The middle east respiratory syndrome coronavirus respiratory infection: an emerging infection from the arabian peninsula

Chapter 4

The middle east respiratory syndrome coronavirus respiratory infection: an emerging infection from the arabian peninsula

J.A. Al-Tawfiq*,**

Z.A. Memish,
*    Speciality Internal Medicine Department, Johns Hopkins Aramco Healthcare, Dhahran, Kingdom of Saudi Arabia
**    Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States
    Ministry of Health, Riyadh, Kingdom of Saudi Arabia
    Alfaisal University, College of Medicine, Riyadh, Kingdom of Saudi Arabia


Middle East Respiratory Syndrome coronavirus (MERS-CoV) was initially isolated from a patient who was admitted to a private hospital in the Western part of the Kingdom of Saudi Arabia in 2012. Subsequently, MERS-CoV resulted in many sporadic cases, multiple intrafamilial transmission, and major outbreaks in healthcare settings. Of all the cases reported within the Kingdom of Saudi Arabia, 38% of the cases were primary, 45% were healthcare-associated infection, and 14% were household infections. The clinical spectrum of the MERS-CoV infection ranges from asymptomatic infections, mild or moderately symptomatic cases, and severe disease requiring intensive care unit admissions and may result in death. Within healthcare settings, transmissions of MERS-CoV are facilitated by overcrowding, poor infection control measures, unrecognized infections, and superspreader phenomenon. Currently, there is no approved therapy for MERS-CoV and there are no vaccines.






health-care facilities

1. Introduction

Coronaviruses (CoV) are a group of viruses known to cause mild to severe diseases in humans. Known human coronaviruses causing disease belong to the genera alpha-coronavirus and beta-coronavirus. These viruses usually cause mild upper respiratory tract disease in humans. The Middle East Respiratory Syndrome Coronavirus (MERS-CoV) belongs to the beta-coronaviruses and was first identified in the Kingdom of Saudi Arabia in 2012.1 The virus was isolated from the sputum of a 60-year-old man who presented with community acquired pneumonia and subsequently developed a fatal disease associated with acute renal failure and respiratory failure.1 Since Apr. 2012 to date, the virus has caused a total of 1611 cases including 575 deaths that were reported by the World Health Organization in 26 countries.2 The majority of these cases occurred in the Arabian Peninsula and the other cases were linked to this geographic area, usually through travel. The disease has a wide range of clinical presentation and epidemiology.37 The clinical spectrum ranges from mild disease to a rapidly fatal disease. The presence of asymptomatic cases was also described. Three main factors contribute to the transmission of MERS-CoV, these are the virus, the host, and the environment. Cases occurred as sporadic patients, limited intrafamilial transmission, and clusters of healthcare associated transmissions. The sporadic cases may result from camel to human transmission with subsequent cases being secondary cases among human contacts. The virus seems to have a peculiar tendency to cause healthcare-associated transmissions as exemplified by multiple hospital outbreaks, as will be discussed later. The emergence of MERS-CoV caused great attention to the emergent respiratory pathogens and the potential for global spread of the disease with the current spread of globalization. Understanding the pathogen, the mode of transmission, and the spectrum of the diseases allows the development of preventive measures and the application of effective infection control practices. The prospect for the development of a novel therapy or the use of previous therapy for the treatment of MERS-CoV would further enhance our abilities to combat the disease. Here, we review the epidemiology of the disease, clinical presentations, and the outcome.

2. The organism

Coronaviruses are parts of the Nidovirales order. The name stems from the presence of crown-like spikes on their surfaces. Coronaviruses were first identified as human pathogens in the mid-1960s. Coronaviruses are enveloped RNA viruses and there are four virus clusters within the Coronavirinae subfamily: alpha, beta, gamma, and delta coronaviruses. Pathogenic human coronaviruses are classified into the genera alpha-coronavirus (HCoV-229E and HCoV-NL63) and beta-coronavirus (HCoV-OC43, HCoV-HKU1, and SARS-CoV).1 MERS-CoV emerged as a significant pathogen after the initial identification in 2012 from a patient with rapidly fatal community acquired pneumonia and is the first human coronavirus in lineage C of the beta-coronavirus genus.1,8 The MERS-CoV virus is known to have multiple clades circulating in humans. In one study, four different phylogenetic MERS-CoV clades were circulating in Saudi Arabia in Sep. 2012 to May 2013.9 Only one clade persisted at the end of the observation period.9 The length of each clade was different: Al-Hasa clade from Apr. 21, 2013 to Jun. 22, 2013 (62 days), Riyadh_3 clade from Feb. 5, 2013 to Jul. 2, 2013 (147 days), Buraidah_1 clade from May 3, 2013 to Aug. 5, 2013 (84 days), and Hafr-Al-Batin_1 clade from Jun. 4, 2013 to Oct. 1, 2013 (119 days).9 Most of the cases in the 2014 Jeddah outbreak belong to a single clade indicating human-to-human transmission.10 The imported case into South Korea showed that the MERS-CoV is a recombinant of groups 3 and 5 elements and that the recombination event occurred in the second half of 2014.11

