Surveillance and Testing for Middle East Respiratory Syndrome Coronavirus, Saudi Arabia, April 2015–February 2016
Identifieur interne : 000684 ( Pmc/Corpus ); précédent : 000683; suivant : 000685Surveillance and Testing for Middle East Respiratory Syndrome Coronavirus, Saudi Arabia, April 2015–February 2016
Auteurs : Abdulaziz A. Bin Saeed ; Glen R. Abedi ; Abdullah G. Alzahrani ; Iyad Salameh ; Fatima Abdirizak ; Raafat Alhakeem ; Homoud Algarni ; Osman A. El Nil ; Mutaz Mohammed ; Abdullah M. Assiri ; Hail M. Alabdely ; John T. Watson ; Susan I. GerberSource :
- Emerging Infectious Diseases [ 1080-6040 ] ; 2017.
Abstract
Saudi Arabia has reported >80% of the Middle East respiratory syndrome coronavirus (MERS-CoV) cases worldwide. During April 2015–February 2016, Saudi Arabia identified and tested 57,363 persons (18.4/10,000 residents) with suspected MERS-CoV infection; 384 (0.7%) tested positive. Robust, extensive, and timely surveillance is critical for limiting virus transmission.
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DOI: 10.3201/eid2304.161793
PubMed: 28322710
PubMed Central: 5367404
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Surveillance and Testing for Middle East Respiratory Syndrome Coronavirus, Saudi Arabia, April 2015–February 2016</title><author><name sortKey="Bin Saeed, Abdulaziz A" sort="Bin Saeed, Abdulaziz A" uniqKey="Bin Saeed A" first="Abdulaziz A." last="Bin Saeed">Abdulaziz A. Bin Saeed</name></author><author><name sortKey="Abedi, Glen R" sort="Abedi, Glen R" uniqKey="Abedi G" first="Glen R." last="Abedi">Glen R. Abedi</name></author><author><name sortKey="Alzahrani, Abdullah G" sort="Alzahrani, Abdullah G" uniqKey="Alzahrani A" first="Abdullah G." last="Alzahrani">Abdullah G. Alzahrani</name></author><author><name sortKey="Salameh, Iyad" sort="Salameh, Iyad" uniqKey="Salameh I" first="Iyad" last="Salameh">Iyad Salameh</name></author><author><name sortKey="Abdirizak, Fatima" sort="Abdirizak, Fatima" uniqKey="Abdirizak F" first="Fatima" last="Abdirizak">Fatima Abdirizak</name></author><author><name sortKey="Alhakeem, Raafat" sort="Alhakeem, Raafat" uniqKey="Alhakeem R" first="Raafat" last="Alhakeem">Raafat Alhakeem</name></author><author><name sortKey="Algarni, Homoud" sort="Algarni, Homoud" uniqKey="Algarni H" first="Homoud" last="Algarni">Homoud Algarni</name></author><author><name sortKey="El Nil, Osman A" sort="El Nil, Osman A" uniqKey="El Nil O" first="Osman A." last="El Nil">Osman A. El Nil</name></author><author><name sortKey="Mohammed, Mutaz" sort="Mohammed, Mutaz" uniqKey="Mohammed M" first="Mutaz" last="Mohammed">Mutaz Mohammed</name></author><author><name sortKey="Assiri, Abdullah M" sort="Assiri, Abdullah M" uniqKey="Assiri A" first="Abdullah M." last="Assiri">Abdullah M. Assiri</name></author><author><name sortKey="Alabdely, Hail M" sort="Alabdely, Hail M" uniqKey="Alabdely H" first="Hail M." last="Alabdely">Hail M. Alabdely</name></author><author><name sortKey="Watson, John T" sort="Watson, John T" uniqKey="Watson J" first="John T." last="Watson">John T. Watson</name></author><author><name sortKey="Gerber, Susan I" sort="Gerber, Susan I" uniqKey="Gerber S" first="Susan I." last="Gerber">Susan I. Gerber</name></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">28322710</idno><idno type="pmc">5367404</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5367404</idno><idno type="RBID">PMC:5367404</idno><idno type="doi">10.3201/eid2304.161793</idno><date when="2017">2017</date><idno type="wicri:Area/Pmc/Corpus">000684</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000684</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Surveillance and Testing for Middle East Respiratory Syndrome Coronavirus, Saudi Arabia, April 2015–February 2016</title><author><name sortKey="Bin Saeed, Abdulaziz A" sort="Bin Saeed, Abdulaziz A" uniqKey="Bin Saeed A" first="Abdulaziz A." last="Bin Saeed">Abdulaziz A. Bin Saeed</name></author><author><name sortKey="Abedi, Glen R" sort="Abedi, Glen R" uniqKey="Abedi G" first="Glen R." last="Abedi">Glen R. Abedi</name></author><author><name sortKey="Alzahrani, Abdullah G" sort="Alzahrani, Abdullah G" uniqKey="Alzahrani A" first="Abdullah G." last="Alzahrani">Abdullah G. Alzahrani</name></author><author><name sortKey="Salameh, Iyad" sort="Salameh, Iyad" uniqKey="Salameh I" first="Iyad" last="Salameh">Iyad Salameh</name></author><author><name sortKey="Abdirizak, Fatima" sort="Abdirizak, Fatima" uniqKey="Abdirizak F" first="Fatima" last="Abdirizak">Fatima Abdirizak</name></author><author><name sortKey="Alhakeem, Raafat" sort="Alhakeem, Raafat" uniqKey="Alhakeem R" first="Raafat" last="Alhakeem">Raafat Alhakeem</name></author><author><name sortKey="Algarni, Homoud" sort="Algarni, Homoud" uniqKey="Algarni H" first="Homoud" last="Algarni">Homoud Algarni</name></author><author><name sortKey="El Nil, Osman A" sort="El Nil, Osman A" uniqKey="El Nil O" first="Osman A." last="El Nil">Osman A. El Nil</name></author><author><name sortKey="Mohammed, Mutaz" sort="Mohammed, Mutaz" uniqKey="Mohammed M" first="Mutaz" last="Mohammed">Mutaz Mohammed</name></author><author><name sortKey="Assiri, Abdullah M" sort="Assiri, Abdullah M" uniqKey="Assiri A" first="Abdullah M." last="Assiri">Abdullah M. Assiri</name></author><author><name sortKey="Alabdely, Hail M" sort="Alabdely, Hail