antibodies against Middle East Respiratory Syndrome Coronavirus.

To determine how long antibodies against Middle East respiratory syndrome coronavirus persist, we measured long-term antibody responses among persons serologically positive or indeterminate after a 2012 outbreak in Jordan. Antibodies, including neutralizing antibodies, were detectable in 6 (86%) of 7 persons for at least 34 months after the outbreak.

Stillbirth during infection with Middle East respiratory syndrome coronavirus.

We conducted an epidemiologic investigation among survivors of an outbreak of Middle East respiratory syndrome coronavirus (MERS-CoV) infection in Jordan. A second-trimester stillbirth occurred during the course of an acute respiratory illness that was attributed to MERS-CoV on the basis of exposure history and positive results of MERS-CoV serologic testing. This is the first occurrence of stillbirth during an infection with MERS-CoV and may have bearing upon the surveillance and management of pregnant women in settings of unexplained respiratory illness potentially due to MERS-CoV. Future prospective investigations of MERS-CoV should ascertain pregnancy status and obtain further pregnancy-related data, including biological specimens for confirmatory testing.

Hospital-associated outbreak of Middle East respiratory syndrome coronavirus: a serologic, epidemiologic, and clinical description.

BACKGROUND: In April 2012, the Jordan Ministry of Health investigated an outbreak of lower respiratory illnesses at a hospital in Jordan; 2 fatal cases were retrospectively confirmed by real-time reverse transcription polymerase chain reaction (rRT-PCR) to be the first detected cases of Middle East respiratory syndrome (MERS-CoV). METHODS: Epidemiologic and clinical characteristics of selected potential cases were assessed through serum blood specimens, medical record reviews, and interviews with surviving outbreak members, household contacts, and healthcare personnel. Cases of MERS-CoV infection were identified using 3 US Centers for Disease Control and Prevention serologic tests for detection of anti-MERS-CoV antibodies. RESULTS: Specimens and interviews were obtained from 124 subjects. Seven previously unconfirmed individuals tested positive for anti-MERS-CoV antibodies by at least 2 of 3 serologic tests, in addition to 2 fatal cases identified by rRT-PCR. The case-fatality rate among the 9 total cases was 22%. Six subjects were healthcare workers at the outbreak hospital, yielding an attack rate of 10% among potentially exposed outbreak hospital personnel. There was no evidence of MERS-CoV transmission at 2 transfer hospitals having acceptable infection control practices. CONCLUSIONS: Novel serologic tests allowed for the detection of otherwise unrecognized cases of MERS-CoV infection among contacts in a Jordanian hospital-associated respiratory illness outbreak in April 2012, resulting in a total of 9 test-positive cases. Serologic results suggest that further spread of this outbreak to transfer hospitals did not occur. Most subjects had no major, underlying medical conditions; none were on hemodialysis. Our observed case-fatality rate was lower than has been reported from outbreaks elsewhere.

Rapid Response Teams' Initiative: Critical Role and Impact on National and Eastern Mediterranean Regional Emergency Management Capacity Building.

Rapid response teams (RRTs) are essential to contain the harmful effects of emergency situations and to coordinate actions in the fragile environment of the Eastern Mediterranean region (EMR). The Global Health Development and the Eastern Mediterranean Public Health Network (EMPHNET) implemented RRTs to fill the human resources gap and to enable the member states to build their capacity in rapid assessment and response to public health events to reduce human suffering. To build the capacity of the member states in the field of rapid response and to build a strong team of rapid response specialists at the regional level, EMPHNET implemented this initiative at two levels. The first was a basic regional RRT course (July 2012). It was an introductory course for the selected candidates to provide insight and to enhance the knowledge and skills needed to be part of an RRT. The training included 32 participants from nine EMR countries. The course was designed to allow the facilitators and selection committee to select 15 to 20 potential candidates for the advanced RRT course. The second was the advanced RRT course (September 2010 to October 2012) for training the trainers and preparing the RRTs for deployment. A series of RRT training workshops were held, with more than 650 health staff from 12 countries trained. In all workshops that were conducted during 2016-2017, the trainees showed significant improvement in their knowledge and skills.

