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Kerman Iran MERS Clusters Linked To Umrah KSA Pilgrims
Recombinomics Commentary 07:15
July 3, 2014

The patient is a 44-year-old male, national, health-care worker (HCW) resident of Kerman province located in southeast Iran. He developed mild symptoms of an influenza-like illness on 6 June 2014. His condition deteriorated as he developed dyspnea and was admitted to hospital on 17 June 2014. Specimens were collected on 17 June 2014 and initially tested negative for MERS-CoV on 18 June 2014. His condition continued to deteriorate and he was transferred to an Intensive Care Unit (ICU) on 19 June 2014. Additional specimens were collected that day and tested positive for MERS-CoV on 20 June 2014.

The SARI patient had a history of travel to Saudi Arabia to perform Umrah between 5 and 15 May 2014. He was diagnosed with SARI on 17 May 2014 and was admitted on the same day. Specimens were collected from him on 22 May 2014 and tested negative for influenza and for MERS-CoV on 24 May 2014. He was transferred to ICU on 26 May 2014 and was intubated. On 30 May 2014, the SARI patient died.

The above comments from the July 2 WHO MERS update describe the 4th confirmed MERS case in Iran, as well as the second index case who had traveled to Saudi Arabia to perform Umrah and returned to infect contacts in Kerman, Iran.

The index case for the first cluster was female who had ILI (influenza-like illness), but was not MERS confirmed.  However. MERS was confirmed in two contacts (sisters aged 50 and 52) who were hospitalized on May 17.  Partial sequences
(from May 17 collections 82772-Kerman and 82769-Kerman) from the two sisters were identical to each other as well as the sequence from Orlando, Florida (Florida/USA-2_Saudi Arabia_2014), which was also the Jeddah sub-clade.  A health care worker (HCW - 35F) linked to the two sisters was also confirmed, but that case was mild (the older sister subsequently died).

The more recent cluster involved a male pilgrim who was diagnosed with SARI (severe acute respiratory illness), but tested negative for MERS.  However, an HCW contact, who initially also tested negative, subsequently tested positive and is the likely source of the third sequence from Iran
(80946-Tehran), which differed from the Kerman sequences at one position.

Thus, although both clusters are similar (confirmed cases in Kerman linked to pilgrims who returned from performing Umrah in Saudi Arabia, but were not MERS lab confirmed in either country), the clusters were distinct and linkage between the pilgrims is unclear.  The indirect evidence for MERS in two pilgrims returning to Iran raises concerns that the number of such cases is large and not limited to Iran.  These cases were MERS linked due to onward transmission to residents in Kerman, who were subsequently MERS ab confirmed.

These two clusters raise serious Ramadan concerns involving pilgrims in Mecca and Medina, who will return home later this month.

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