M" uniqKey="Alabdely H" first="Hail M." last="Alabdely">Hail M. Alabdely</name></author><author><name sortKey="Watson, John T" sort="Watson, John T" uniqKey="Watson J" first="John T." last="Watson">John T. Watson</name></author><author><name sortKey="Gerber, Susan I" sort="Gerber, Susan I" uniqKey="Gerber S" first="Susan I." last="Gerber">Susan I. Gerber</name></author></analytic><series><title level="j">Emerging Infectious Diseases</title><idno type="ISSN">1080-6040</idno><idno type="eISSN">1080-6059</idno><imprint><date when="2017">2017</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>Saudi Arabia has reported >80% of the Middle East respiratory syndrome coronavirus (MERS-CoV) cases worldwide. During April 2015–February 2016, Saudi Arabia identified and tested 57,363 persons (18.4/10,000 residents) with suspected MERS-CoV infection; 384 (0.7%) tested positive. Robust, extensive, and timely surveillance is critical for limiting virus transmission.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct></listBibl></div1></back></TEI><pmc article-type="brief-report"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">Emerg Infect Dis</journal-id><journal-id journal-id-type="iso-abbrev">Emerging Infect. Dis</journal-id><journal-id journal-id-type="publisher-id">EID</journal-id><journal-title-group><journal-title>Emerging Infectious Diseases</journal-title></journal-title-group><issn pub-type="ppub">1080-6040</issn><issn pub-type="epub">1080-6059</issn><publisher><publisher-name>Centers for Disease Control and Prevention</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">28322710</article-id><article-id pub-id-type="pmc">5367404</article-id><article-id pub-id-type="publisher-id">16-1793</article-id><article-id pub-id-type="doi">10.3201/eid2304.161793</article-id><article-categories><subj-group subj-group-type="heading"><subject>Dispatch</subject></subj-group><subj-group subj-group-type="article-type"><subject>Dispatch</subject></subj-group><subj-group subj-group-type="TOC-title"><subject>Surveillance and Testing for Middle East Respiratory Syndrome Coronavirus, Saudi Arabia, April 2015–February 2016</subject></subj-group></article-categories><title-group><article-title>Surveillance and Testing for Middle East Respiratory Syndrome Coronavirus, Saudi Arabia, April 2015–February 2016</article-title><alt-title alt-title-type="running-head">Surveillance for MERS-CoV, Saudi Arabia</alt-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Bin Saeed</surname><given-names>Abdulaziz A.</given-names></name></contrib><contrib contrib-type="author" corresp="yes"><name><surname>Abedi</surname><given-names>Glen R.</given-names></name></contrib><contrib contrib-type="author"><name><surname>Alzahrani</surname><given-names>Abdullah G.</given-names></name></contrib><contrib contrib-type="author"><name><surname>Salameh</surname><given-names>Iyad</given-names></name></contrib><contrib contrib-type="author"><name><surname>Abdirizak</surname><given-names>Fatima</given-names></name></contrib><contrib contrib-type="author"><name><surname>Alhakeem</surname><given-names>Raafat</given-names></name></contrib><contrib contrib-type="author"><name><surname>Algarni</surname><given-names>Homoud</given-names></name></contrib><contrib contrib-type="author"><name><surname>El Nil</surname><given-names>Osman A.</given-names></name></contrib><contrib contrib-type="author"><name><surname>Mohammed</surname><given-names>Mutaz</given-names></name></contrib><contrib contrib-type="author"><name><surname>Assiri</surname><given-names>Abdullah M.</given-names></name></contrib><contrib contrib-type="author"><name><surname>Alabdely</surname><given-names>Hail M.</given-names></name></contrib><contrib contrib-type="author"><name><surname>Watson</surname><given-names>John T.</given-names></name></contrib><contrib contrib-type="author"><name><surname>Gerber</surname><given-names>Susan I.</given-names></name></contrib><aff id="aff1">Ministry of Health, Riyadh, Saudi Arabia (A.A. Bin Saeed, A.G. Alzahrani, I. Salameh, R. Alhakeem, H. Algarni, O.A. El Nil, M. Mohammed, A.M. Assiri, H.M. Alabdely);</aff><aff id="aff2">Centers for Disease Control and Prevention, Atlanta, Georgia, USA (G.R. Abedi, F. Abdirizak, J.T. Watson, S.I. Gerber).</aff></contrib-group><author-notes><corresp id="cor1">Address for correspondence: Glen R Abedi, Centers for Disease Control and Prevention; 1600 Clifton Rd NE, Mailstop A34, Atlanta, GA 30329-4027, USA; email: <email xlink:href="gabedi@cdc.gov">gabedi@cdc.gov</email></corresp></author-notes><pub-date pub-type="ppub"><month>4</month><year>2017</year></pub-date><volume>23</volume><issue>4</issue><fpage>682</fpage><lpage>685</lpage><abstract><p>Saudi Arabia has reported >80% of the Middle East respiratory syndrome coronavirus (MERS-CoV) cases worldwide. During April 2015–February 2016, Saudi Arabia identified and tested 57,363 persons (18.4/10,000 residents) with suspected MERS-CoV infection; 384 (0.7%) tested positive. Robust, extensive, and timely surveillance is critical for limiting virus transmission.