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Novel Coronavirus Update

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  1. Novel Coronavirus Update David L. Swerdlow, MD Associate Director for Science NCIRD, CDC May 28, 2013

  2. Coronaviruses (CoVs) • First identified in the 1960s • Found in many animals including bats • Six human CoVs had been identified: • Most mild • Severe: • SARS-CoV • Novel coronavirus 2012 (NCoV)

  3. Coronaviruses- EM Petal-shaped spikes Size:120-160 nm diameter

  4. SARS Epidemic • Outbreak 2002-2003 • 8,098 probable cases, 774 deaths • Estimated economic losses >$30B • Super-spreading events helped seed global spread • E.g., traveler at Hong Kong hotel spread virus to several countries • Control strategies: Surveillance, isolation of ill, quarantine of exposed, infection control

  5. Transmission of SARS • Observations • Primarily healthcare workers and household members • Infrequent instances of community transmission • Masking was shown to greatly reduce transmission (Wu et al., EID, 2004;10:210-215) • Transmission rate estimate, 2.7 secondary infections generated per case on average (Riley et al., 2003) • Super Spreaders

  6. Emergence of a Novel Virus Recognition of a novel coronavirus, Saudi Arabia and Qatar Healthcare facility cluster, Saudi Arabia UK family cluster Oct., 2012 May, 2013 April, 2012 Sept,, 2012 Feb., 2013 March, 2013 April, 2013 Healthcare facility cluster, France Imported UAE case Into Germany Jordan cluster 1st family cluster, Saudi Arabia

  7. Middle East Respiratory Syndrome Coronavirus (MERS-CoV) de Groot et al. J Virol. May, 2013; Epub ahead of print

  8. MERS-CoV- current situation • 44 laboratory confirmed cases with 23 deaths (50%) • Onsets between April 2012 and May 15, 2013 • Gender: 10 Females, 33 Males (75%) [1 Unknown] • Median age (min, max) in years: 56 (24,94) • Cases (deaths) by country of residence: • Saudi Arabia 32 (18), UK 3 (2), Jordan 2 (2), Qatar 2 (0), UAE 1(1), France 2(0), Tunisia 2 (0). • Most with underlying conditions • Two were returning travelers, 2 medical transfers

  9. MERS-CoV - clusters • Jordan: 4/12-- 2 cases, 2 deaths + 10 ill HCWs and 1 ill contact (Hospital) • Saudi Arabia: 10/12-- 3 cases, 2 deaths (Family) • Saudi Arabia: 2/13-- 2 cases, 1 death (Close contact) • United Kingdom: 2/13-- 3 cases, 2 deaths (Retuning traveler and family) • Saudi Arabia, Eastern Province: 4/13- current-- 22 cases, 10 deaths (Initially hospital) • France- 65 yo French traveler returning from UAE with illness onset April 23- and 51 yo hospital roommate • Tunisia: 5/22—2 sibling cases. First laboratory confirmed cases of MERS-CoV in Tunisia. A retrospective investigation for a probable case in another family member (father) is ongoing.

  10. MERS-CoV Confirmed cases 2012-2013 2012 2013

  11. MERS-CoV Outbreak in Al-Ahsa governorate April – May 2013 • Al-Ahsa governorate in eastern region. • 22 confirmed cases, 10 deaths • 16 males, 6 females; Ages 24 - 94 years • Initial cases associated with one healthcare facility but now also: • Family contacts • Healthcare workers • Two cases with no link to the healthcare facility • Most cases with comorbidities

  12. Confirmed Cases of MERS-CoV, Al-Ahsa governorate, April-May 2013

  13. Evidence for person-to person transmission • Jordan hospital outbreak • KSA family clusters • Cluster after traveler returned to UK • KSA hospital outbreak- including family members and healthcare workers • Tunisia family cluster

  14. Genetic characterization, novel Coronavirus • Five sequences posted • UK (2), KSA (1), Jordan (1), Germany (1) • High level of homology • No recent sequences available • Most similar to bat coronaviruses (isolated from Ghana and Europe)

  15. Domestic Activities • Case definition and guidance developed and disseminated • 2 MMWRs published • Health advisory sent to state and local health departments • Investigating persons with travel link and severe respiratory illness • 15 samples: all negative • Serology developed • PCR diagnostics developed and distributed

  16. Novel Coronavirus Information

  17. Global activities • Collaboration with WHO, Jordan, Egypt, KSA, NAMRU, etc. • Team to KSA in October 2012 • Team currently in Jordan (May 2013) • Supplied diagnostic reagents widely • Global Disease Detection/Eastern Mediterranean Acute Resp Infection Surveillance (EMARIS): SARI surveillance tests negative to date • 3,329 Egypt, 572 Jordan, 34 Oman

  18. Importance of diagnostic testing • Critical to know who is a case in order to prevent additional cases in order to: • Institute appropriate infection control measures • Permit isolation of cases, quarantine of exposed • Important to be disseminated to states/local HD and internationally to allow for rapid testing

  19. Treatment/vaccines • Possible SARS treatments • ribavirin with and without corticosteroids • ribavirin with protease inhibitors • interferon (alfacon) with corticosteroids • definitive treatment regimen was not clearly established • Novel CoV: Interferon alpha 2b + ribavirin in vitro • SARS vaccines were in development

  20. CDC Case Definitions • Patients to be investigated (referred to as “Patient Under Investigation”): • A person with an acute respiratory infection, which may include fever (≥ 38°C , 100.4°F) and cough; AND • suspicion of pulmonary parenchymal disease (e.g. pneumonia or Acute Respiratory Distress Syndrome (ARDS)) based on clinical or radiological evidence of consolidation; AND • travel to or residence in an area where infection with novel coronavirus has recently been reported or where transmission could have occurred;* AND • not already explained by any other infection or etiology, including all clinically indicated tests for community-acquired pneumonia according to local management guidelines. *Arabian peninsula or neighboring countries

  21. Cellular characteristics • SARS uses angiotensin-converting enzyme 2 (ACE2) to gain entry into cells • nCoVuses dipeptidyl peptidase 4 (DPP4 or CD26) as a functional receptor

  22. Summary- novel coronavirus • Cases have occurred in multiple locations over a >1 year period, accelerating recently • Clear evidence for person-to-person spread (although not sustained) • No clear environmental source • Recent healthcare worker illness is very concerning, reminiscent of SARS 2003