Middle East Respiratory Syndrome
New England Journal of Medicine
Yaseen M. Arabi, M.D., Hanan H. Balkhy, M.D., Frederick G. Hayden, M.D., Abderrezak Bouchama, M.D., Thomas Luke, M.D., J. Kenneth Baillie, M.D., Ph.D., Awad Al-Omari, M.D., Ali H. Hajeer, Ph.D., Mikiko Senga, Ph.D., Mark R. Denison, M.D., Jonathan S. Nguyen-Van-Tam, D.M., Nahoko Shindo, M.D., Ph.D., Alison Bermingham, Ph.D., James D. Chappell, M.D., Ph.D., Maria D. Van Kerkhove, Ph.D., and Robert A. Fowler, M.D., C.M., M.S. (Epi)
From the Departments of Intensive Care (Y.M.A., A. Bouchama), Infection Prevention and Control (H.H.B.), and Pathology and Laboratory (A.H.H.), King Abdulaziz Medical City, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center (Y.M.A., H.H.B., A. Bouchama, A.H.H.), the Department of Intensive Care, Dr. Sulaiman Al‑Habib Group Hospitals (A.A.‑O.), and Alfaisal University (A.A.‑O.) — all in Riyadh, Saudi Arabia; the Department of Medicine, Division of Infectious Diseases and International Health, University of Virginia School of Medicine, Charlottesville (F.G.H.); the Department of Viral and Rickettsial Diseases, Naval Medical Research Center, Silver Spring, MD (T.L.); the Roslin Institute, University of Edinburgh, and Intensive Care Unit, Royal Infirmary of Edinburgh, Edinburgh (J.K.B.), the Health Protection and Influenza Research Group, Division of Epidemiology and Public Health, University of Nottingham, Nottingham (J.S.N.‑V.‑T.), and the Virus Reference Laboratory, Public Health England, London (A. Bermingham) — all in the United Kingdom; the Department of Pandemic and Epidemic Diseases, World Health Organization, Geneva (M.S., N.S.,R.A.F.); the Department of Pediatrics, Vanderbilt University School of Medicine, Nashville (M.R.D., J.D.C.); the Center for Global Health, Institut Pasteur, Paris (M.D.V.K.); and the Institute of Health Policy Management and Evaluation, University of Toronto, and the Department of Critical Care Medicine and Department of Medicine, Sunnybrook Health Sciences Centre — both in Toronto (R.A.F.). Address reprint requests to Dr. Arabi at King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, P.O. Box 22490, Riyadh, 11426, Saudi Arabia, or at email@example.com.
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Between September 2012 and January 20, 2017, the World Health Organization (WHO) received reports from 27 countries of 1879 laboratory-confirmed cases in humans of the Middle East respiratory syndrome (MERS) caused by infection with the MERS coronavirus (MERS-CoV) and at least 659 related deaths. Cases of MERS-CoV infection continue to occur, including sporadic zoonotic infections in humans across the Arabian Peninsula, occasional importations and associated clusters in other regions, and outbreaks of nonsustained human-to-human transmission in health care settings. Dromedary camels are considered to be the most likely source of animal-to-human transmission. MERS-CoV enters host cells after binding the dipeptidyl peptidase 4 (DPP-4) receptor and the carcinoembryonic antigen–related cell-adhesion molecule 5 (CEACAM5) cofactor ligand, and it replicates efficiently in the human respiratory epithelium. Illness begins after an incubation period of 2 to 14 days and frequently results in hypoxemic respiratory failure and the need for multiorgan support. However, asymptomatic and mild cases also occur. Real-time reverse-transcription–polymerase-chain-reaction (RT-PCR) testing of respiratory secretions is the mainstay for diagnosis, and samples from the lower respiratory tract have the greatest yield among seriously ill patients. There is no antiviral therapy of proven efficacy, and thus treatment remains largely supportive; potential vaccines are at an early developmental stage. There are multiple gaps in knowledge regarding the evolution and transmission of the virus, disease pathogenesis, treatment, and prospects for a vaccine. The ongoing occurrence of MERS in humans and the associated high mortality call for a continued collaborative approach toward gaining a better understanding of the infection both in humans and in animals. MERS-CoV was first identified in September 2012 in a patient from Saudi Arabia who had hypoxemic respiratory failure and multiorgan illness. Subsequent cases have included infections in humans across the Arabian Peninsula, occasional importations and associated clusters in other regions, and outbreaks of nonsustained human-to-human transmission in health care settings.