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Lack of Transmission among Close Contacts of Patient with Case of Middle East Respiratory Syndrome Imported into the United States, 2014 - Volume 21, Number 7—July 2015 - Emerging Infectious Disease journal - CDC

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Lack of Transmission among Close Contacts of Patient with Case of Middle East Respiratory Syndrome Imported into the United States, 2014 - Volume 21, Number 7—July 2015 - Emerging Infectious Disease journal - CDC

Volume 21, Number 7—July 2015


Lack of Transmission among Close Contacts of Patient with Case of Middle East Respiratory Syndrome Imported into the United States, 2014

Lucy Breakwell1, Kimberly Pringle1, Nora Chea1, Donna Allen, Steve Allen, Shawn Richards, Pam Pantones, Michelle Sandoval, Lixia Liu, Michael Vernon, Craig Conover, Rashmi Chugh, Alfred DeMaria, Rachel Burns, Sandra Smole, Susan I. Gerber, Nicole J Cohen, David Kuhar, Lia M. Haynes, Eileen Schneider, Alan Kumar, Minal Kapoor, Marlene Madrigal, David L. Swerdlow, and Daniel R. FeikinComments to Author 
Author affiliations: Centers for Disease Control and Prevention, Atlanta, Georgia, USA (L. Breakwell, K. Pringle, N. Chea, M. Sandoval, S.I. Gerber, N.J. Cohen, D. Kuhar, L.M. Haynes, E. Schneider, D.L. Swerdlow, D.R. Feikin);Indiana State Health Department, Indianapolis, Indiana, USA (D. Allen, S. Allen, S. Richards, P. Pantones, M. Sandoval, L. Liu)Cook County Department of Public Health, Oak Forest, Illinois, USA (M. Vernon)Illinois Department of Public Health, Chicago, Illinois, USA (C. Conover)DuPage County Health Department, Wheaton, Illinois, USA (R. Chugh)Massachusetts Department of Public Health, Jamaica Plain, Massachusetts, USA (A. DeMaria, R. Burns, S. Smole)Community Hospital, Munster, Indiana, USA (A. Kumar, M. Kapoor, M. Madrigal)


In May 2014, a traveler from the Kingdom of Saudi Arabia was the first person identified with Middle East respiratory syndrome coronavirus (MERS-CoV) infection in the United States. To evaluate transmission risk, we determined the type, duration, and frequency of patient contact among health care personnel (HCP), household, and community contacts by using standard questionnaires and, for HCP, global positioning system (GPS) tracer tag logs. Respiratory and serum samples from all contacts were tested for MERS-CoV. Of 61 identified contacts, 56 were interviewed. HCP exposures occurred most frequently in the emergency department (69%) and among nurses (47%); some HCP had contact with respiratory secretions. Household and community contacts had brief contact (e.g., hugging). All laboratory test results were negative for MERS-CoV. This contact investigation found no secondary cases, despite case-patient contact by 61 persons, and provides useful information about MERS-CoV transmission risk. Compared with GPS tracer tag recordings, self-reported contact may not be as accurate.
Middle East respiratory syndrome coronavirus (MERS-CoV) is a lineage C betacoronavirus that was first reported in September 2012 in a patient from the Kingdom of Saudi Arabia (1). By September 8, 2014, a total of 837 laboratory-confirmed cases and 292 associated deaths had been reported by the World Health Organization. All reported case-patients have resided in or had recent travel to the Arabian Peninsula and neighboring countries (2).
Clusters of MERS-CoV infection have occurred within extended families, households, and healthcare settings (36). Contact investigations around imported cases in the United Kingdom, France, and Tunisia identified cases among household and healthcare contacts, suggesting person-to-person transmission (79). However, these investigations found limited onward transmission: a maximum of 3 second-generation cases were found among investigations with total contacts ranging from 7–163 persons (79). Other contact investigations of imported cases outside of the Middle East have found no secondary transmission (1013).
On April 29, 2014, the Indiana State Department of Health (ISDH) informed the Centers for Disease Control and Prevention (CDC) of a patient under investigation for MERS-CoV infection. A clinical specimen from the patient was confirmed positive by CDC on May 2, 2014 (5); this infection was identified as the first imported MERS case in the United States. The case-patient, a physician and resident of Saudi Arabia, traveled by airplane to Chicago, Illinois, USA, via London, United Kingdom, then by bus to Indiana, USA. He stayed with his family in Indiana for 4 days, during which time he twice met with a business associate in Illinois before seeking medical care at an Indiana hospital; multiple healthcare personnel (HCP) at the hospital were exposed to the patient (14). Given the uncertainty around how MERS-CoV is transmitted, we conducted a comprehensive contact investigation of this case to characterize exposures in household, community, and hospital settings and to quantify the risk of transmission. We also compared contact reported by HCP during standardized interviews with those in global positioning system (GPS) tracer tag recordings.

Dr. Breakwell is an Epidemic Intelligence Service (EIS) Officer with the Meningitis and Vaccine Preventable Diseases Branch at CDC whose primary research interests focus on pertussis vaccine effectiveness and meningococcal disease outbreaks. Dr. Pringle is an EIS Officer with the Viral Gastroenteritis Branch at CDC whose primary research interests are vaccine efficacy and impact of the rotavirus vaccine internationally and surveillance of norovirus domestically. Dr. Chea is an EIS Officer of Prevention and Response Branch of the Division of Healthcare Quality Promotion, CDC, whose primary research interests include health care–associated infections and infection prevention and control.


We thank Community Hospital Munster, Indiana; Indiana State Department of Health; Illinois Department of Public Health; Massachusetts Department of Public Health; Cook County Department of Public Health, Illinois; and Dupage County Health Department, Illinois, for their participation in this investigation. We also acknowledge the work of Hayat Caidi, Congrong Miao, Jennifer Harcourt, Azaibi Tamin, Seyhan Boyoglu-Barnum, and Suvang Trivedi on serologic testing.


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Suggested citation for this article: Breakwell L, Pringle K, Chea N, Allen D, Allen S, Richards S, et al. Lack of transmission among close contacts of patient with imported case of Middle East respiratory syndrome into the United States, 2014. Emerg Infect Dis. 2015 Jul [date cited].http://dx.doi.org/10.3201/eid2107.150054
DOI: 10.3201/eid2107.150054
1These authors contributed equally to this article.

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