</p></abstract><kwd-group kwd-group-type="author"><title>Keywords: </title><kwd>surveillance</kwd><kwd>testing</kwd><kwd>respiratory infections</kwd><kwd>Middle East respiratory syndrome coronavirus</kwd><kwd>MERS-CoV</kwd><kwd>Saudi Arabia</kwd><kwd>viruses</kwd><kwd>zoonoses</kwd><kwd>surveillance practices</kwd><kwd>infection control</kwd><kwd>transmission</kwd></kwd-group></article-meta></front><body><p>Middle East respiratory syndrome (MERS) coronavirus (CoV) causes severe respiratory illness in humans, with death occurring in >35% of reported cases (<xref rid="R1" ref-type="bibr"><italic>1</italic></xref>). MERS has been documented among persons with close contact with known case-patients in healthcare (<xref rid="R2" ref-type="bibr"><italic>2</italic></xref>) and household (<xref rid="R3" ref-type="bibr"><italic>3</italic></xref>) settings and among persons with recent contact with dromedaries (<xref rid="R4" ref-type="bibr"><italic>4</italic></xref>). Proper clinical management of persons with suspected MERS-CoV infection who seek care in a healthcare setting relies upon adherence to recommended infection-control precautions (<xref rid="R5" ref-type="bibr"><italic>5</italic></xref>), which in turn depends upon the early recognition of cases.</p><p>The International Health Regulations Emergency Committee of the World Health Organization reported that data sharing for this disease, including sharing of surveillance results, “remains limited and has fallen short of expectations” (<xref rid="R6" ref-type="bibr"><italic>6</italic></xref>). To determine the extent of MERS surveillance in Saudi Arabia, we reviewed electronic surveillance data collected during April 1, 2015–February 1, 2016, to describe trends in surveillance for MERS and to compare demographic and clinical features among persons tested.</p><sec><title>The Study</title><p>In Saudi Arabia, persons who should be tested for MERS-CoV include suspect case-patients who meet at least 1 of 4 case definition categories (<xref ref-type="local-data" rid="SD1">Technical Appendix</xref> Table). In brief, the categories are persons with community-acquired pneumonia (category I); healthcare-associated pneumonia (II); symptoms after exposure to a MERS-CoV case-patient (III); or unexplained febrile illness (IV). The case definition was revised in May 2014 (<xref rid="R7" ref-type="bibr"><italic>7</italic></xref>); additional refinements were made in June 2015 (<xref rid="R8" ref-type="bibr"><italic>8</italic></xref>). The 2015 definition included changes to the approach for testing children <underline><</underline>14 years of age with nonsevere illness (testing is reserved for children with exposure to camels or camel products or to a confirmed or suspected MERS case-patient). In addition to suspected cases, testing is recommended for close contacts of persons with confirmed MERS-CoV infection, regardless of symptoms, and can also be requested at the discretion of an infectious disease consultant. Tests are performed on respiratory specimens at 5 regional laboratories using real-time PCR (<xref rid="R9" ref-type="bibr"><italic>9</italic></xref>).</p><p>Since March 7, 2015, official reporting of cases referred for MERS-CoV testing in Saudi Arabia has exclusively been documented through the Health Electronic Surveillance Network (HESN). When a suspected case-patient is identified for testing, the referring hospital reports demographic and basic clinical data to HESN (<xref ref-type="fig" rid="F1">Figure 1</xref>). After specimens are submitted and testing completed, the regional laboratory reports the result to HESN. For positive cases, the referring hospital submits additional clinical information, and the local Health Affairs Directorate (HAD) initiates an investigation of exposures and contacts. For negative test results, no further action is taken in HESN. Surveillance activities occur in each of the 20 local HADs and among Hajj pilgrims. We analyzed demographic, clinical, and laboratory data for persons reported to HESN during April 1, 2015–February 1, 2016, in aggregate and by HAD using Microsoft Excel 2013 (Microsoft Corp., Redmond, WA, USA) and SAS version 9.3 (SAS Institute, Inc., Cary, NC, USA).</p><fig id="F1" fig-type="figure" position="float"><label>Figure 1</label><caption><p>Reporting pathway for data regarding persons tested for Middle East respiratory syndrome coronavirus infection to the Health Electronic Surveillance Network (HESN), Saudi Arabia, 2014–2016.</p></caption><graphic xlink:href="16-1793-F1"></graphic></fig><p>A total of 57,363 suspected MERS case-patients were identified and tested during the study period; 384 (0.7%) tested positive (<xref ref-type="table" rid="T1">Table 1</xref>). Among those for whom nationality and sex were known, 70.3% were Saudi (compared with 67.3% of the general population) and 54.3% were male. Rates of positivity among those with known age differed by age group; highest and lowest rates were among persons 50–65 and <underline><</underline>14 years of age, respectively (<xref ref-type="table" rid="T1">Table 1</xref>). The month with the highest number of tested persons was November 2015 (n = 9,197) (<xref ref-type="fig" rid="F2">Figure 2</xref>), and the month with the highest percentage of positive tested persons was August 2015 (3.4% of 4,770 tested persons).