Travel-related MERS-CoV cases: an assessment of exposures and risk factors in a group of Dutch travellers returning from the Kingdom of Saudi Arabia, May 2014
Identifieur interne : 000F45 ( Pmc/Checkpoint ); précédent : 000F44; suivant : 000F46Travel-related MERS-CoV cases: an assessment of exposures and risk factors in a group of Dutch travellers returning from the Kingdom of Saudi Arabia, May 2014
Auteurs : Ewout B. Fanoy [Pays-Bas, Suède] ; Marianne Ab Van Der Sande [Pays-Bas] ; Marleen Kraaij-Dirkzwager [Pays-Bas] ; Kees Dirksen [Pays-Bas] ; Marcel Jonges [Pays-Bas] ; Wim Van Der Hoek [Pays-Bas] ; Marion Pg Koopmans [Pays-Bas] ; Douwe Van Der Werf [Pays-Bas] ; Gerard Sonder [Pays-Bas] ; Charlie Van Der Weijden [Pays-Bas] ; Jet Van Der Heuvel [Pays-Bas] ; Luc Gelinck [Pays-Bas] ; Jolande W. Bouwhuis [Pays-Bas] ; Arianne B. Van Gageldonk-Lafeber [Pays-Bas]Source :
- Emerging Themes in Epidemiology [ 1742-7622 ] ; 2014.
Abstract
In May 2014, Middle East respiratory syndrome coronavirus (MERS-CoV) infection, with closely related viral genomes, was diagnosed in two Dutch residents, returning from a pilgrimage to Medina and Mecca, Kingdom of Saudi Arabia (KSA). These patients travelled with a group of 29 other Dutch travellers. We conducted an epidemiological assessment of the travel group to identify likely source(s) of infection and presence of potential risk factors.
All travellers, including the two cases, completed a questionnaire focussing on potential human, animal and food exposures to MERS-CoV. The questionnaire was modified from the WHO MERS-CoV questionnaire, taking into account the specific route and activities of the travel group.
Twelve non-cases drank unpasteurized camel milk and had contact with camels. Most travellers, including one of the two patients (Case 1), visited local markets, where six of them consumed fruits. Two travellers, including Case 1, were exposed to coughing patients when visiting a hospital in Medina. Four travellers, including Case 1, visited two hospitals in Mecca. All travellers had been in contact with Case 1 while he was sick, with initially non-respiratory complaints. The cases were found to be older than the other travellers and both had co-morbidities.
This epidemiological study revealed the complexity of MERS-CoV outbreak investigations with multiple potential exposures to MERS-CoV reported such as healthcare visits, camel exposure, and exposure to untreated food products. Exposure to MERS-CoV during a hospital visit is considered a likely source of infection for Case 1 but not for Case 2. For Case 2, the most likely source could not be determined. Exposure to MERS-CoV via direct contact with animals or dairy products seems unlikely for the two Dutch cases. Furthermore, exposure to a common but still unidentified source cannot be ruled out. More comprehensive research into sources of infection in the Arabian Peninsula is needed to strengthen and specify the prevention of MERS-CoV infections.
The online version of this article (doi:10.1186/1742-7622-11-16) contains supplementary material, which is available to authorized users.
