Line list 15 cases from Apr/12 to Feb/13 No. Date of onset Age Sex Probable place of infection Outcome cluster 1 2012.04.?? 40 F Jordan Dead Hospital A 2 2012.04.?? 25 M Jordan Dead 3 2012.06.06 60 M Saudi Arabia Dead 4 2012.09.03 49 M Qatar/Saudi Arabia Alive 5 2012.10.10 45 M Saudi Arabia Alive 6 2012.10.12 45 M Qatar Alive 7 2012.10.14* 70 M Saudi Arabia Dead 8 2012.10.28 39 M Saudi Arabia Dead Family A 9 2012.11.04 31 M Saudi Arabia Alive 10 2013.01.24 61 F Saudi Arabia Dead 11 2013.01.26 60 M Saudi Arabia/Pakistan Alive 12 2013.02.05 ?? F United Kingdom Alive Family B 13 2013.02.06 ?? M United Kingdom Dead 14 2013.02.05 69 M Saudi Arabia Dead 15 2013.02.24 39 M Saudi Arabia Dead* Date of hospitalization
2012 Apr – Zarqa, Jordan – Hospital cluster On 19 Apr 2012, Jordan MOH reported an outbreak of pneumonia in the Zarqa Public Hospital’s ICU. 7 nurses, 1 doctor and 1 brother of a nurse were among the 11 affected. 1 of the nurses died. In Nov 2012, testing of stored samples from two died patients of this cluster confirmed novel coronavirus infection, and a number of HCWs with pneumonia associated with the cases were considered probable cases. Index case among this cluster cannot be determined. No history of travel or contact with animals.
2012 Jun – Jeddah, Saudi Arabia – Sporadic case 60y male, occupation unknown, no travel history, “limited exposure to animals prior to onset”, onset on 06.06, hospitalized on 06.13, died on 06.20.
2012 Sep – Doha, Qatar – Sporadic case 49y male, occupation unknown, travel history to Saudi Arabia, “limited exposure to animals prior to onset”, onset on 2012.09.03, hospitalized on 09.07.
2012 Oct~Nov – Qatar & SA– Sporadic cases & family cluster SA case: 45y male. Qatar case: 45y male. SA household cluster: Father: 70y, many comorbidities, hospitalized on 2012.10.14, died on 10.24. Son A: 39y, onset on 10.28, died four days later. Son B: 31y, similar illness, test positive, discharged on 11.20. Grandson: similar illness, test negative, discharged on 11.20.
2013 Jan~Feb – SA – Sporadic cases 61y female, onset on 2013.01.24, died on 02.10, travel history to Egypt (2013.01.10-18). 69y male, onset on 2013.02.05, died on 02.19, no contact or travel history. 39y male, onset on 2013.02.24, died on 03.02.
2013 Jan~Feb – SA→UK – Family cluster Index case: 60y male, travel to Pakistan (2012.12.16~2013.01.20) and Saudi Arabia (01.20~01.28), onset on 01.26, hospitalized on 01.31, co-infected with influenza A(H1N1). Adult female member of extended family, limited exposure to the index case on three occasions in hospital (possibility of an intermediary case), onset on 02.05, mild influenza-like illness. Adult male household member, in sustained close contact with the index case at home, pre-existing medical conditions, onset on 02.06, died on 02.17. Saudi Arabia
Clinical picture Common symptoms: fever, cough, shortness of breath, and breathing difficulties Milder ILI may present Radiological features: pulmonary parenchymal disease (pneumonia or ARDS) Complications: renal failure, pericarditis, heart failure, DIC, multiple organ failure Deaths: Fatality rate = 9/15 = 60% 4~14d after onset, 2~10d after hospitalization
Spatial distributionJordan → Saudi Arabia → Qatar→ United Kingdom Existence in other parts of the world cannot be excluded
Interpersonal distribution All confirmed cases are adults (25y~70y) At least 1 child was involved in SA’s household cluster, with similar but milder illness and negative test Male : Female = 12:3 Occupation of most cases unknown A number of HCWs (at least 7 nurses and 1 doctor) were involved in Jordan’s hospital cluster, with at least 1 nurse died
Route of transmission Undetermined Droplet and direct contact probably
Susceptibility Undetermined Presumably universal Presumable vulnerability in elder people with pre-existing medical conditions Lower risk for children and women?
Human-to-human transmission Most family members and HCWs closely exposed to confirmed and probable cases did not develop disease Probably occurred in the 3 clusters Settings: hospital, household Index case may not be apparent Route of exposure not clear Observed case interval 5~14 days Secondary transmission not excluded Intermediary case is possible Existence and role of latent infection or milder cases not clear
Resume of evidencesSuggestive Undetermined The virus is persistent Spatial spread Limited transmissibility Epidemic center up to the moment Source of infection Route of exposure Biological, behavioral, and occupational risk factors Possibility of evolution
Risk assessmentConditions up to the moment The risk for any person to be infected is extremely low The risk for any person travelling to affected areas to be infected is very low The risk of human-to-human transmission for any infected patient is lowThe risk of the virus to evolve to be more transmissible is undetermined, and actually no intervention is taken to reduce this risk
Surveillance Surveillance for severe acute respiratory infections (SARI) and careful review of any unusual patterns Patients with unexplained pneumonia Patients with unexplained, severe, progressive or complicated respiratory illness not responding to treatment Persons travelling from or resident in areas known to be affected Clusters of SARI SARI in health care workers
Travel measures WHO does not advise special screening at points of entry nor any travel or trade restrictions
Case definition Confirmed case A person with laboratory confirmation of infection with the novel coronavirus Probable case A person with an acute respiratory infection with clinical, radiological, or histopathological evidence of pulmonary parenchymal disease (pneumonia or ARDS); AND No possibility of laboratory confirmation for novel coronavirus either because the patient or samples are not available for testing; AND Close contact with a laboratory confirmed case
Case management Droplet precautions should be added to standard precautions for any patient known or suspected to have infection with novel coronavirus Airborne precautions should be used for aerosol-generating procedures