3. MERS-CoV epidemiology

Since Apr. 2012 to Oct. 2015, a total of 1611 cases including 575 deaths have been reported by the World Health Organization in 26 countries.2 Most of these cases were reported from Saudi Arabia (Table 4.1). Multiple healthcare associated infections occurred within Saudi Arabia and contributed to the significant increase in the number of the cases. The most studied outbreaks occurred in Al-Hasa,7 Jeddah,1216 and Riyadh.1216 The Al-Hasa outbreak occurred in Apr. 2013 and involved 23 confirmed cases and 11 probable cases of MERS-CoV in 4 hospitals.7 In Mar.–Apr. 2014, a large number of cases were reported in Saudi Arabia and the United Arab Emirates.1216 During the 2014 Jeddah outbreak, a total of 14 hospitals were involved and they had a total of 128 cases.10,13 The largest outbreak outside the Arabian Peninsula occurred in the Republic of Korea and was initiated by an index patient after returning from a trip to multiple countries in the Middle East (Bahrain/Saudi Arabia/UAE/Qatar).16 In about 2 weeks, the outbreak involved 5 health care facilities and there were 63 cases.17 Subsequently, the outbreak in the Republic of Korea involved 72 health care facilities and 6 health care facilities had nosocomial transmission.18 The total number of cases as of Jun. 26, 2015 were 182 cases with 31 deaths.19,20

Table 4.1

Number of Cases and Deaths of MERS-CoV Among Most Frequent Countries

Country Number of Cases Number of Deaths (% Case Fatality Rate)
Saudi Arabia 1255 539 (43)
South Korea 185 36 (19.5)
United Arab Emirates 81 11 (13.6)
Jordan 35 14 (40)
Qatar 13 5 (38.5)
All countries 1611 275 (35.7)

4. Clinical presentations

The clinical presentation of MERS-CoV varies from asymptomatic or mildly symptomatic cases to severe and often fatal disease. A large number of the patients had underlying medical comorbidities.37 These comorbidities include: diabetes mellitus (44%), cardiac disease (21%), renal failure (26%), hemodialysis (6.2%), and hypertension (24%) (Table 4.2).6,7,2125

Table 4.2

Most Common Underlying Comorbidities, Clinical Signs and Symptoms, and Laboratory Findings in Patients With MERS-CoV From Various Studies



Diabetes Mellitus 44
Cardiac disease 20.7
Renal failure 25.9
Hemodialysis 6.2
Malignancy 1.6
Hypertension 23.8

Clinical signs and symptoms

Fever 75.6
Dyspnea 61.7
Chest pain 15
Cough 62.2
Hemoptysis 8.3
Sore throat 6.7
Headache 9.8
Myalgia 15.5
Vomiting 20.7
Diarrhea 22.8
Weakness 18.7
Abdominal pain 14
Rhinorrhea 4.7
Lymphopenia 31.6
Thrombocytopenia 11.9

According to the Saudi Ministry of Health, 38% of the cases were primary, 45% were healthcare-associated infection, and 14% were household infections.26 These numbers summarize three epidemiological pattern of the disease: sporadic cases occurring in the communities, probably from an animal contact, and human to human transmission as a result of healthcare-associated infection and intrafamilial transmission of MERS-CoV.3,5,7,2729

Most of the affected patients were adults with a mean age of 56 years (range: 14–94) years4,21 and a number of pediatric cases were described.3032 A study of 1898 combined nasal and throat swabs yielded no MERS-CoV by PCR in children <2 years of age in Jordan.33 The relative low number of MERS-CoV in children is not readily explained.