Url:
DOI: 10.1186/1742-7622-11-16
PubMed: 25328533
PubMed Central: 4200475
Affiliations:
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PMC:4200475Le document en format XML
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xml:lang="fr">Pays-Bas</country><wicri:regionArea>Bilthoven</wicri:regionArea></affiliation></author><author><name sortKey="Dirksen, Kees" sort="Dirksen, Kees" uniqKey="Dirksen K" first="Kees" last="Dirksen">Kees Dirksen</name><affiliation wicri:level="3"><nlm:aff id="Aff5">Public Health Service Haaglanden, Den Haag, The Netherlands</nlm:aff><country xml:lang="fr">Pays-Bas</country><wicri:regionArea>Public Health Service Haaglanden, Den Haag</wicri:regionArea><placeName><settlement type="city">La Haye</settlement><region nuts="2" type="province">Hollande-Méridionale</region></placeName></affiliation></author><author><name sortKey="Jonges, Marcel" sort="Jonges, Marcel" uniqKey="Jonges M" first="Marcel" last="Jonges">Marcel Jonges</name><affiliation wicri:level="1"><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="GRID">grid.31147.30</institution-id><institution-id institution-id-type="ISNI">0000 0001 2208 0118</institution-id><institution>National Institute for 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sort="Koopmans, Marion Pg" uniqKey="Koopmans M" first="Marion Pg" last="Koopmans">Marion Pg Koopmans</name><affiliation wicri:level="1"><nlm:aff id="Aff6"><institution-wrap><institution-id institution-id-type="GRID">grid.5645.2</institution-id><institution-id institution-id-type="ISNI">000000040459992X</institution-id><institution>Erasmus Medical Center,</institution></institution-wrap>Rotterdam, The Netherlands</nlm:aff><country xml:lang="fr">Pays-Bas</country><wicri:regionArea>Rotterdam</wicri:regionArea></affiliation></author><author><name sortKey="Van Der Werf, Douwe" sort="Van Der Werf, Douwe" uniqKey="Van Der Werf D" first="Douwe" last="Van Der Werf">Douwe Van Der Werf</name><affiliation wicri:level="1"><nlm:aff id="Aff7">Public Health Service IJsselland, Zwolle, The Netherlands</nlm:aff><country xml:lang="fr">Pays-Bas</country><wicri:regionArea>Public Health Service IJsselland, Zwolle</wicri:regionArea><wicri:noRegion>Zwolle</wicri:noRegion></affiliation></author><author><name sortKey="Sonder, Gerard" sort="Sonder, Gerard" uniqKey="Sonder G" first="Gerard" last="Sonder">Gerard Sonder</name><affiliation wicri:level="1"><nlm:aff id="Aff8"><institution-wrap><institution-id institution-id-type="GRID">grid.413928.5</institution-id><institution-id institution-id-type="ISNI">0000 0000 9418 9094</institution-id><institution>Public Health Service Amsterdam,</institution></institution-wrap>Amsterdam, The Netherlands</nlm:aff><country xml:lang="fr">Pays-Bas</country><wicri:regionArea>Amsterdam</wicri:regionArea></affiliation></author><author><name sortKey="Van Der Weijden, Charlie" sort="Van Der Weijden, Charlie" uniqKey="Van Der Weijden C" first="Charlie" last="Van Der Weijden">Charlie Van Der Weijden</name><affiliation wicri:level="1"><nlm:aff id="Aff9"><institution-wrap><institution-id institution-id-type="GRID">grid.413928.5</institution-id><institution-id institution-id-type="ISNI">0000 0000 9418 9094</institution-id><institution>Public Health Service Flevoland,</institution></institution-wrap>Lelystad, The Netherlands</nlm:aff><country xml:lang="fr">Pays-Bas</country><wicri:regionArea>Lelystad</wicri:regionArea></affiliation></author><author><name sortKey="Van Der Heuvel, Jet" sort="Van Der Heuvel, Jet" uniqKey="Van Der Heuvel J" first="Jet" last="Van Der Heuvel">Jet Van Der Heuvel</name><affiliation wicri:level="1"><nlm:aff id="Aff10">Public Health Service Hart voor Brabant’s, Hertogenbosch, The Netherlands</nlm:aff><country xml:lang="fr">Pays-Bas</country><wicri:regionArea>Public Health Service Hart voor Brabant’s, Hertogenbosch</wicri:regionArea><wicri:noRegion>Hertogenbosch</wicri:noRegion></affiliation></author><author><name sortKey="Gelinck, Luc" sort="Gelinck, Luc" uniqKey="Gelinck L" first="Luc" last="Gelinck">Luc Gelinck</name><affiliation wicri:level="1"><nlm:aff id="Aff11"><institution-wrap><institution-id