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MERS Jeddah Cluster Exported To The Netherlands
Recombinomics Commentary 02:00
May 17, 2014

The patient developed first symptoms on 1 May 2014 while in Medina, SaudiArabia. He was evaluated at an emergency care department in Mecca on 6 May and given antibiotics; he did not have respiratory symptoms while in Saudi Arabia. On return to the Netherlands, on 10 May, his condition deteriorated, including development of respiratory symptoms, and he was hospitalized on the same day. On 13 May, he tested positive for MERS-CoV. Currently, the patient is in the ICU in a stable condition.

This second patient is a 73-year old female citizen of the Netherlands and a close family member of the first case. Both patients were on the same trip through the Kingdom of Saudi Arabia and shared a hotel room throughout the entire journey. This second patient has co-morbidities and developed first symptoms, including some breathing difficulties, on 5 May 2014 in Mecca, Saudi Arabia. Upon return to the Netherlands on 10 May, the patient presented with mild respiratory symptoms and fever, but these were not severe enough for her to seek medical help.
The above comments from WHO describe the index case (70M in red) in the confirmed MERS cluster in The Netherlands, as well as his roommate (73F) who also developed symptoms while performing Umrah in the Kingdom of Saudi Arabia (KSA).  In media reports, the son of the index case (who was also in the pilgrim group), indicated that his father developed symptoms after visiting a hospital in Medina, and his father was not in a group that visited a camel farm in KSA.

These two cases increase the number of Jeddah exports (it is likely that the entire group flew together on a flight from Jeddah to Amsterdam) to nine, although the above detail suggests the MERS infection originated in Medina. Sequences from cases in Jeddah and Mecca define a sub-clade which has been identified in 33 out of 33 sequences from samples collected between April 3 and May 10.  These cases include 30 cases in Jeddah from 3 or more hospitals, as well as a case in Mecca.  The same novel sub-clade was confirmed in sequences from a Jeddah export to Athens, Greece
(Spike and N gene sequences, Greece-Saudi Arabia_2014), as well as Orlando, Florida, USA, Florida/USA-2_Saudi Arabia_2014,.  The detection of the same sub-clade in all cases linked to Jeddah and Mecca since April 2014 signal clonal expansion and sustained MERS transmission.

Christian Droston has updated six nearly complete sequences,
four hospitals in Jeddah and Mecca ((C8826 and C9055) collected on April 12 and April 14 from hospital A and C, respectively, as well as Mecca (C9355) collected on April 15.  The three earlier sequences were from two hospitals ((C7149 and C7770 from hospital A collected on April 3 and 7, respectively as well as C7569 from hospital B collected on April 5) at his website (and has noted that 25 additional partial Spike gene sequences match the six nearly complete sequences, and the CDC has deposited partial sequences (Spike and N gene contained ORF8b) from the export to Greece and a full sequence of the export to the United States. 

The novel Jeddah sub-clade has 11 defining polymorphisms, including 2 in the Spike gene and 3 in ORF8b.  All 33 sequences contain the relevant markers.  Thus, even partial sequences can be used to confirm the linkage of the novel sub-clade.

Following the Jeddah outbreak, new cases have been cited in Mecca, Medina, and Taif.  The sequence from Mecca confirms the spread of the Jeddah to Mecca.  It is likely that the Drosten lab has already sequenced samples from additional cases in Mecca as well as those in Medina and Taif.  Similarly, it is likely that the Erasmus lab (EMC) in The Netherlands has sequence data on the cluster in the Netherlands and NAMRU-3 has sequence data on the export to Cairo, Egypt, which also was a likely Jeddah export.  The status sequences on other exported cases including two exports in Jordan, which have produced onward transmission, as well as exports to Malaysia and the UAE is unclear, but the immediate release of full or partial sequences would be useful.

Genbank is developing a MERS sequence page similar to access pages for influenza sequences, including H1N1pdm09.

The clonal expansion of the novel Jeddah sub-clade and associated sustained transmission raises serious pandemic concerns.

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