Against the backdrop of 33 more Middle East respiratory syndrome coronavirus (MERS-CoV) cases reported by Saudi Arabia—some in Mecca—and the United Arab Emirates (UAE), the World Health Organization (WHO) today raised concerns about the ongoing spike in cases, especially in healthcare settings, and offered to help the countries pull together a global team to help investigate and assess the risks.

The WHO aired the issues in a press release that its Eastern Mediterranean office (EMRO) in Cairo e-mailed to journalists. The statement came amid two separate announcements of cases from Saudi Arabia's health ministry—one reporting 11 new cases and the other reporting 13 new illnesses, two of them fatal, along with two other deaths. In addition, WHO headquarters in Geneva announced details about nine MERS-CoV cases that it received from the UAE on April 16, 18, and 21.

The statements from Saudi Arabia included details about the first cases reported in the holy city of Mecca, including one in a Turkish pilgrim.

WHO offers assistance

Ala Alwan, MD, EMRO's director, said in the statement that 75% of recently reported infections are secondary cases, considered to have been spread from other people. "The majority of these secondary cases have been infected within the healthcare setting and are mainly healthcare workers, although several patients are also considered to have been infected with MERS-CoV while in hospital for other reasons," he added.

Underscoring WHO EMRO's concerns about illness links to health settings, three of Saudi Arabia's MERS-CoV case-patients reported today are healthcare workers, two from Jeddah and one from Riyadh. Also, two of the UAE patients had hospital exposure: one while visiting a facility and the other a patient who had been hospitalized since late February for another medical condition.

Among other common threads in today's cases, 17 had underlying medical conditions, and 10 are listed as contacts of other confirmed cases. Most of the patients who had known contact with a lab-confirmed case-patient have no symptoms or only mild symptoms.

WHO EMRO said that though most of the cases involve asymptomatic or mild infections and don't spread the virus to others, key information gaps remain about the transmission of the virus and the route of infection. One of the unanswered questions is the type of exposure in healthcare settings that transmit the virus.

Therefore, the WHO is offering to gather international expertise to help the two countries probe the recent outbreaks to identify the transmission chain in the clusters and if the pattern signals any new risks.

The WHO also raised concerns about a fresh round of MERS-CoV infections in people who visited Saudi Arabia or the UAE, as recent cases were reported in Greece, Jordan, Malaysia, and the Philippines. It said that though no further spread of the virus has been linked to those cases, earlier imported cases in France and the United Kingdom resulted in limited human-to-human spread.

It urged nations to stay vigilant and enhance surveillance to detect any sign that the virus has changed in a way that makes it more transmissible among humans.

Saudi Arabia reports 24 cases

Saudi Arabia said today in its first statement (posted in English on the health ministry's web site) that four of the 11 case-patients reported today are from Riyadh, six are from Jeddah, and one is from Mecca. All 11 of the cases are residents of Saudi Arabia. Ten are adults, ranging in age from 24 to 81 years old. One is a 13-year-old Jeddah resident, a contact of a previous case, who is asymptomatic.

Of the 11 patients, eight are being treated in intensive care units (ICUs), two are listed in stable condition, and one is asymptomatic. Three of the patients are healthcare workers.

Later today the health ministry announced 13 more cases, according to a machine translation of a statement posted in Arabic. Five cases are reported from Riyadh, two from Jeddah, four from Mecca, one from Medina, and one from Jordan, which appears to be an imported case from Saudi Arabia.

The statement contained several details about the cases that haven't typically been included in past ministry statements, such as hospitalization locations and dates, which underlying medical conditions they have, and if they have pneumonia and are on respirators. It's not clear if the added details in the latest statement are the result of the country's recent change in health ministers. Earlier in the week Saudi Arabia reassigned its health minister and appointed labor minister Adel bin Mohammad Faqih as acting health minister.

One of the patients is a 65-year-old pilgrim from Turkey who is hospitalized in stable condition in Mecca.

Two deaths were reported among the 13 new cases: an 80-year-old man with several underlying medical conditions who died at a Riyadh hospital on Apr 22 and a 52-year-old who was hospitalized in Mecca and also died on Apr 22. Saudi Arabian officials also reported two other deaths in presumably previously confirmed cases, which include a 45-year-old health worker from Al-Kharj governorate who died on Apr 21 and a 29-year-old who died at King Fahd Hospital in Jeddah on Apr 22.

Five of the patients are hospitalized at a military hospital in Riyadh, one is at King Faisal Specialist Hospital in Jeddah, one is hospitalized in Medina, one at a security force hospital in Mecca, and three apparently at another hospital in Mecca.

Of the 13 cases, two patients died, three are on respirators, three are being treated in ICUs, four are stable, and one is asymptomatic. Hospitalization dates, listed for 10 of the patients, range from Mar 27 through Apr 21.

Patient ages range from 13 to 88, though most are middle-aged and older adults.

MERS sickens nine more in UAE

Details about the nine cases in the UAE were included in a statement today from the WHO. All of the patients are adults from Abu Dhabi, ranging in age from 28 to 73 years old. One is a 52-year-old woman who got sick after traveling to Jeddah in Saudi Arabia from Apr 5 through Apr 16, where she visited the hospital three times. One of the others is a 73-year-old woman who had been hospitalized since Feb 26 for another medical condition and was admitted to the ICU on Apr 14.

Six of the UAE cases, all reported to the WHO on Apr 16, had close contact with a lab-confirmed case that was reported on Apr 10. Three are women and three are men. Four had mild illnesses and two were asymptomatic. Only one of them had an underlying medical condition.

With the flurry of recent new cases and lack of clarity in some of the recent health ministry statements, the outbreak total is unclear. FluTrackers, an infectious disease news message board, maintains a running list of lab-confirmed MERS-CoV cases, along with an updated overall case count. However, it said today that some of the cases appear to have already been reported, such as that of a 52-year-old UAE woman reported today, and that as of today it will no longer track the overall count, though it will continue to provide daily case totals.

The WHO said today in the EMRO statement that it has received reports of 253 lab-confirmed cases, including 93 deaths. FluTrackers, in its last case count, said there were 364 cases reported by health ministries. Meanwhile, Saudi Arabia's health ministry said today that it has now recorded 285 infections from MERS-CoV, 83 of them fatal.

See also:

Apr 23 Saudi Arabian health ministry statement in English on 11 cases

Apr 23 WHO EMRO press release

Apr 23 Saudi Arabian health ministry statement in Arabic on 13 cases

Apr 23 WHO statement

Saudi Arabian health ministry main media page

Apr 21 CIDRAP News story "Saudi Arabia sacks health chief as MERS cases surge"