institution-id-type="GRID">grid.414842.f</institution-id><institution-id institution-id-type="ISNI">0000000403956796</institution-id><institution>Medical Centre Haaglanden,</institution></institution-wrap>The Hague, The Netherlands</nlm:aff><country xml:lang="fr">Pays-Bas</country><wicri:regionArea>The Hague</wicri:regionArea></affiliation></author><author><name sortKey="Bouwhuis, Jolande W" sort="Bouwhuis, Jolande W" uniqKey="Bouwhuis J" first="Jolande W" last="Bouwhuis">Jolande W. Bouwhuis</name><affiliation wicri:level="1"><nlm:aff id="Aff12">Isalaklinieken, Zwolle, The Netherlands</nlm:aff><country xml:lang="fr">Pays-Bas</country><wicri:regionArea>Isalaklinieken, Zwolle</wicri:regionArea><wicri:noRegion>Zwolle</wicri:noRegion></affiliation></author><author><name sortKey="Van Gageldonk Lafeber, Arianne B" sort="Van Gageldonk Lafeber, Arianne B" uniqKey="Van Gageldonk Lafeber A" first="Arianne B" last="Van Gageldonk-Lafeber">Arianne B. Van Gageldonk-Lafeber</name><affiliation wicri:level="1"><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="GRID">grid.31147.30</institution-id><institution-id institution-id-type="ISNI">0000 0001 2208 0118</institution-id><institution>National Institute for Public Health and the Environment,</institution><institution>Centre for Infectious Disease Control,</institution></institution-wrap>Bilthoven, The Netherlands</nlm:aff><country xml:lang="fr">Pays-Bas</country><wicri:regionArea>Bilthoven</wicri:regionArea></affiliation></author></analytic><series><title level="j">Emerging Themes in Epidemiology</title><idno type="eISSN">1742-7622</idno><imprint><date when="2014">2014</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec><title>Background</title><p>In May 2014, Middle East respiratory syndrome coronavirus (MERS-CoV) infection, with closely related viral genomes, was diagnosed in two Dutch residents, returning from a pilgrimage to Medina and Mecca, Kingdom of Saudi Arabia (KSA). These patients travelled with a group of 29 other Dutch travellers. We conducted an epidemiological assessment of the travel group to identify likely source(s) of infection and presence of potential risk factors.</p></sec><sec><title>Methods</title><p>All travellers, including the two cases, completed a questionnaire focussing on potential human, animal and food exposures to MERS-CoV. The questionnaire was modified from the WHO MERS-CoV questionnaire, taking into account the specific route and activities of the travel group.</p></sec><sec><title>Results</title><p>Twelve non-cases drank unpasteurized camel milk and had contact with camels. Most travellers, including one of the two patients (Case 1), visited local markets, where six of them consumed fruits. Two travellers, including Case 1, were exposed to coughing patients when visiting a hospital in Medina. Four travellers, including Case 1, visited two hospitals in Mecca. All travellers had been in contact with Case 1 while he was sick, with initially non-respiratory complaints. The cases were found to be older than the other travellers and both had co-morbidities.</p></sec><sec><title>Conclusions</title><p>This epidemiological study revealed the complexity of MERS-CoV outbreak investigations with multiple potential exposures to MERS-CoV reported such as healthcare visits, camel exposure, and exposure to untreated food products. Exposure to MERS-CoV during a hospital visit is considered a likely source of infection for Case 1 but not for Case 2. For Case 2, the most likely source could not be determined. Exposure to MERS-CoV via direct contact with animals or dairy products seems unlikely for the two Dutch cases. Furthermore, exposure to a common but still unidentified source cannot be ruled out. More comprehensive research into sources of infection in the Arabian Peninsula is needed to strengthen and specify the prevention of MERS-CoV infections.</p></sec><sec><title>Electronic supplementary material</title><p>The online version of this article (doi:10.1186/1742-7622-11-16) contains supplementary material, which is available to authorized users.