</p><table-wrap id="T1" position="float"><label>Table 1</label><caption><title>Demographic characteristics of persons tested for Middle East respiratory syndrome coronavirus, Saudi Arabia, April 1, 2015–February 1, 2016</title></caption><table frame="hsides" rules="groups"><col width="153" span="1"></col><col width="108" span="1"></col><col width="85" span="1"></col><col width="72" span="1"></col><col width="63" span="1"></col><thead><tr><th valign="bottom" align="left" scope="col" rowspan="1" colspan="1">Characteristic</th><th valign="bottom" align="center" scope="col" rowspan="1" colspan="1">No. (%) confirmed</th><th valign="bottom" align="center" scope="col" rowspan="1" colspan="1">No. (%) not confirmed</th><th valign="bottom" align="center" scope="col" rowspan="1" colspan="1">No. (%) total</th><th valign="bottom" align="center" scope="col" rowspan="1" colspan="1">% Positive</th></tr></thead><tbody><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1">Overall<hr></hr></td><td valign="top" align="center" rowspan="1" colspan="1">384<hr></hr></td><td valign="top" align="center" rowspan="1" colspan="1">56,979 (99.3)<hr></hr></td><td valign="top" align="center" rowspan="1" colspan="1">57,363 (100.0)<hr></hr></td><td valign="top" align="center" rowspan="1" colspan="1">0.7<hr></hr></td></tr><tr><td valign="top" align="left" scope="col" rowspan="1" colspan="1">Sex</td><td valign="top" align="left" rowspan="1" colspan="1"></td><td valign="top" align="left" rowspan="1" colspan="1"></td><td valign="top" align="left" rowspan="1" colspan="1"></td><td valign="top" align="left" rowspan="1" colspan="1"></td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> F</td><td valign="top" align="center" rowspan="1" colspan="1">156</td><td valign="top" align="center" rowspan="1" colspan="1">25,863 (45.7)</td><td valign="top" align="center" rowspan="1" colspan="1">26,019 (45.7)</td><td valign="top" align="center" rowspan="1" colspan="1">0.6</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> M</td><td valign="top" align="center" rowspan="1" colspan="1">226</td><td valign="top" align="center" rowspan="1" colspan="1">30,718 (54.3)</td><td valign="top" align="center" rowspan="1" colspan="1">30,944 (54.3)</td><td valign="top" align="center" rowspan="1" colspan="1">0.7</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> Total<hr></hr></td><td valign="top" align="center" rowspan="1" colspan="1">382<hr></hr></td><td valign="top" align="center" rowspan="1" colspan="1">56,581<hr></hr></td><td valign="top" align="center" rowspan="1" colspan="1">56,963<hr></hr></td><td valign="top" align="center" rowspan="1" colspan="1">0.7<hr></hr></td></tr><tr><td valign="top" align="left" scope="col" rowspan="1" colspan="1">Nationality</td><td valign="top" align="left" rowspan="1" colspan="1"></td><td valign="top" align="left" rowspan="1" colspan="1"></td><td valign="top" align="left" rowspan="1" colspan="1"></td><td valign="top" align="left" rowspan="1" colspan="1"></td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> Saudi</td><td valign="top" align="center" rowspan="1" colspan="1">246</td><td valign="top" align="center" rowspan="1" colspan="1">34,628 (70.3)</td><td valign="top" align="center" rowspan="1" colspan="1">34,874 (70.3)</td><td valign="top" align="center" rowspan="1" colspan="1">0.7</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> Non Saudi</td><td valign="top" align="center" rowspan="1" colspan="1">107 </td><td valign="top" align="center" rowspan="1" colspan="1">14,604 (29.7)</td><td valign="top" align="center" rowspan="1" colspan="1">14,711 (29.7)</td><td valign="top" align="center" rowspan="1" colspan="1">0.7</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> Total<hr></hr></td><td valign="top" align="center" rowspan="1" colspan="1">353<hr></hr></td><td valign="top" align="center" rowspan="1" colspan="1">49,232<hr></hr></td><td valign="top" align="center" rowspan="1" colspan="1">49,585<hr></hr></td><td valign="top" align="center" rowspan="1" colspan="1">0.7<hr></hr></td></tr><tr><td valign="top" align="left" scope="col" rowspan="1" colspan="1">Reason for testing</td><td valign="top" align="left" rowspan="1" colspan="1"></td><td valign="top" align="left" rowspan="1" colspan="1"></td><td valign="top" align="left" rowspan="1" colspan="1"></td><td valign="top" align="left" rowspan="1" colspan="1"></td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> Suspected case*</td><td valign="top" align="center" rowspan="1" colspan="1">286 </td><td valign="top" align="center" rowspan="1" colspan="1">47,592 (89.1)</td><td valign="top" align="center" rowspan="1" colspan="1">47,878 (89.0)</td><td valign="top" align="center" rowspan="1" colspan="1">0.6</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> Category I</td><td valign="top" align="center" rowspan="1" colspan="1">87</td><td valign="top" align="center" rowspan="1" colspan="1">32,284 (60.5)</td><td valign="top" align="center" rowspan="1" colspan="1">32,371 (60.2)</td><td valign="top" align="center" rowspan="1" colspan="1">0.3</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> Category II</td><td valign="top" align="center" rowspan="1" colspan="1">67</td><td valign="top" align="center" rowspan="1" colspan="1">2,662 (5.0)</td><td valign="top" align="center" rowspan="1" colspan="1">2,729 (5.1)</td><td valign="top" align="center" rowspan="1" colspan="1">2.5</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> Category III</td><td valign="top" align="center" rowspan="1" colspan="1">107</td><td valign="top" align="center" rowspan="1" colspan="1">4,669 (8.7)</td><td