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Another  Beta2c Coronavirus Cluster In Riyadh?
Recombinomics Commentary 12:00
March 7, 2013

He had no travel history outside Riyadh, but had been in contact with one of his children who had a mild cold.

He was in his usual state of health until October 9, when he presented to a local private clinic for the first time with a complaint of fever of 38oC and a cough that had become productive.

The above comments are from a publication in the Saudi Medical Journal entitled “Recovery from severe novel coronavirus infection,” which describes the 3rd confirmed nCoV case, who is the first confirmed case from Riyadh.  This case has not been reported as a familial cluster, but the above description raises concerns that the nCoV is widespread in Saudi Arabia, but testing and detection is largely limited to severe cases who are hospitalized with pneumonia, and milder cases, such as the child cited above, are considered as cases with a “mild cold” and are not tested.  Since the infection of the first confirmed case, all but one of the confirmed and probable cases has links to Saudi Arabia (in multiple locations), but only one series has been classified as a confired cluster.

The first confirmed case (60M) was from Bisha, but was hospitalized and died in Jeddah.  The second confirmed case (49M) was from Doha, Qatar, but developed mild symptoms while performing Umrah in Saudi Arabia, as did several travel companions.  His initial symptoms resolved after he returned to Qatar, but two week later the symptoms returned and his deteriorating condition led to air ambulance transport to the UK, where he has been hospitalized for five months.  13 contact health care workers (out of 65) developed mild symptoms, but tested negative. 

The third case is the one described above who had contact with one of his children who had a “mild cold”. 

The fourth confirmed case (31M) was part of a familial cluster.  His father (70M) and brother (39M) died and were also confirmed, while another family member (M) had similar symptoms, but tested negative. 

The fifth confirmed case was from Qatar and is the only case infected since the summer of 2012 with no link to Saudi Arabia.  Contact health care workers with mild symptoms tested negative.

Two additional confirmed cases with no linkage to Saudi Arabia died in April, 2012 and were part of a large cluster (including approximately 10 probable cases) linked to an ICU in Jordan (probable cases included 6 nurses and a doctor).  None of the surviving cluster cases were confirmed, although several were hospitalized with severe pneumonia and WHO has classified the epidemiologically linked patients as probable cases.

All of the 2013 cases have links to Saudi Arabia.  The first confirmed case (60M) also developed symptoms in Saudi Arabia while performing Umrah.  After he returned to the UK he was nCoV confirmed, as were 2 family members with no recent travel outside of the UK.  His son (39M) died, but another family member (30F) had milder symptoms and recovered without treatment. A fourth symptomatic family member tested negative and also recovered without treatment.  The first confirmed 2013 in Saudi Arabia (61F) was said to have developed symptoms abroad, but was confirmed and died in Riyadh.  The most recent confirmed case (69M). died in the province of Al-Qassim in Saudi Arabia and had not recently traveled outside of the country.

The strong linkage to Saudi Arabia coupled with linkage to milder cases who either tested negative or were not tested, raises concerns that the nCoV is common in Saudi Arabia, but the sensitivity of the assay largely limits detection to samples collected from the lower respiratory tract, including sputum samples.  Consequently, almost all confirmed cases develop severe pneumonia and most die.  However, these severe cases represent a small fraction of the infections, due to heavily biased testing and a strong requirement for samples from the lower respiratory tract.

Although the negative results in symptomatic contacts of confirmed cases increases concerns that more extensive testing will produce more false negatives, an expanded testing, particularly of sputum samples from milder cases, is long overdue, as similarities with the 2002/2003 SARS-CoV outbreak continue to increase.

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