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Zaki, Am" uniqKey="Zaki A">AM Zaki</name></author><author><name sortKey="Van Boheemen, S" uniqKey="Van Boheemen S">S van Boheemen</name></author><author><name sortKey="Bestebroer, Tm" uniqKey="Bestebroer T">TM Bestebroer</name></author><author><name sortKey="Osterhaus, Ad" uniqKey="Osterhaus A">AD Osterhaus</name></author><author><name sortKey="Fouchier, Ra" uniqKey="Fouchier R">RA Fouchier</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name 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uniqKey="Jansen C">C Jansen</name></author><author><name sortKey="Jonges, M" uniqKey="Jonges M">M Jonges</name></author><author><name sortKey="Raj, S" uniqKey="Raj S">S Raj</name></author><author><name sortKey="Thurkow, I" uniqKey="Thurkow I">I Thurkow</name></author><author><name sortKey="Van Gageldonk Lafeber, R" uniqKey="Van Gageldonk Lafeber R">R van Gageldonk-Lafeber</name></author><author><name sortKey="Van Der Eijk, A" uniqKey="Van Der Eijk A">A van der Eijk</name></author><author><name sortKey="Koopmans, M" uniqKey="Koopmans M">M Koopmans</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Arabi, Ym" uniqKey="Arabi Y">YM Arabi</name></author><author><name sortKey="Arifi, Aa" uniqKey="Arifi A">AA Arifi</name></author><author><name sortKey="Balkhy, Hh" uniqKey="Balkhy H">HH Balkhy</name></author><author><name sortKey="Najm, H" uniqKey="Najm H">H Najm</name></author><author><name sortKey="Aldawood, As" uniqKey="Aldawood A">AS Aldawood</name></author><author><name sortKey="Ghabashi, A" uniqKey="Ghabashi A">A Ghabashi</name></author><author><name sortKey="Hawa, H" uniqKey="Hawa H">H Hawa</name></author><author><name sortKey="Alothman, A" uniqKey="Alothman A">A Alothman</name></author><author><name sortKey="Khaldi, A" uniqKey="Khaldi A">A Khaldi</name></author><author><name sortKey="Al Raiy, B" uniqKey="Al Raiy B">B Al Raiy</name></author></analytic></biblStruct><biblStruct></biblStruct></listBibl></div1></back></TEI><pmc article-type="research-article"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">Emerg Themes Epidemiol</journal-id><journal-id journal-id-type="iso-abbrev">Emerg Themes Epidemiol</journal-id><journal-title-group><journal-title>Emerging Themes in Epidemiology</journal-title></journal-title-group><issn pub-type="epub">1742-7622</issn><publisher><publisher-name>BioMed Central</publisher-name><publisher-loc>London</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">25328533</article-id><article-id pub-id-type="pmc">4200475</article-id><article-id pub-id-type="publisher-id">133</article-id><article-id pub-id-type="doi">10.1186/1742-7622-11-16</article-id><article-categories><subj-group subj-group-type="heading"><subject>Research Article</subject></subj-group></article-categories><title-group><article-title>Travel-related MERS-CoV cases: an assessment of exposures and risk factors in a group of Dutch travellers returning from the Kingdom of Saudi Arabia, May 2014</article-title></title-group><contrib-group><contrib contrib-type="author" corresp="yes"><name><surname>Fanoy</surname><given-names>Ewout B</given-names></name><on-behalf-of>the members of the MERS-CoV outbreak investigation team of The Netherlands, The Netherlands </on-behalf-of><address><email>Ewout.Fanoy@rivm.nl</email></address><xref ref-type="aff" rid="Aff15"></xref><xref ref-type="aff" rid="Aff1">1</xref><xref ref-type="aff" rid="Aff2">2</xref><xref ref-type="aff" rid="Aff3">3</xref><xref ref-type="aff" rid="Aff13">13</xref></contrib><contrib contrib-type="author"><name><surname>van der Sande</surname><given-names>Marianne AB</given-names></name><address><email>Marianne.van.der.sande@rivm.nl</email></address><xref ref-type="aff" rid="Aff1">1</xref><xref ref-type="aff" rid="Aff4">4</xref></contrib><contrib contrib-type="author"><name><surname>Kraaij-Dirkzwager</surname><given-names>Marleen</given-names></name><address><email>Marleen.Kraaij@rivm.nl</email></address><xref ref-type="aff" rid="Aff1">1</xref></contrib><contrib contrib-type="author"><name><surname>Dirksen</surname><given-names>Kees</given-names></name><address><email>kees.dirksen@ggdhaaglanden.nl</email></address><xref ref-type="aff" rid="Aff5">5</xref></contrib><contrib