valign="top" align="center" rowspan="1" colspan="1">4,776 (8.9)</td><td valign="top" align="center" rowspan="1" colspan="1">2.2</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> Category IV</td><td valign="top" align="center" rowspan="1" colspan="1">25</td><td valign="top" align="center" rowspan="1" colspan="1">7,977 (14.9)</td><td valign="top" align="center" rowspan="1" colspan="1">8,002 (14.9)</td><td valign="top" align="center" rowspan="1" colspan="1">0.3</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> Recommended by infectious disease consultant</td><td valign="top" align="center" rowspan="1" colspan="1">66</td><td valign="top" align="center" rowspan="1" colspan="1">3,256 (6.1)</td><td valign="top" align="center" rowspan="1" colspan="1">3,322 (6.2)</td><td valign="top" align="center" rowspan="1" colspan="1">2.0</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> Patient asymptomatic</td><td valign="top" align="center" rowspan="1" colspan="1">19</td><td valign="top" align="center" rowspan="1" colspan="1">2,555 (4.8)</td><td valign="top" align="center" rowspan="1" colspan="1">2,574 (4.8)</td><td valign="top" align="center" rowspan="1" colspan="1">0.7</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> Total<hr></hr></td><td valign="top" align="center" rowspan="1" colspan="1">371<hr></hr></td><td valign="top" align="center" rowspan="1" colspan="1">53,403<hr></hr></td><td valign="top" align="center" rowspan="1" colspan="1">53,774<hr></hr></td><td valign="top" align="center" rowspan="1" colspan="1">0.7<hr></hr></td></tr><tr><td valign="top" align="left" scope="col" rowspan="1" colspan="1">Month of report</td><td valign="top" align="left" rowspan="1" colspan="1"></td><td valign="top" align="left" rowspan="1" colspan="1"></td><td valign="top" align="left" rowspan="1" colspan="1"></td><td valign="top" align="left" rowspan="1" colspan="1"></td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> April 2015</td><td valign="top" align="center" rowspan="1" colspan="1">10</td><td valign="top" align="center" rowspan="1" colspan="1">4,953 (8.7)</td><td valign="top" align="center" rowspan="1" colspan="1">4,963 (8.7)</td><td valign="top" align="center" rowspan="1" colspan="1">0.2</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> May 2015</td><td valign="top" align="center" rowspan="1" colspan="1">54</td><td valign="top" align="center" rowspan="1" colspan="1">4,414 (7.7)</td><td valign="top" align="center" rowspan="1" colspan="1">4,468 (7.8)</td><td valign="top" align="center" rowspan="1" colspan="1">1.2</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> June 2015</td><td valign="top" align="center" rowspan="1" colspan="1">24</td><td valign="top" align="center" rowspan="1" colspan="1">3,090 (5.4)</td><td valign="top" align="center" rowspan="1" colspan="1">3,114 (5.4)</td><td valign="top" align="center" rowspan="1" colspan="1">0.8</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> July 2015</td><td valign="top" align="center" rowspan="1" colspan="1">24</td><td valign="top" align="center" rowspan="1" colspan="1">2,634 (4.6)</td><td valign="top" align="center" rowspan="1" colspan="1">2,658 (4.6)</td><td valign="top" align="center" rowspan="1" colspan="1">0.9</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> August 2015</td><td valign="top" align="center" rowspan="1" colspan="1">160</td><td valign="top" align="center" rowspan="1" colspan="1">4,610 (8.1)</td><td valign="top" align="center" rowspan="1" colspan="1">4,770 (8.3)</td><td valign="top" align="center" rowspan="1" colspan="1">3.4</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> September 2015</td><td valign="top" align="center" rowspan="1" colspan="1">66</td><td valign="top" align="center" rowspan="1" colspan="1">6,520 (11.4)</td><td valign="top" align="center" rowspan="1" colspan="1">6,586 (11.5)</td><td valign="top" align="center" rowspan="1" colspan="1">1.0</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> October 2015</td><td valign="top" align="center" rowspan="1" colspan="1">28</td><td valign="top" align="center" rowspan="1" colspan="1">7,568 (13.3)</td><td valign="top" align="center" rowspan="1" colspan="1">7,596 (13.2)</td><td valign="top" align="center" rowspan="1" colspan="1">0.4</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> November 2015</td><td valign="top" align="center" rowspan="1" colspan="1">6</td><td valign="top" align="center" rowspan="1" colspan="1">9,191 (16.1)</td><td valign="top" align="center" rowspan="1" colspan="1">9,197 (16.0)</td><td valign="top" align="center" rowspan="1" colspan="1">0.1</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> December 2015</td><td valign="top" align="center" rowspan="1" colspan="1">5</td><td valign="top" align="center" rowspan="1" colspan="1">7,280 (12.8)</td><td valign="top" align="center" rowspan="1" colspan="1">7,285 (12.7)</td><td valign="top" align="center" rowspan="1" colspan="1">0.1</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> January 2016</td><td valign="top" align="center" rowspan="1" colspan="1">6</td><td valign="top" align="center" rowspan="1" colspan="1">6,487 (11.4)</td><td valign="top" align="center" rowspan="1" colspan="1">6,493 (11.3)</td><td valign="top" align="center" rowspan="1" colspan="1">0.1</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> February 2016</td><td