Ahead of Print -Contact Investigation for Imported Case of Middle East Respiratory Syndrome, Germany - Volume 20, Number 4—April 2014 - Emerging Infectious Disease journal - CDC

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Ahead of Print -Contact Investigation for Imported Case of Middle East Respiratory Syndrome, Germany - Volume 20, Number 4—April 2014 - Emerging Infectious Disease journal - CDC

Volume 20, Number 4—April 2014

Research

Contact Investigation for Imported Case of Middle East Respiratory Syndrome, Germany

Article Contents

• Methods
• Results
• Discussion
• References
• Figure 1
• Figure 2
• Table
• Suggested Citation

Annicka Reuss , Annette Litterst, Christian Drosten, Michael Seilmaier, Merle Böhmer1, Petra Graf, Hermann Gold, Clemens-Martin Wendtner, Arina Zanuzdana, Lars Schaade, Walter Haas, and Udo Buchholz

Author affiliations: Robert Koch Institute, Berlin, Germany (A. Reuss, M, Böhmer, A. Zanuzdana, L. Schaade, W. Haas, U. Buchholz); Department of Health and Environment, Munich, Germany (A. Litterst, P. Graf, H. Gold); University of Bonn Medical Centre Institute of Virology, Bonn, Germany (C. Drosten); Hospital Schwabing, Munich, Germany (M. Seilmaier, C.-M. Wendtner);Bavarian Health and Food Safety Authority, Oberschleißheim, Germany (M. Böhmer)

Suggested citation for this article

Abstract

On March 19, 2013, a patient from United Arab Emirates who had severe respiratory infection was transferred to a hospital in Germany, 11 days after symptom onset. Infection with Middle East respiratory syndrome coronavirus (MERS-CoV) was suspected on March 21 and confirmed on March 23; the patient, who had contact with an ill camel shortly before symptom onset, died on March 26. A contact investigation was initiated to identify possible person-to-person transmission and assess infection control measures. Of 83 identified contacts, 81 were available for follow-up. Ten contacts experienced mild symptoms, but test results for respiratory and serum samples were negative for MERS-CoV. Serologic testing was done for 53 (75%) of 71 nonsymptomatic contacts; all results were negative. Among contacts, the use of FFP2/FFP3 face masks during aerosol exposure was more frequent after MERS-CoV infection was suspected than before. Infection control measures may have prevented nosocomial transmission of the virus.

Middle East respiratory syndrome coronavirus (MERS-CoV) infection was initially reported to the World Health Organization (WHO) in September 2012 (1,2). By November 11, 2013, a total of 153 laboratory-confirmed cases of human infection with MERS-CoV had been identified; 64 (42%) of those with confirmed cases had died (3). Most (63%) case-patients had severe respiratory disease; 76% also had >1 underlying chronic condition (4). The median age of case-patients was 50 years (range 14 months to 94 years). All cases were directly or indirectly related to countries in the Middle East or on the Arabian Peninsula.

MERS-CoV shows a close genetic relationship with coronaviruses found in bats (1,5–10), but no zoonotic link has been confirmed. Person-to-person transmission has been reported in the work environment, among family contacts, or to health care workers (HCWs) (11–13). Although situations involving consecutive human transmission events have been documented (13), none of the known clusters have led to sustained person-to-person transmission in the general population. In Europe, single imported infections have been reported in the United Kingdom, Germany, France, and Italy, and secondary cases have been reported in the United Kingdom, France, and Italy (12,14,15). Because a large proportion of cases are fatal and the virus could acquire the ability to spread more efficiently (as was the case with severe acute respiratory syndrome coronavirus), WHO has recommended thorough contact investigations for confirmed human cases to identify, quantify, and prevent person-to-person transmission (16).

In Germany, MERS-CoV infection was initially reported in a person from Qatar (17). He was in his third week of illness and was already on mechanical ventilation when he was admitted to a hospital in Essen in October 2012. A retrospective contact investigation found no indication of person-to-person transmission to contacts in Germany (17).

Figure 1

Figure 1. Timeline for patient history and contact investigation in imported case of Middle East respiratory syndrome (MERS), Germany, 2013.

On March 23, 2013, the Institute for Virology of the University of Bonn reported an imported case of MERS-CoV infection to the Department of Health and Environment in Munich (City Health Department). A 73-year-old man from Abu Dhabi, United Arab Emirates, had been admitted to a hospital in Munich and had positive test results for MERS-CoV infection (Figure 1). Clinical details and virologic findings have been reported elsewhere (18). Briefly, the patient had underlying multiple myeloma and had received several modes of treatment, including high-dose chemotherapy and autologous stem-cell transplantation in 2009. On March 8, 2013, influenza-like illness with fever and cough developed in the patient. After his symptoms worsened, he was hospitalized in his country on March 10 with a diagnosis of pneumonia; he was intubated on March 17 and transferred by flight ambulance services to Germany on March 19, eleven days after illness onset, for further intensive care treatment and mechanical ventilation.

General infection control guidelines of the Munich hospital required that patients from areas such as the Middle East, where prevalence of multidrug-resistant pathogens is high, be isolated until colonization or infection with a multidrug-resistant pathogen is ruled out. This rule is particularly enforced when patients have been previously hospitalized in the country of origin. Thus, at the time of hospital admission in Germany, the patient was isolated from other patients. When MERS-CoV infection was suspected and included in the differential diagnosis on March 21, standard hygiene measures for HCWs were changed to infection control measures as recommended for severe acute respiratory syndrome patients, including the use of FFP2 face masks for usual patient care (19).

MERS-CoV infection was diagnosed in the patient on March 23; he died on March 26 of multiorgan failure and acute respiratory distress syndrome. After MERS-CoV infection was diagnosed, the City Health Department, in cooperation with the state health department, the Institute for Virology in Bonn, and the Robert Koch Institute, initiated an investigation to 1) monitor all contacts of the patient to identify possible person-to-person transmission, 2) assess infection control measures, and 3) explore possible sources for the patient’s infection to prevent further cases.

Dr Reuss is an epidemiologist at the Respiratory Infections Unit, Robert Koch Institute, Berlin, Germany. Her research interests include emerging infectious respiratory diseases, pandemic preparedness, and influenza vaccination.

References

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Figures

• Figure 1. Timeline for patient history and contact investigation in imported case of Middle East respiratory syndrome (MERS), Germany, 2013.
• Figure 2. Daily number of health care workers who had contact with a patient infected with Middle East respiratory syndrome (MERS) coronavirus who was hospitalized in Germany, March 19–26, 2013.

Table

• Table. Results of contact investigation of patient with imported MERS-CoV infection, Germany, 2013

Suggested citation for this article: Reuss A, Litterst A, Drosten C, Seilmaier M, Böhmer M, Graf P, et al. Contact investigation for imported case of Middle East respiratory syndrome, Germany. Emerg Infect Dis [Internet]. 2014 Apr [date cited]. http://dx.doi.org/10.3201/eid2004.131375

DOI: 10.3201/eid2004.131375

1Postgraduate Training for Applied Epidemiology, Robert Koch Institute, Berlin, Germany, associated with European Programme for Intervention Epidemiology Training, European Centre for Disease Prevention and Control, Stockholm, Sweden.