Although, initially MERS-CoV cases were severe requiring intensive care unit services, subsequent cases included less severe disease.34 The proportion of asymptomatic cases varied from 0% to 30%.34 The initial phase of the clinical illness is nonspecific and includes fever and mild nonproductive cough lasting several days.4,7 Progressive pneumonia then follows with multiorgan failure and this may result in death with a case fatality rate of 30% to 60%.4,21 Most of the patients present with fever (87%), cough (87%), and shortness of breath (48%) (Table 4.2).4,7 About 35% of patients may have gastrointestinal symptoms such as: diarrhea (22%) and vomiting (17%). Of the total cases, 50% had 2 medical comorbidities, diabetes, and chronic renal disease.4 Acute renal failure developed in a proportion of patients, and three patients developed neurological signs: altered level of consciousness, confusion or coma, ataxia, and focal motor deficit.22

Many nonspecific laboratory abnormalities exist in patients with MERS-CoV and include: leucopenia (14%), lymphopenia (34%), thrombocytopenia (36%), increased lactate dehydrogenase (LDH) (49%), and increased hepatic transaminases (11–15%).4,7,21,2225,35 Chest radiographic abnormalities include: increased bronchovascular markings (17%), unilateral infiltrate (43%), bilateral infiltrates (22%), and diffuse reticulonodular pattern (4%).7 Other studies showed ground-glass opacity in 66% and consolidation in 18%.3637 In one study utilizing CT-scan imaging, the lower lobes were more commonly involved than the upper and middle lobes combined.37 In fatal cases, the mean number of lung segments involved was 12.3 segments compared to 3.4 segments in those who survived.37

Laboratory diagnosis relies on respiratory tract samples for the detection of MERS-CoV using real-time reverse transcriptase polymerase-chain-reaction (RT-PCR). The virus may be detected in the lower and upper respiratory tract samples. Lower respiratory tract samples yielded better diagnostic results,38 and had higher viral loads.39 Lower respiratory tract samples had the highest viral loads (mean 5.01 × 106 copies/mL), compared with upper respiratory tract samples (2 × 104 copies/mL), urine (1.26 × 102 copies/mL), stool (1.58 × 104 copies/mL), and serum (2.51 × 103 copies/mL).39 Serologic tests had been used for the diagnosis of MERS-CoV.40,41 Data on the sensitivity and specificity of antibody tests for MERS-CoV are limited. In one study, the use of plaque reduction neutralization tests (PRNT), microneutralisation (MN), MERS-spike pseudoparticle neutralization (ppNT) and MERS S1-enzyme-linked immunosorbent assay (ELISA) were found to be sensitive and specific.41

5. Treatment of MERS-CoV

The main therapeutic options for MERS-CoV infection are not known. In vitro, MERS-CoV is sensitive to alpha interferon (IFN-α).42 No randomized controlled trials exists to establish the efficacy and side effects of any therapeutic modalities. Learning from the SARS experience, interferon and ribavirin was suggested as a therapy for MERS-CoV.43 The combination of interferon-α2b and ribavirin prevented pneumonia in animals.44 The first report of the use of ribavirin and interferon showed no survival advantage45 because the combination was started late in the course of the disease.45 A 14-day survival advantage was documented with this combination but there was no survival advantage at 28 days.24 There was no difference in therapy between interferon-α2a with ribavirin and interferon-β1a with ribavirin in treating MERS-CoV.25 In a case report from Greece, pegylated interferon, ribavirin, and lopinavir/ritonavir was initiated on day 13 of illness.46 MERS-CoV was detectable in the respiratory tract secretions of the patient for 4 weeks after onset illness and viraemia lasted 2 days after initiation of therapy.46

6. Preventive and control of MERS-CoV

The prospect for the control and prevention of MERS-CoV relies on the identification of the definite host, the interruption of the animal to human transmission, and the application of the proper infection control measures in the healthcare settings. The available data links dromedary camels with human cases of MERS-CoV.47 A high prevalence of MERS-CoV antibodies was detected in dromedary camels from across the Arabian Peninsula, North Africa, and Eastern Africa.4854 In addition, viral MERS-CoV was detected in samples from dromedary camels in multiple locations in the Arabian Peninsula using RT-PCR.52,5461 The main infection control measures in healthcare settings include: contact isolation, droplet isolation, and airborne infection isolation precautions especially when during aerosol generating procedures.62 The centers for disease control and preventions (CDC) recommends placing patients with suspected or confirmed MERS-CoV infection in an airborne infection isolation rooms (AIIR).63

