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Iran MERS Cluster Raises KSA Pilgrim Export Concerns
Recombinomics Commentary 23:45
May 26, 2014

According to News and Information, Ministry of Health and Medical Education (Web Da), Dr. Mohammad Mahdi reportedly announced the news while adding 4 new suspected corona virus related to a family in the province have been observed in 2 cases infection has been confirmed that the two sisters in Kerman, one of them is ill and undergoing treatment in certain circumstances.

The above translation describes a MERS cluster in Kerman, Iran.  Two cases (sisters) have been confirmed, and 4 more family members are suspect cases.  Although the above report has been widely reported in Iran, all reports are virtually identical.  The source of the infection is unclear, but the citation of discussions with the Red Crescent in the Kingdom of Saudi Arabia (KSA) regarding Umrah and Hajj pilgrims suggests the two confirmed cases were pilgrims who recently returned from KSA.
The announcement from Iran comes on the same days as a KSA report citing no confirmed MERS, raising concerns that the number of confirmed cases in KSA is a gross under-representation of true infections, leading to repeated exports to various countries monitoring travelers from KSA.  The Netherlands recently reported two such cases who appear to have been infected in Medina while traveling in KSA while performing Umrah.  Sequence from those two cases, (including ORF1a sequence from
Netherlands_1 and Netherlands_2 which had T1976A which was also uniquely found in Indiana/USA-1_Saudi Arabia_2014) matched the recent export from Riyadh to Munster, Indiana, with onward transmission to Chicago, Illinois.  These matches indicate two major sub-clades are circulating in KSA and infecting pilgrims. One sub-clade is the one above, detected in four cases in two countries.  MERS sequences from an explosion of cases in Riyadh and Medina have been withheld, but the recent sequences by labs in the United States and the Netherlands suggest this sub-clade is widespread. 

In addition to this Riyadh/Medina sub-clade, another sub-clade has been detected in Jeddah exports to Orlando, Florida and Athens, Greece.  These exports matched sequences from cases in Jeddah and Mecca.

Thus, pilgrims to KSA are exposed to both sub-clades through travel in Mecca and Medina, leading to exports to Malaysia and The Netherlands, as well as confirmed cases within KSA, who were pilgrims from Turkey and Indonesia.

Details on the cluster in Iran, including travel detail and disease onset dates would be useful, as would sequence data, since the Drosten lab, which has exclusive access to samples from KSA cases has limited release of recent MERS cases to the six sequences from Jeddah and Mecca, which were from samples collected prior to April 16.

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