Abstract

BackgroundThe ongoing transmission of the Middle East respiratory syndrome coronavirus (MERS-CoV) in the Middle East and its expansion to other regions are raising concerns of a potential pandemic. An in-depth analysis about both population and molecular epidemiology of this pathogen is needed.MethodsMERS cases reported globally as of June 2020 were collected mainly from World Health Organization official reports, supplemented by other reliable sources. Determinants for case fatality and spatial diffusion of MERS were assessed with Logistic regressions and Cox proportional hazard models, respectively. Phylogenetic and phylogeographic analyses were performed to examine the evolution and migration history of MERS-CoV.ResultsA total of 2562 confirmed MERS cases with 150 case clusters were reported with a case fatality rate of 32.7% (95% CI: 30.9‒34.6%). Saudi Arabia accounted for 83.6% of the cases. Age of ≥ 65 years old, underlying conditions and ≥ 5 days delay in diagnosis were independent risk factors for death. However, a history of animal contact was associated with a higher risk (adjusted OR = 2.97, 95% CI: 1.10–7.98) among female cases < 65 years but with a lower risk (adjusted OR = 0.31, 95% CI: 0.18–0.51) among male cases ≥ 65 years old. Diffusion of the disease was fastest from its origin in Saudi Arabia to the east, and was primarily driven by the transportation network. The most recent sub-clade C5.1 (since 2013) was associated with non-synonymous mutations and a higher mortality rate. Phylogeographic analyses pointed to Riyadh of Saudi Arabia and Abu Dhabi of the United Arab Emirates as the hubs for both local and international spread of MERS-CoV.ConclusionsMERS-CoV remains primarily locally transmitted in the Middle East, with opportunistic exportation to other continents and a potential of causing transmission clusters of human cases. Animal contact is associated with a higher risk of death, but the association differs by age and sex. Transportation network is the leading driver for the spatial diffusion of the disease. These findings how this pathogen spread are helpful for targeting public health surveillance and interventions to control endemics and to prevent a potential pandemic.Graphical abstract

Highlights

  • The ongoing transmission of the Middle East respiratory syndrome coronavirus (MERS-CoV) in the Mid‐ dle East and its expansion to other regions are raising concerns of a potential pandemic

  • The disease is caused by the Middle East respiratory syndrome coronavirus (MERS-CoV) which can be highly pathogenic in humans

  • Death occurred in 802 patients, leading to a case fatality rate (CRF) of 32.7%

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Summary

Introduction

The ongoing transmission of the Middle East respiratory syndrome coronavirus (MERS-CoV) in the Mid‐ dle East and its expansion to other regions are raising concerns of a potential pandemic. Middle East respiratory syndrome (MERS) is a respiratory infectious disease first discovered in the Kingdom of Saudi Arabia in September 2012 [1]. The disease is caused by the Middle East respiratory syndrome coronavirus (MERS-CoV) which can be highly pathogenic in humans. As of 30 May 2020, a total of 27 countries in the Middle East, North Africa, Europe, Northeast Asia, and North America have reported 2562 laboratory-confirmed MERS cases and 881 associated deaths, according to the World Health Organization (WHO) [2]. The vast majority of MERS cases were reported by the Saudi Arabia, followed by Republic of Korea [2]. In February 2018, WHO formally incorporated MERS into the Research and Development Blueprint (the R&D Blueprint) to promote research in this area [4]

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