7. Summary

MERS-CoV infection is an emerging infectious disease with a high mortality rate. The exact incidence and prevalence of the disease was evaluated in a large population based survey using serology in the Kingdom of Saudi Arabia. The study showed that anti-MERS-CoV antibodies were present in 0·15% of 10,009 people.40 The mean age of seropositive individuals was significantly younger than that of patients with reported, laboratory-confirmed, primary MERS (43·5 years vs 53·8 years), and that men had a higher antibody prevalence than did women [11 (0·25%) of 4341 vs two (0·05%) of 4378] and antibody prevalence was significantly higher in central versus coastal provinces [14 (0·26%) of 5479 vs one (0·02%) of 4529].40 The diagnosis of MERS-CoV infection relies on detection of the virus using real-time RT-PCR. Currently, the best therapeutic options for MERS-CoV are not known and there are no available vaccines.


1. Zaki AM, van Boheemen S, Bestebroer TM, Osterhaus AD, Fouchier RA. Isolation of a novel coronavirus from a man with pneumonia in Saudi Arabia. N Engl J Med. 2012;367:18141820.

2. World Health Organization.

3. AlBarrak AM, Stephens GM, Hewson R, Memish ZA. Recovery from severe novel coronavirus infection. Saudi Med J. 2012;33:12651269.

4. Assiri A, Al-Tawfiq JA, Al-Rabeeah AA, Al-Rabiah FA, Al-Hajjar S, Al-Barrak A, Flemban H, Al-Nassir WN, Balkhy HH, Al-Hakeem RF, Makhdoom HQ, Zumla AI, Memish ZA. Epidemiological, demographic, and clinical characteristics of 47 cases of Middle East respiratory syndrome coronavirus disease from Saudi Arabia: a descriptive study. Lancet Infect Dis. 2013;13(9):752761.

5. Bermingham A, Chand MA, Brown CS, Aarons E, Tong C, Langrish C, Hoschler K, Brown K, Galiano M, Myers R, Pebody RG, Green HK, Boddington NL, Gopal R, Price N, Newsholme W, Drosten C, Fouchier RA, Zambon M. Severe respiratory illness caused by a novel coronavirus, in a patient transferred to the United Kingdom from the Middle East, September 2012. Euro Surveill. 2012;17(40):20290.

6. Buchholz U, Müller MA, Nitsche A, Sanewski A, Wevering N, Bauer-Balci T, Bonin F, Drosten C, Schweiger B, Wolff T, Muth D, Meyer B, Buda S, Krause G, Schaade L, Haas W. Contact investigation of a case of human novel coronavirus infection treated in a German hospital, October–November 2012. Euro Surveill. 2013;18(8).

7. Assiri A, McGeer A, Perl TM, et al. Hospital outbreak of Middle East respiratory syndrome coronavirus. N Engl J Med. 2013;369(5):407416.

8. de Groot RJ, Baker SC, Baric RS, et al. Middle East respiratory syndrome coronavirus (MERS-CoV): announcement of the Coronavirus Study Group. J Virol. 2013;87:77907792.

9. Cotten M, Watson SJ, Zumla AI, et al. Spread, circulation, and evolution of the Middle East respiratory syndrome coronavirus. MBio. 2014;5:e01013e01062.

10. Drosten C, Muth D, Corman VM, Hussain R, Al Masri M, HajOmar W, Landt O, Assiri A, Eckerle I, Al Shangiti A, Al-Tawfiq JA, Albarrak A, Zumla A, Rambaut A, Memish ZA. An observational, laboratory-based study of outbreaks of Middle East respiratory syndrome coronavirus in Jeddah and Riyadh, kingdom of Saudi Arabia, 2014. Clin Infect Dis. 2015;60(3):369.

11. Wang Y, Liu D, Shi W, Lu R, Wang W, Zhao Y, Deng Y, Zhou W, Ren H, Wu J, Wang Y, Wu G, Gao GF, Tan W. Origin and possible genetic recombination of the Middle East respiratory syndrome coronavirus from the first imported case in China: phylogenetics and coalescence analysis. MBio. 2015;6(5): pii: e01280-15.

12. World Health Organization. Middle East respiratory syndrome coronavirus (MERS-CoV): summary of current situation, literature update and risk assessment–as of 5 February 2015.; 2015.

