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Mild MERS-CoV Onward Transmission Raises Concerns
Recombinomics Commentary 10:30
June 10, 2013

E 'was discharged the child of 18 months admitted to the pediatric Meyer in Florence because it tested positive for coronavirus , called SARS new . This was announced by the Region of Tuscany, to add that the "baby's fine and is back at home."

E 'was released this afternoon by the department of infectious diseases of Careggi the woman, the second patient were positive coronavirus. The last test was negative, his physical condition is good, so she was sent home.

E 'was discharged yesterday evening from the ward of infectious diseases of the hospital Careggi of Florence also the first patient, the so-called'' index case'', the citizen Kuwaiti that it was positive result to the coronavirus to the return from a trip in Jordan. Le his clinical condition were gia 'good in previously. Yesterday and 'result completely negative the swab Nasopharyngeal, and therefore the patient, 45 Years, an employee of a hotel in Florence, and' been postponed at home.

The above translations describe the discharge of the MERS-CoV confirmed cases in Italy.  The index case (45M) was a Kuwaiti national who lived in Italy but had traveled in Jordan prior to his return to Florence.  One family member (2F) and co-worker (42F) developed symptoms and were confirmed, but recovered after brief hospitalizations.  The index case had bi-lateral pneumonia, but also recovered and has been discharged (see map).

The outcome for the two cases, which represent onward transmission of MERS-CoV, was similar to other onward transmission cases which were part of clusters in Tunisia, France, and England.  In Tunisia the index case (66M) had developed symptoms after travel to Qatar and Saudi Arabia.  Although he died, two children (36F and 34M) had mild symptoms and recovered without treatment or hospitalization.  In France the index case (73M) developed symptoms after a trip to Dubai, UAE.  He also died, but a patient (51M) who shared a hospital room subsequently developed symptoms after discharge and was re-hospitalized, where he recovered and was discharged.  The fourth cluster was in England where the index case (60M0 developed symptoms while performing Umrah in Saudi Arabia.  He also died, as did his son (39M) who was under treatment for a brain tumor.  However, the sister (30F) of the index case had mild symptoms and also recovered without hospitalization or treatment.

Thus, all four of the index cases who developed SARS-like symptoms during or after travel to the Middle East generated clusters associated with MERS-CoV onward transmission in Italy, Tunisia, France and England.  The seven confirmed cases who were infected outside of the Middle East included three cases who recovered without treatment of hospitalization, two who were briefly hospitalized, one who recovered after developing severe pneumonia, and one who died.  The one death out of seven cases produce a case fatality rate (CFR) of 14%, which is markedly lower than the case fatality rate in Saudi Arabia where 25 of the 40 confirmed cases have died and most of the surviving cases remain hospitalized.  Only 7 of the 15 surviving cases have been discharged, so the CFR for the cases with outcomes is 78%.  All seven of the surviving cases were hospitalized and most had severe pneumonia.

These differences in CFR raise serious surveillance concerns.  Each of the four clusters had an index case who was infected in the Middle East, and 3 of the 4 index cases died.  However, the onward transmission, which was identified outside of the Middle East, involved relatively mild cases. 

The two severe cases had significant medical issues.  One was under treatment for a brain tumor, while the other was hospitalized when infected.  In contrast, the other five were relatively young and without reported medical issues.  Three (30F, 35F, 36M) recovered without hospitalization or treatment.  While the other two (2F and 42F) were only briefly hospitalized.

The detection of onward transmission of mild MERS-CoV in previously healthy contacts in England, France, Tunisia, and Italy and the dramatic CFR differences between these cases and those reported in Saudi Arabia raise serious pandemic concerns, which will be exacerbated by upcoming pilgrimages associated with Ramadan and the Hajj.

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