valign="top" align="center" rowspan="1" colspan="1">1 </td><td valign="top" align="center" rowspan="1" colspan="1">232 (0.4)</td><td valign="top" align="center" rowspan="1" colspan="1">233 (0.4)</td><td valign="top" align="center" rowspan="1" colspan="1">0.4</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> Total<hr></hr></td><td valign="top" align="center" rowspan="1" colspan="1">384<hr></hr></td><td valign="top" align="center" rowspan="1" colspan="1">56,979<hr></hr></td><td valign="top" align="center" rowspan="1" colspan="1">57,363<hr></hr></td><td valign="top" align="center" rowspan="1" colspan="1">0.7<hr></hr></td></tr><tr><td valign="top" align="left" scope="col" rowspan="1" colspan="1">Age, y</td><td valign="top" align="left" rowspan="1" colspan="1"></td><td valign="top" align="left" rowspan="1" colspan="1"></td><td valign="top" align="left" rowspan="1" colspan="1"></td><td valign="top" align="left" rowspan="1" colspan="1"></td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> 0–14</td><td valign="top" align="center" rowspan="1" colspan="1">10</td><td valign="top" align="center" rowspan="1" colspan="1">8,022 (14.2)</td><td valign="top" align="center" rowspan="1" colspan="1">8,032 (14.1)</td><td valign="top" align="center" rowspan="1" colspan="1">0.1</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> 15–34</td><td valign="top" align="center" rowspan="1" colspan="1">97 </td><td valign="top" align="center" rowspan="1" colspan="1">17,621 (31.1)</td><td valign="top" align="center" rowspan="1" colspan="1">17,718 (31.1)</td><td valign="top" align="center" rowspan="1" colspan="1">0.5</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> 35–49</td><td valign="top" align="center" rowspan="1" colspan="1">82</td><td valign="top" align="center" rowspan="1" colspan="1">10,201 (18.0)</td><td valign="top" align="center" rowspan="1" colspan="1">10,283 (18.0)</td><td valign="top" align="center" rowspan="1" colspan="1">0.8</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> 50–65</td><td valign="top" align="center" rowspan="1" colspan="1">109</td><td valign="top" align="center" rowspan="1" colspan="1">10,082 (17.8)</td><td valign="top" align="center" rowspan="1" colspan="1">10,191 (17.9)</td><td valign="top" align="center" rowspan="1" colspan="1">1.1</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"><underline>></underline>66</td><td valign="top" align="center" rowspan="1" colspan="1">84 </td><td valign="top" align="center" rowspan="1" colspan="1">10,692 (18.9)</td><td valign="top" align="center" rowspan="1" colspan="1">10,776 (18.9)</td><td valign="top" align="center" rowspan="1" colspan="1">0.8</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> Total</td><td valign="top" align="center" rowspan="1" colspan="1">382</td><td valign="top" align="center" rowspan="1" colspan="1">56,618</td><td valign="top" align="center" rowspan="1" colspan="1">57,000</td><td valign="top" align="left" rowspan="1" colspan="1"></td></tr></tbody></table><table-wrap-foot><p>*Categories: I, acute respiratory illness with clinical and/or radiologic evidence of pulmonary parenchymal disease (pneumonia or acute respiratory distress syndrome); II, a hospitalized patient with healthcare associated pneumonia based on clinical and radiological evidence; III, upper or lower respiratory illness within 2 weeks after exposure to a confirmed or probable case of MERS-CoV; IV, unexplained acute febrile (<underline>></underline>38°C) illness, and body aches, headache, diarrhea, or nausea/vomiting, with or without respiratory symptoms, and leukopenia (white blood cell count <3.5 × 10<sup>9</sup>/L) and thrombocytopenia (platelets <150 × 10<sup>9</sup>/L). Descriptions are from the Saudi Arabia Ministry of Health MERS-CoV Case Definition and Surveillance Guidance–Updated June 2015 (<ext-link ext-link-type="uri" xlink:href="http://www.moh.gov.sa/en/CCC/Regulations/Case%20Definition.pdf">http://www.moh.gov.sa/en/CCC/Regulations/Case%20Definition.pdf</ext-link>).</p></table-wrap-foot></table-wrap><fig id="F2" fig-type="figure" position="float"><label>Figure 2</label><caption><p>Number persons tested and percent positive for Middle East respiratory syndrome coronavirus, Saudi Arabia, April 1, 2015–February 1, 2016.</p></caption><graphic xlink:href="16-1793-F2"></graphic></fig><p>Among tested persons for whom the reason for testing was known, 89.0% met the clinical case definition for suspected MERS (<xref ref-type="table" rid="T1">Table 1</xref>). The remaining 11.0% were those recommended for testing by an infectious disease consultant and asymptomatic contacts of confirmed case-patients. More than half of those tested (60.2%) met the category I definition (community-acquired pneumonia) for a suspected case-patient; 0.3% tested positive. The highest positivity rate, 2.5%, was among persons meeting the category II definition for a suspected case-patient (healthcare-associated pneumonia). Among all persons with presumed exposure to MERS case-patients (persons meeting categories II, III and asymptomatic contacts of confirmed case-patients), the positivity rate was 1.9%. Among the 185 confirmed case-patients with available occupational information, 35 (18.9%) were healthcare workers (data not shown).