13. Oboho IK, Tomczyk SM, Al-Asmari AM, et al. 2014 MERS-CoV outbreak in Jeddah—a link to health care facilities. N Engl J Med. 2015;372:846.

14. World Health Organization. Middle East respiratory syndrome coronavirus (MERS-CoV) summary and literature update – as of 9 May 2014.; 2015.

15. Fagbo SF, Skakni L, Chu DKW, et al. Molecular epidemiology of hospital outbreak of Middle East respiratory syndrome, Riyadh, Saudi Arabia. Emerg Infect Dis. 2015 Nov;21(11):19811988.

16. WHO. Middle East respiratory syndrome coronavirus (MERS-CoV)—Republic of Korea. Available at:; 2015.

17. FluTrackers. South Korea Coronavirus MERS Case List—including imported and exported cases. Available at:; 2015.

18. World Health Organization. Middle East respiratory syndrome coronavirus (MERS-CoV): summary and risk assessment of current situation in the Republic of Korea and China—as of 19 June 2015. Available at:; 2015.

19. World health organization. Middle East respiratory syndrome coronavirus (MERS-CoV). MERS-CoV in Republic of Korea at a glance. Available at:; 2015.

20. Cowling BJ, Park M, Fang VJ, Wu P, Leung GM, Wu JT. Preliminary epidemiological assessment of MERS-CoV outbreak in South Korea, May to June 2015. Euro Surveill. 2015;20(25): pii=21163.

21. Al-Tawfiq JA, Memish ZA. Managing MERS-CoV in the healthcare setting. Hosp Pract. 2015;43(3):158163.

22. Arabi YM, Harthi A, Hussein J, Bouchama A, Johani S, Hajeer AH, Saeed BT, Wahbi A, Saedy A, AlDabbagh T, Okaili R, Sadat M, Balkhy H. Severe neurologic syndrome associated with Middle East respiratory syndrome corona virus (MERS-CoV). Infection. 2015;43(4):495501.

23. Al-Tawfiq JA, Hinedi K, Ghandour J, Khairalla H, Musleh S, Ujayli A, Memish ZA. Middle East respiratory syndrome coronavirus: a case-control study of hospitalized patients. Clin Infect Dis. 2014;59(2):160165.

24. Omrani AS, Saad MM, Baig K, Bahloul A, Abdul-Matin M, Alaidaroos AY, Almakhlafi GA, Albarrak MM, Memish ZA, Albarrak AM. Ribavirin and interferon alfa-2a for severe Middle East respiratory syndrome coronavirus infection: a retrospective cohort study. Lancet Infect Dis. 2014;14(11):10901095.

25. Shalhoub S, Farahat F, Al-Jiffri A, Simhairi R, Shamma O, Siddiqi N, Mushtaq A. IFN-α2a or IFN-β1a in combination with ribavirin to treat Middle East respiratory syndrome coronavirus pneumonia: a retrospective study. J Antimicrob Chemother. 2015;70(7):21292132.

26. Saudi Ministry of Health.; 2015.

27. Memish ZA, Zumla AI, Al-Hakeem RF, Al-Rabeeah AA, Stephens GM. Family cluster of Middle East respiratory syndrome coronavirus infections. N Engl J Med. 2013;368:24872494.

28. Hijawi B, Abdallat M, Sayaydeh A, et al. Novel coronavirus infections in Jordan, April 2012: epidemiological findings from a retrospective investigation. East Mediterr Health J. 2013;19(Suppl. 1):S12S18.

29. Health Protection Agency (HPA) UK Novel Coronavirus Investigation team. Evidence of person-to-person transmission within a family cluster of novel coronavirus infections, United Kingdom, February 2013. Euro Surveill 2013;18:20427.

30. WHO. Global alert and response (GAR): Middle East respiratory syndrome coronavirus (MERS-CoV)—update. July 7, 2013.; 2015.

31. Memish ZA, Al-Tawfiq JA, Assiri A, AlRabiah FA, Al Hajjar S, Albarrak A, Flemban H, Alhakeem RF, Makhdoom HQ, Alsubaie S, Al-Rabeeah AA. Middle East respiratory syndrome coronavirus disease in children. Pediatr Infect Dis J. 2014;33(9):904906.

32. Thabet F, Chehab M, Bafaqih H, Al Mohaimeed S. Middle East respiratory syndrome coronavirus in children. Saudi Med J. 2015;36(4):484486.