contrib-type="author"><name><surname>Jonges</surname><given-names>Marcel</given-names></name><address><email>marcel.jonges@rivm.nl</email></address><xref ref-type="aff" rid="Aff1">1</xref></contrib><contrib contrib-type="author"><name><surname>van der Hoek</surname><given-names>Wim</given-names></name><address><email>wim.van.der.hoek@rivm.nl</email></address><xref ref-type="aff" rid="Aff1">1</xref></contrib><contrib contrib-type="author"><name><surname>Koopmans</surname><given-names>Marion PG</given-names></name><address><email>m.koopmans@erasmusmc.nl</email></address><xref ref-type="aff" rid="Aff6">6</xref></contrib><contrib contrib-type="author"><name><surname>van der Werf</surname><given-names>Douwe</given-names></name><address><email>D.vander.Werf@ggdijsselland.nl</email></address><xref ref-type="aff" rid="Aff7">7</xref></contrib><contrib contrib-type="author"><name><surname>Sonder</surname><given-names>Gerard</given-names></name><address><email>gsonder@ggd.amsterdam.nl</email></address><xref ref-type="aff" rid="Aff8">8</xref></contrib><contrib contrib-type="author"><name><surname>van der Weijden</surname><given-names>Charlie</given-names></name><address><email>C.vanderWeijden@ggdflevoland.nl</email></address><xref ref-type="aff" rid="Aff9">9</xref></contrib><contrib contrib-type="author"><name><surname>van der Heuvel</surname><given-names>Jet</given-names></name><address><email>j.vd.heuvel@ggdhvb.nl</email></address><xref ref-type="aff" rid="Aff10">10</xref></contrib><contrib contrib-type="author"><name><surname>Gelinck</surname><given-names>Luc</given-names></name><address><email>GelLuc@mchaaglanden.nl</email></address><xref ref-type="aff" rid="Aff11">11</xref></contrib><contrib contrib-type="author"><name><surname>Bouwhuis</surname><given-names>Jolande W</given-names></name><address><email>J.W.Bouwhuis@isala.nl</email></address><xref ref-type="aff" rid="Aff12">12</xref></contrib><contrib contrib-type="author"><name><surname>van Gageldonk-Lafeber</surname><given-names>Arianne B</given-names></name><address><email>rianne.van.gageldonk@rivm.nl</email></address><xref ref-type="aff" rid="Aff1">1</xref></contrib><aff id="Aff1"><label>1</label><institution-wrap><institution-id institution-id-type="GRID">grid.31147.30</institution-id><institution-id institution-id-type="ISNI">0000 0001 2208 0118</institution-id><institution>National Institute for Public Health and the Environment,</institution><institution>Centre for Infectious Disease Control,</institution></institution-wrap>Bilthoven, The Netherlands</aff><aff id="Aff2"><label>2</label><institution-wrap><institution-id institution-id-type="GRID">grid.418914.1</institution-id><institution-id institution-id-type="ISNI">0000000417918889</institution-id><institution>European Programme for Intervention Epidemiology Training (EPIET),</institution><institution>European Centre for Disease Prevention and Control (ECDC),</institution></institution-wrap>Stockholm, Sweden</aff><aff id="Aff3"><label>3</label><institution-wrap><institution-id institution-id-type="GRID">grid.413928.5</institution-id><institution-id institution-id-type="ISNI">0000 0000 9418 9094</institution-id><institution>Public Health Service region of Utrecht,</institution></institution-wrap>Zeist, The Netherlands</aff><aff id="Aff4"><label>4</label><institution-wrap><institution-id institution-id-type="GRID">grid.7692.a</institution-id><institution-id institution-id-type="ISNI">0000000090126352</institution-id><institution>Julius Center,</institution><institution>University Medical Center Utrecht,</institution></institution-wrap>Utrecht, The Netherlands</aff><aff id="Aff5"><label>5</label>Public Health Service Haaglanden, Den Haag, The Netherlands</aff><aff id="Aff6"><label>6</label><institution-wrap><institution-id institution-id-type="GRID">grid.5645.2</institution-id><institution-id institution-id-type="ISNI">000000040459992X</institution-id><institution>Erasmus Medical Center,</institution></institution-wrap>Rotterdam, The Netherlands</aff><aff id="Aff7"><label>7</label>Public Health Service IJsselland, Zwolle, The Netherlands</aff><aff id="Aff8"><label>8</label><institution-wrap><institution-id