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Six Jeddah MERS Exports Raise SARS Concerns
Recombinomics Commentary 22:30
May 1, 2014

The patient is a 27 year-old man who has been living in Riyadh, Saudi Arabia for the past 4 years. The patient had contact with a previously laboratory-confirmed case (his uncle) who died on 19 April, and another laboratory-confirmed case (neighbour of his uncle) who is still under treatment in a hospital in Jeddah, Saudi Arabia. The patient became ill on 22 April, returned to Egypt on 25 April and was laboratory-confirmed with MERS-CoV on 26 April. The patient is currently in a stable condition.

The above comments from today’s WHO MERS update describe the sixth recent Jeddah export, which in this case was to Egypt.  Prior WHO updates on April 24, 23, 20, 17, 11 describe 5 other Jeddah exports to Jordan (25M), UAE (52F), Greece (69M), Malaysia (54M), and Jordan (52M), respectively.  For the most recent Jordan case there was lab confirmed onward transmission to a paramedic in Jordan.  Both Jordan import cases have died, as has the Malaysian case, while the case in Greece is in critical condition. Both cases in Jordan, as well as the case in Greece, sought medical treatment for MERS symptoms in the Kingdom of Saudi Arabia (KSA), but MERS was not diagnosed.  Similarly, the UAE case received three courses of dialysis treatment in a hospital in Jeddah prior to returning to the UAE.

The six cases (who were all diagnosed with MERS outside of KSA) raise serious concerns about MERS transmission in Jeddah, but WHO has failed to issue any updates on MERS cases in Jeddah since April 14, when they described earlier cases.  The most recent Jeddah cases were three cases described in an April 10 KSA update, but the WHO update only gave the age and gender for these case.  No information was provided on their condition, or dates linked to disease onset or hospitalizations, which serve as a supplement to the KSA-MoH reports, which prior to the replacement of the Minister of Health also failed to provide key details on cases.  The number of KSA cases identified by the KSA-MoH, beginning with the April 10 report is 190 lab confirmed MERS cases, including 106 from Jeddah.

WHO has sent a delegation to Jeddah to investigate, but recent comments that the explosion of cases is due to seasonal factors is unfortunate.  Three sequences from Jeddah cases from early April
(Jeddah_C7569, Jeddah_C7149, Jeddah_C7770) indicate a novel sub-clade is circulating in Jeddah with 9 polymorphisms that are unique to that sub-clade, which include non-synonymous changes in ORF1a (P1794S), S (Q833R), and OFR8b (L6Q and L40P).  In a addition, a tenth polymorphism, G28941C, which is also present in a small subset of Al-Hasa sequences (AH19, AH26, AH27, AH28), produces non-synonymous changes in ORF8b (K60N) and the N gene (D126H), which is also in HKU-1, a human beta2a coronavirus.

Reports that partial sequences of the S gene from 25 additional Jeddah case match the first three released sequences increase concerns that the novel MERS sub-clade is widespread in Jeddah, leading to an explosion of cases and the six exported cases described above.

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