33. Khuri-Bulos N, Payne DC, Lu X, Erdman D, Wang L, Faouri S, Shehabi A, Johnson M, Becker MM, Denison MR, Williams JV, Halasa NB. Middle East respiratory syndrome coronavirus not detected in children hospitalized with acute respiratory illness in Amman, Jordan, March 2010 to September 2012. Clin Microbiol Infect. 2014;20(7):678682.

34. Al-Tawfiq JA, Memish ZA. Middle East respiratory syndrome coronavirus: epidemiology and disease control measures. Infect Drug Resist. 2014;7:281287.

35. Eckerle I, Müller MA, Kallies S, Gotthardt DN, Drosten C. In-vitro renal epithelial cell infection reveals a viral kidney tropism as a potential mechanism for acute renal failure during Middle East Respiratory Syndrome (MERS) Coronavirus infection. Virol J. 2013;10:359.

36. Das KM, Lee EY, Al Jawder SE, Enani MA, Singh R, Skakni L, Al-Nakshabandi N, AlDossari K, Larsson SG. Acute Middle East respiratory syndrome coronavirus: temporal lung changes observed on the chest radiographs of 55 patients. AJR Am J Roentgenol. 2015;205(3):W267W274.

37. Das KM, Lee EY, Enani MA, AlJawder SE, Singh R, Bashir S, Al-Nakshbandi N, AlDossari K, Larsson SG. CT correlation with outcomes in 15 patients with acute Middle East respiratory syndrome coronavirus. AJR Am J Roentgenol. 2015;204(4):736742.

38. Memish ZA, Al-Tawfiq JA, Makhdoom HQ, Assiri A, Alhakeem RF, Albarrak A, Alsubaie S, Al-Rabeeah AA, Hajomar WH, Hussain R, Kheyami AM, Almutairi A, Azhar EI, Drosten C, Watson SJ, Kellam P, Cotten M, Zumla A. Respiratory tract samples, viral load, and genome fraction yield in patients with Middle East respiratory syndrome. J Infect Dis. 2014;210(10):15901594.

39. Corman VM, Albarrak AM, Omrani AS, Albarrak MM, Farah ME, Almasri M, Muth D, Sieberg A, Meyer B, Assiri AM, Binger T, Steinhagen K, Lattwein E, Al-Tawfiq J, Müller MA, Drosten C, Memish ZA. Viral shedding and antibody response in 37 patients with MERS-coronavirus infection. Clin Infect Dis. 2016 Feb 15;62(4):477483.

40. Müller MA, Meyer B, Corman VM, Al-Masri M, Turkestani A, Ritz D, Sieberg A, Aldabbagh S, Bosch BJ, Lattwein E, Alhakeem RF, Assiri AM, Albarrak AM, Al-Shangiti AM, Al-Tawfiq JA, Wikramaratna P, Alrabeeah AA, Drosten C, Memish ZA. Presence of Middle East respiratory syndrome coronavirus antibodies in Saudi Arabia: a nationwide, cross-sectional, serological study. Lancet Infect Dis. 2015;15(5):559564.

41. Park SW, Perera RA, Choe PG, Lau EH, Choi SJ, Chun JY, Oh HS, Song KH, Bang JH, Kim ES, Kim HB, Park WB, Kim NJ, Poon LL, Peiris M, Oh MD. Comparison of serological assays in human Middle East respiratory syndrome (MERS)-coronavirus infection. Euro Surveill. 2015;20(41).

42. de Wilde AH, Raj VS, Oudshoorn D, Bestebroer TM, van Nieuwkoop S, Limpens RW, Posthuma CC, van der Meer Y, Bárcena M, Haagmans BL, Snijder EJ, van den Hoogen BG. MERS-coronavirus replication induces severe in vitro cytopathology and is strongly inhibited by cyclosporin A or interferon-α treatment. J Gen Virol. 2013;94(Pt 8):17491760.

43. Momattin H, Mohammed K, Zumla A, Memish ZA, Al-Tawfiq JA. Therapeutic options for Middle East respiratory syndrome coronavirus (MERS-CoV)–possible lessons from a systematic review of SARS-CoV therapy. Int J Infect Dis. 2013;17(10):e792e798.