institution-id-type="GRID">grid.413928.5</institution-id><institution-id institution-id-type="ISNI">0000 0000 9418 9094</institution-id><institution>Public Health Service Amsterdam,</institution></institution-wrap>Amsterdam, The Netherlands</aff><aff id="Aff9"><label>9</label><institution-wrap><institution-id institution-id-type="GRID">grid.413928.5</institution-id><institution-id institution-id-type="ISNI">0000 0000 9418 9094</institution-id><institution>Public Health Service Flevoland,</institution></institution-wrap>Lelystad, The Netherlands</aff><aff id="Aff10"><label>10</label>Public Health Service Hart voor Brabant’s, Hertogenbosch, The Netherlands</aff><aff id="Aff11"><label>11</label><institution-wrap><institution-id institution-id-type="GRID">grid.414842.f</institution-id><institution-id institution-id-type="ISNI">0000000403956796</institution-id><institution>Medical Centre Haaglanden,</institution></institution-wrap>The Hague, The Netherlands</aff><aff id="Aff12"><label>12</label>Isalaklinieken, Zwolle, The Netherlands</aff><aff id="Aff13"><label>13</label><institution-wrap><institution-id institution-id-type="GRID">grid.31147.30</institution-id><institution-id institution-id-type="ISNI">0000 0001 2208 0118</institution-id><institution>National Institute for Public Health and the Environment,</institution><institution>Epidemiology and Surveillance Unit,</institution></institution-wrap>Antonie van Leeuwenhoeklaan 9, Bilthoven, MA 3721 The Netherlands</aff><aff id="Aff15"><label>15</label>the members of the MERS-CoV outbreak investigation team of The Netherlands, The Netherlands</aff></contrib-group><pub-date pub-type="epub"><day>17</day><month>10</month><year>2014</year></pub-date><pub-date pub-type="pmc-release"><day>17</day><month>10</month><year>2014</year></pub-date><pub-date pub-type="collection"><year>2014</year></pub-date><volume>11</volume><elocation-id>16</elocation-id><history><date date-type="received"><day>30</day><month>6</month><year>2014</year></date><date date-type="accepted"><day>2</day><month>10</month><year>2014</year></date></history><permissions><copyright-statement>© Fanoy et al.; licensee BioMed Central Ltd. 2014</copyright-statement><license license-type="OpenAccess"><license-p>This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by/4.0">http://creativecommons.org/licenses/by/4.0</ext-link>), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/publicdomain/zero/1.0/">http://creativecommons.org/publicdomain/zero/1.0/</ext-link>) applies to the data made available in this article, unless otherwise stated.</license-p></license></permissions><abstract id="Abs1"><sec><title>Background</title><p>In May 2014, Middle East respiratory syndrome coronavirus (MERS-CoV) infection, with closely related viral genomes, was diagnosed in two Dutch residents, returning from a pilgrimage to Medina and Mecca, Kingdom of Saudi Arabia (KSA). These patients travelled with a group of 29 other Dutch travellers. We conducted an epidemiological assessment of the travel group to identify likely source(s) of infection and presence of potential risk factors.</p></sec><sec><title>Methods</title><p>All travellers, including the two cases, completed a questionnaire focussing on potential human, animal and food exposures to MERS-CoV. The questionnaire was modified from the WHO MERS-CoV questionnaire, taking into account the specific route and activities of the travel group.</p></sec><sec><title>Results</title><p>Twelve non-cases drank unpasteurized camel milk and had contact with camels. Most travellers, including one of the two patients (Case 1), visited local markets, where six of them consumed fruits. Two travellers, including Case 1, were exposed to coughing patients when visiting a hospital in Medina. Four travellers, including Case 1, visited two hospitals in Mecca. All travellers had been in contact with Case 1 while he was sick, with initially non-respiratory complaints. The cases were found to be older than the other travellers and both had co-morbidities.