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Beta Coronavirus H2H Transmission In Jordan
Recombinomics Commentary 21:30
February 15, 2013

An outbreak of a respiratory illness was reported on 19 April 2012 by the Ministry of Health in Jordan in an intensive care unit in a hospital in Zarqa. Seven nurses and one doctor were among the 11 affected. One of the nurses died. The cause of this outbreak remains unknown to date.
The two cases from Jordan occurred in April 2012. At that time, a number of severe pneumonia cases occurred in the country and the Ministry of Health (MOH) Jordan promptly requested a WHO Collaborating Centre for Emerging and Re-emerging Infectious Diseases (NAMRU – 3) team to immediately assist in the laboratory investigation. The NAMRU-3 team went to Jordan and tested samples from this cluster of cases.

The above comments in blue are from a May 4 ECDC report describing the beta coronavirus cluster in Jordan based on a report issued by the Jordan Ministry of Health (MoH) on April 19, the day the nurse (45F) died.  The 8 health care workers described in the report did not include the intern (25M) who died a week later (April 26). The MoH denied linkage because the intern had cardiac involvement in addition to pulmonary involvement.

However, as noted in the November 30 WHO report (in red) the two fatal cases were confirmed while associated cases were described by WHO as “severe pneumonia cases”.  Although NAMRU-3 failed to confirm the novel coronavirus in the surviving cases, they were classified as “probable” cases by WHO.

The large number of fatal and severe cases in this cluster indicates the virus is readily transmitted in humans which is supported by the fact that 8 of the 12 confirmed cases were from three clusters which had 2 or more confirmed cases and the first two clusters also had symptomatic cases which tested negative but were classified as probable cases.

The failure to confirm the coronavirus in severe pneumonia cases who were linked to confirmed cases, raises serious questions about the sensitivity of the current protocol and assay.  The WHO website recommends collection of samples from the lower respiratory tract, raising additional questions about negative results of samples collected from the upper respiratory tract.

The detail associated with the cases has been limited.  Although the ECDC report provides some information on the health care workers, there has been no information on the number of probable cases linked to the Jordan cluster and the ECDC update of the table of the 11 confirmed cases failed to give the disease onset dates for the two confirmed cases (other than cite the month of April).  The source of the outbreak in Jordan is unknown, but the linkage of cases to the ICU raises concerns that the source of infection was a patient undergoing treatment at the hospital and the 1 week gap in the dates of death for the two confirmed cases supports human to human (H2H) transmission.

H2H transmission is also supported by the gap in disease onset dates in the Riyadh cluster as well as the most recent cluster where the father (60M) developed symptoms in Saudi Arabia while performing Umrah.  When he returned to England, he then infected his son.  Both have been lab confirmed and remain hospitalized. The repoting of a mild case in the third family member significantly raises pandemic concerns.

The third hospitalized UK case has also been lab confirmed and he (49M) also developed symptoms while performing Umrah in August of 2012.  After recovering, his symptoms reappeared after he returned to Qatar and he was transported by air ambulance to England in September, where he was confirmed and remained hospitalized.

The first confirmed case (60M) developed symptoms on June 13, 2012 and was hospitalized and died in Jeddah, which is adjacent to Mecca.  The relationship of these three cases to Mecca as well as the disease onset dates for the cluster in Riyadh, which was at the height of the Haaj, continues to raise concerns that these cases are tightly linked top associated travel. 

Although there have been reports of screening of symptomatic participants, the screening appears to involve nasal swabs and therefore have limited sensitivity.  Moreover, the detection of H1N1pdm09 in the index case of the most recent cluster, raises concerns that the case definition of severe cases with no know etiology may limit testing of cases infected by influenza and the novel coronavirus.

The detection of the novel cornavirus in a mild case in a familial cluster demands a significant expansion of testing to determine the true spread of this novel coronavirus.

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