44. Falzarano D, de Wit E, Martellaro C, Callison J, Munster VJ, Feldmann H. Inhibition of novel βcoronavirus replication by a combination of interferon-α2b and ribavirin. Sci Rep. 2013;3:1686.

45. Al-Tawfiq JA, Momattin H, Dib J, Memish ZA. Ribavirin and interferon therapy in patients infected with the Middle East respiratory syndrome coronavirus: an observational study. Int J Infect Dis. 2014;20:4246.

46. Spanakis N, Tsiodras S, Haagmans BL, Raj VS, Pontikis K, Koutsoukou A, Koulouris NG, Osterhaus AD, Koopmans MP, Tsakris A. Virological and serological analysis of a recent Middle East respiratory syndrome coronavirus infection case on a triple combination antiviral regimen. Int J Antimicrob Agents. 2014;44(6):528532.

47. Omrani S, Al-Tawfiq JA, Memsih ZA. Middle East respiratory syndrome coronavirus (MERS-CoV): animal to human interaction. Pathog Glob Health. 2015;109(8):354362.

48. Reusken CB, Haagmans BL, Muller MA, et al. Middle East respiratory syndrome coronavirus neutralizing serum antibodies in dromedary camels: a comparative serological study. Lancet Infect Dis. 2013;13:859866.

49. Reusken CB, Ababneh M, Raj VS, et al. Middle East Respiratory Syndrome coronavirus (MERS-CoV) serology in major livestock species in an affected region in Jordan, June to September 2013. Euro Surveill. 2013;18:20662.

50. Hemida MG, Perera RA, Wang P, et al. Middle East Respiratory Syndrome (MERS) coronavirus seroprevalence in domestic livestock in Saudi Arabia, 2010 to 2013. Euro Surveill. 2013;18:20659.

51. Alexandersen S, Kobinger GP, Soule G, Wernery U. Middle East respiratory syndrome coronavirus antibody reactors among camels in Dubai, United Arab Emirates, in 2005. Transbound Emerg Dis. 2014;61:105108.

52. Reusken CB, Messadi L, Feyisa A, et al. Geographic distribution of MERS coronavirus among dromedary camels, Africa. Emerg Infect Dis. 2014;20:13701374.

53. Nowotny N, Kolodziejek J. Middle East respiratory syndrome coronavirus (MERS-CoV) in dromedary camels, Oman, 2013. Euro Surveill. 2014;19:20781.

54. Corman VM, Jores J, Meyer B, et al. Antibodies against MERS coronavirus in dromedary camels, Kenya, 1992-2013. Emerg Infect Dis. 2014;20:13191322.

55. Alagaili AN, Briese T, Mishra N, et al. Middle East respiratory syndrome coronavirus infection in dromedary camels in Saudi Arabia. MBio. 2014;5:e00814e00884.

56. Hemida MG, Chu DK, Poon LL, et al. MERS coronavirus in dromedary camel herd, Saudi Arabia. Emerg Infect Dis. 2014;20:12311234.

57. Wernery U, Corman VM, Wong EY, et al. Acute middle East respiratory syndrome coronavirus infection in livestock Dromedaries, Dubai, 2014. Emerg Infect Dis. 2015;21:10191022.

58. Meyer B, Muller MA, Corman VM, et al. Antibodies against MERS Coronavirus in Dromedary Camels, United Arab Emirates, 2003 and 2013. Emerg Infect Dis. 2014;20:552559.

59. Shirato K, Azumano A, Nakao T, et al. Middle East respiratory syndrome coronavirus infection not found in camels in Japan. Jpn J Infect Dis. 2015;68:256258.

60. Chan SM, Damdinjav B, Perera RA, et al. Absence of MERS-Coronavirus in Bactrian Camels, Southern Mongolia, November 2014. Emerg Infect Dis. 2015;21:12691271.

61. Khalafalla AI, Lu X, Al-Mubarak AI, Dalab AH, Al-Busadah KA, Erdman DD. MERS-CoV in upper Respiratory tract and lungs of dromedary camels, Saudi Arabia, 2013–2014. Emerg Infect Dis. 2015;21:11531158.

62. World Health Organization. Infection prevention and control during health care for probable or confirmed cases of novel coronavirus (nCoV) infection Interim guidance: 6 May 2013.; 2013.

63. CDC. Interim Infection Prevention and Control Recommendations for Hospitalized Patients with Middle East Respiratory Syndrome Coronavirus (MERS-CoV).; 2013.

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