</p></sec><sec><title>Conclusions</title><p>This epidemiological study revealed the complexity of MERS-CoV outbreak investigations with multiple potential exposures to MERS-CoV reported such as healthcare visits, camel exposure, and exposure to untreated food products. Exposure to MERS-CoV during a hospital visit is considered a likely source of infection for Case 1 but not for Case 2. For Case 2, the most likely source could not be determined. Exposure to MERS-CoV via direct contact with animals or dairy products seems unlikely for the two Dutch cases. Furthermore, exposure to a common but still unidentified source cannot be ruled out. More comprehensive research into sources of infection in the Arabian Peninsula is needed to strengthen and specify the prevention of MERS-CoV infections.</p></sec><sec><title>Electronic supplementary material</title><p>The online version of this article (doi:10.1186/1742-7622-11-16) contains supplementary material, which is available to authorized users.</p></sec></abstract><kwd-group xml:lang="en"><title>Keywords</title><kwd>Middle East respiratory syndrome coronavirus</kwd><kwd>MERS</kwd><kwd>MERS-CoV</kwd><kwd>Exposure</kwd><kwd>Risk factors</kwd><kwd>Epidemiology</kwd></kwd-group><custom-meta-group><custom-meta><meta-name>issue-copyright-statement</meta-name><meta-value>© The Author(s) 2014</meta-value></custom-meta></custom-meta-group></article-meta></front></pmc><affiliations><list><country><li>Pays-Bas</li><li>Suède</li></country><region><li>Hollande-Méridionale</li></region><settlement><li>La Haye</li></settlement></list><tree><country name="Pays-Bas"><noRegion><name sortKey="Fanoy, Ewout B" sort="Fanoy, Ewout B" uniqKey="Fanoy E" first="Ewout B" last="Fanoy">Ewout B. Fanoy</name></noRegion><name sortKey="Bouwhuis, Jolande W" sort="Bouwhuis, Jolande W" uniqKey="Bouwhuis J" first="Jolande W" last="Bouwhuis">Jolande W. Bouwhuis</name><name sortKey="Dirksen, Kees" sort="Dirksen, Kees" uniqKey="Dirksen K" first="Kees" last="Dirksen">Kees Dirksen</name><name sortKey="Fanoy, Ewout B" sort="Fanoy, Ewout B" uniqKey="Fanoy E" first="Ewout B" last="Fanoy">Ewout B. Fanoy</name><name sortKey="Gelinck, Luc" sort="Gelinck, Luc" uniqKey="Gelinck L" first="Luc" last="Gelinck">Luc Gelinck</name><name sortKey="Jonges, Marcel" sort="Jonges, Marcel" uniqKey="Jonges M" first="Marcel" last="Jonges">Marcel Jonges</name><name sortKey="Koopmans, Marion Pg" sort="Koopmans, Marion Pg" uniqKey="Koopmans M" first="Marion Pg" last="Koopmans">Marion Pg Koopmans</name><name sortKey="Kraaij Dirkzwager, Marleen" sort="Kraaij Dirkzwager, Marleen" uniqKey="Kraaij Dirkzwager M" first="Marleen" last="Kraaij-Dirkzwager">Marleen Kraaij-Dirkzwager</name><name sortKey="Sonder, Gerard" sort="Sonder, Gerard" uniqKey="Sonder G" first="Gerard" last="Sonder">Gerard Sonder</name><name sortKey="Van Der Heuvel, Jet" sort="Van Der Heuvel, Jet" uniqKey="Van Der Heuvel J" first="Jet" last="Van Der Heuvel">Jet Van Der Heuvel</name><name sortKey="Van Der Hoek, Wim" sort="Van Der Hoek, Wim" uniqKey="Van Der Hoek W" first="Wim" last="Van Der Hoek">Wim Van Der Hoek</name><name sortKey="Van Der Sande, Marianne Ab" sort="Van Der Sande, Marianne Ab" uniqKey="Van Der Sande M" first="Marianne Ab" last="Van Der Sande">Marianne Ab Van Der Sande</name><name sortKey="Van Der Sande, Marianne Ab" sort="Van Der Sande, Marianne Ab" uniqKey="Van Der Sande M" first="Marianne Ab" last="Van Der Sande">Marianne Ab Van Der Sande</name><name sortKey="Van Der Weijden, Charlie" sort="Van Der Weijden, Charlie" uniqKey="Van Der Weijden C" first="Charlie" last="Van Der Weijden">Charlie Van Der Weijden</name><name sortKey="Van Der Werf, Douwe" sort="Van Der Werf, Douwe" uniqKey="Van Der Werf D" first="Douwe" last="Van Der Werf">Douwe Van Der Werf</name><name sortKey="Van Gageldonk Lafeber, Arianne B" sort="Van Gageldonk Lafeber, Arianne B" uniqKey="Van Gageldonk Lafeber A" first="Arianne B" last="Van Gageldonk-Lafeber">Arianne B. Van Gageldonk-Lafeber</name></country><country name="Suède"><noRegion><name sortKey="Fanoy, Ewout B" sort="Fanoy, Ewout B" uniqKey="Fanoy E" first="Ewout B" last="Fanoy">Ewout B. Fanoy</name></noRegion></country></tree></affiliations></record>Pour manipuler ce document sous Unix (Dilib)
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