Preventing Emerging and Re-emerging Infections in the Eastern Mediterranean Region: Gaps, Challenges, and Priorities.

BACKGROUND: The Eastern Mediterranean Public Health Network, supported by the Biosecurity Engagement Program, contributed significantly to strengthening the preparedness and response to the emerging and re-emerging infections in the region. OBJECTIVE: This study aimed to determine the gaps, challenges, and priorities for preventing the emerging and re-emerging infections, with a focus on biosafety and biosecurity in four countries of the region, namely, Egypt, Iraq, Jordan, and Morocco. METHODS: A total of two different methods were used to determine the gaps and priorities for preventing the emerging and re-emerging infections. The first method was a rapid assessment for the preparedness and response to the emerging and re-emerging infections in four countries of the region, with a focus on biosafety and biosecurity. The second method was a face-to-face round table meeting of the participating teams for two days, where the teams from all countries presented their countries' profiles, findings, priorities, and gaps based on the countries' assessments. RESULTS: The assessment and meeting resulted in several priorities and recommendations for each of the countries in the areas of legislation and coordination, biosafety and biosecurity, surveillance and human resources, case management and response, infection control and prevention, and risk communication and laboratory capacity. CONCLUSIONS: Many recommendations were relatively consistent throughout, including improving communication or building collaborations to improve the overall health of the country.

Multihospital Outbreak of a Middle East Respiratory Syndrome Coronavirus Deletion Variant, Jordan: A Molecular, Serologic, and Epidemiologic Investigation.

BACKGROUND: An outbreak of Middle East respiratory syndrome coronavirus (MERS-CoV) in Jordan in 2015 involved a variant virus that acquired distinctive deletions in the accessory open reading frames. We conducted a molecular and seroepidemiologic investigation to describe the deletion variant's transmission patterns and epidemiology. METHODS: We reviewed epidemiologic and medical chart data and analyzed viral genome sequences from respiratory specimens of MERS-CoV cases. In early 2016, sera and standardized interviews were obtained from MERS-CoV cases and their contacts. Sera were evaluated by nucleocapsid and spike protein enzyme immunoassays and microneutralization. RESULTS: Among 16 cases, 11 (69%) had health care exposure and 5 (31%) were relatives of a known case; 13 (81%) were symptomatic, and 7 (44%) died. Genome sequencing of MERS-CoV from 13 cases revealed 3 transmissible deletions associated with clinical illness during the outbreak. Deletion variant sequences were epidemiologically clustered and linked to a common transmission chain. Interviews and sera were collected from 2 surviving cases, 23 household contacts, and 278 health care contacts; 1 (50%) case, 2 (9%) household contacts, and 3 (1%) health care contacts tested seropositive. CONCLUSIONS: The MERS-CoV deletion variants retained human-to-human transmissibility and caused clinical illness in infected persons despite accumulated mutations. Serology suggested limited transmission beyond that detected during the initial outbreak investigation.

Acute respiratory infections among returning Hajj pilgrims-Jordan, 2014.

BACKGROUND: The emergence of Middle East Respiratory Syndrome coronavirus (MERS-CoV) has prompted enhanced surveillance for respiratory infections among pilgrims returning from the Hajj, one of the largest annual mass gatherings in the world. OBJECTIVES: To describe the epidemiology and etiologies of respiratory illnesses among pilgrims returning to Jordan after the 2014 Hajj. STUDY DESIGN: Surveillance for respiratory illness among pilgrims returning to Jordan after the 2014 Hajj was conducted at sentinel health care facilities using epidemiologic surveys and molecular diagnostic testing of upper respiratory specimens for multiple respiratory pathogens, including MERS-CoV. RESULTS: Among the 125 subjects, 58% tested positive for at least one virus; 47% tested positive for rhino/enterovirus. No cases of MERS-CoV were detected. CONCLUSIONS: The majority of pilgrims returning to Jordan from the 2014 Hajj with respiratory illness were determined to have a viral etiology, but none were due to MERS-CoV. A greater understanding of the epidemiology of acute respiratory infections among returning travelers to other countries after Hajj should help optimize surveillance systems and inform public health response practices.