</p><p>Most tested persons were reported in the course of routine surveillance through a local HAD. Nationwide, 18.4 persons/10,000 inhabitants were tested, and 1.2/100,000 were MERS-CoV–positive (<xref rid="R10" ref-type="bibr"><italic>10</italic></xref>) (<xref ref-type="table" rid="T2">Table 2</xref>). Rates of testing and positivity varied by HAD; the highest testing rates were in Ahsa HAD, followed by Riyadh HAD. Najran HAD had the highest percentage of positive persons (<xref ref-type="table" rid="T2">Table 2</xref>).</p><table-wrap id="T2" position="float"><label>Table 2</label><caption><title>Middle East respiratory syndrome cases by local Health Affairs Directorate and among Hajj pilgrims, Saudi Arabia, April 1, 2015–February 1, 2016*</title></caption><table frame="hsides" rules="groups"><col width="117" span="1"></col><col width="73" span="1"></col><col width="73" span="1"></col><col width="73" span="1"></col><col width="100" span="1"></col><col width="45" span="1"></col><thead><tr><th valign="bottom" align="left" scope="col" rowspan="1" colspan="1">Surveillance population</th><th valign="bottom" align="center" scope="col" rowspan="1" colspan="1">Population</th><th valign="bottom" align="center" scope="col" rowspan="1" colspan="1">No. positive/no. tested</th><th valign="bottom" align="center" scope="col" rowspan="1" colspan="1">No. tested/10,000 population</th><th valign="bottom" align="center" scope="col" rowspan="1" colspan="1">No. confirmed cases/100,000 population</th><th valign="bottom" align="center" scope="col" rowspan="1" colspan="1">% Positive</th></tr></thead><tbody><tr><td valign="top" align="left" scope="col" rowspan="1" colspan="1">Local Health Affairs Directorate</td><td valign="top" align="left" rowspan="1" colspan="1"></td><td valign="top" align="left" rowspan="1" colspan="1"></td><td valign="top" align="left" rowspan="1" colspan="1"></td><td valign="top" align="left" rowspan="1" colspan="1"></td><td valign="top" align="left" rowspan="1" colspan="1"></td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> Riyadh</td><td valign="top" align="center" rowspan="1" colspan="1">7,717,467</td><td valign="top" align="center" rowspan="1" colspan="1">276/22,322</td><td valign="top" align="center" rowspan="1" colspan="1">28.9</td><td valign="top" align="center" rowspan="1" colspan="1">3.6</td><td valign="top" align="center" rowspan="1" colspan="1">1.2</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> Jeddah</td><td valign="top" align="center" rowspan="1" colspan="1">4,224,568</td><td valign="top" align="center" rowspan="1" colspan="1">10/6,606</td><td valign="top" align="center" rowspan="1" colspan="1">15.6</td><td valign="top" align="center" rowspan="1" colspan="1">0.2</td><td valign="top" align="center" rowspan="1" colspan="1">0.2</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> Eastern</td><td valign="top" align="center" rowspan="1" colspan="1">3,019,461</td><td valign="top" align="center" rowspan="1" colspan="1">2/7,319</td><td valign="top" align="center" rowspan="1" colspan="1">24.2</td><td valign="top" align="center" rowspan="1" colspan="1">0.1</td><td valign="top" align="center" rowspan="1" colspan="1">0</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> Makkah</td><td valign="top" align="center" rowspan="1" colspan="1">2,111,127</td><td valign="top" align="center" rowspan="1" colspan="1">2/3,729</td><td valign="top" align="center" rowspan="1" colspan="1">17.7</td><td valign="top" align="center" rowspan="1" colspan="1">0.1</td><td valign="top" align="center" rowspan="1" colspan="1">0.1</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> Madinah</td><td valign="top" align="center" rowspan="1" colspan="1">2,012,749</td><td valign="top" align="center" rowspan="1" colspan="1">8/2,258</td><td valign="top" align="center" rowspan="1" colspan="1">11.2</td><td valign="top" align="center" rowspan="1" colspan="1">0.4</td><td valign="top" align="center" rowspan="1" colspan="1">0.4</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> Asir</td><td valign="top" align="center" rowspan="1" colspan="1">1,766,212</td><td valign="top" align="center" rowspan="1" colspan="1">6/1,730</td><td valign="top" align="center" rowspan="1" colspan="1">9.8</td><td valign="top" align="center" rowspan="1" colspan="1">0.3</td><td valign="top" align="center" rowspan="1" colspan="1">0.3</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> Jazan</td><td valign="top" align="center" rowspan="1" colspan="1">1,533,496</td><td valign="top" align="center" rowspan="1" colspan="1">0/790</td><td valign="top" align="center" rowspan="1" colspan="1">5.2</td><td valign="top" align="center" rowspan="1" colspan="1">0</td><td valign="top" align="center" rowspan="1" colspan="1">0</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> Qasim</td><td valign="top" align="center" rowspan="1" colspan="1">1,370,727</td><td valign="top" align="center" rowspan="1" colspan="1">5/1,091</td><td valign="top" align="center" rowspan="1" colspan="1">8.0</td><td valign="top" align="center" rowspan="1" colspan="1">0.4</td><td valign="top" align="center" rowspan="1" colspan="1">0.5</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> Taif</td><td valign="top" align="center" rowspan="1" colspan="1">1,257,888</td><td valign="top" align="center" rowspan="1" colspan="1">7/1,866</td><td valign="top" align="center" rowspan="1" colspan="1">14.8</td><td valign="top" align="center" rowspan="1" colspan="1">0.6</td><td valign="top" align="center" rowspan="1" colspan="1">0.4</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> Ahsa</td><td valign="top" align="center" rowspan="1" colspan="1">1,193,373</td><td valign="top" align="center" rowspan="1" colspan="1">57/5,359</td><td valign="top" align="center" rowspan="1" colspan="1">44.9</td><td valign="top" align="center" rowspan="1" colspan="1">4.8</td><td valign="top" align="center" rowspan="1" colspan="1">1.1</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> Tabuk</td><td valign="top" align="center" rowspan="1" colspan="1">887,383</td><td valign="top" align="center" rowspan="1" colspan="1">1/732</td><td valign="top" align="center" rowspan="1" colspan="1">8.2</td><td valign="top" align="center" rowspan="1" colspan="1">0.1</td><td valign="top" align="center" rowspan="1" colspan="1">0.1</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> Hail</td><td valign="top" align="center" rowspan="1" colspan="1">670,468</td><td valign="top" align="center" rowspan="1" colspan="1">0/685</td><td valign="top" align="center" rowspan="1" colspan="1">10.2</td><td valign="top" align="center" rowspan="1" colspan="1">0</td><td valign="top" align="center" rowspan="1" colspan="1">0</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> Najran</td><td valign="top" align="center" rowspan="1" colspan="1">568,631</td><td valign="top" align="center" rowspan="1" colspan="1">10/494</td><td valign="top" align="center" rowspan="1" colspan="1">8.7</td><td valign="top" align="center" rowspan="1" colspan="1">1.8</td><td valign="top" align="center" rowspan="1" colspan="1">2.0</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> Baha</td><td valign="top" align="center" rowspan="1" colspan="1">461,360</td><td valign="top" align="center" rowspan="1" colspan="1">0/184</td><td valign="top" align="center" rowspan="1" colspan="1">4.0</td><td valign="top" align="center" rowspan="1" colspan="1">0</td><td valign="top" align="center" rowspan="1" colspan="1">0</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> Hafr al-Batin</td><td valign="top" align="center" rowspan="1" colspan="1">437,349</td><td valign="top" align="center" rowspan="1" colspan="1">0/145</td><td valign="top" align="center" rowspan="1" colspan="1">3.3</td><td valign="top" align="center" rowspan="1" colspan="1">0</td><td valign="top" align="center" rowspan="1" colspan="1">0</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> Bisha</td><td valign="top" align="center" rowspan="1" colspan="1">379,521</td><td valign="top" align="center" rowspan="1" colspan="1">0/227</td><td valign="top" align="center" rowspan="1" colspan="1">6.0</td><td valign="top" align="center" rowspan="1" colspan="1">0</td><td valign="top" align="center" rowspan="1" colspan="1">0</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> Northern Borders</td><td valign="top" align="center" rowspan="1" colspan="1">359,297</td><td valign="top" align="center" rowspan="1" colspan="1">0/240</td><td valign="top" align="center" rowspan="1" colspan="1">6.7</td><td valign="top" align="center" rowspan="1" colspan="1">0</td><td valign="top" align="center" rowspan="1" colspan="1">0</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> Jauf</td><td valign="top" align="center" rowspan="1" colspan="1">329,277</td><td valign="top" align="center" rowspan="1" colspan="1">0/390</td><td valign="top" align="center" rowspan="1" colspan="1">11.8</td><td valign="top" align="center" rowspan="1" colspan="1">0</td><td valign="top" align="center" rowspan="1" colspan="1">0</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> Qunfudha</td><td valign="top" align="center" rowspan="1" colspan="1">304,392</td><td valign="top" align="center" rowspan="1" colspan="1">0/183</td><td valign="top" align="center" rowspan="1" colspan="1">6.0</td><td valign="top" align="center" rowspan="1" colspan="1">0</td><td valign="top" align="center" rowspan="1" colspan="1">0</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> Qurayat</td><td valign="top" align="center" rowspan="1" colspan="1">165,629</td><td valign="top" align="center" rowspan="1" colspan="1">0/122</td><td valign="top" align="center" rowspan="1" colspan="1">7.4</td><td valign="top" align="center" rowspan="1" colspan="1">0</td><td valign="top" align="center" rowspan="1" colspan="1">0</td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> Total<hr></hr></td><td valign="top" align="center" rowspan="1" colspan="1">30,770,375<hr></hr></td><td valign="top" align="center" rowspan="1" colspan="1">384/56,472<hr></hr></td><td valign="top" align="center" rowspan="1" colspan="1">18.4<hr></hr></td><td valign="top" align="center" rowspan="1" colspan="1">1.2<hr></hr></td><td valign="top" align="center" rowspan="1" colspan="1">0.7<hr></hr></td></tr><tr><td valign="top" align="left" scope="col" rowspan="1" colspan="1">Hajj pilgrims</td><td valign="top" align="left" rowspan="1" colspan="1"></td><td valign="top" align="left" rowspan="1" colspan="1"></td><td valign="top" align="left" rowspan="1" colspan="1"></td><td valign="top" align="left" rowspan="1" colspan="1"></td><td valign="top" align="left" rowspan="1" colspan="1"></td></tr><tr><td valign="top" align="left" scope="row" rowspan="1" colspan="1"> Total</td><td valign="top" align="center" rowspan="1" colspan="1">1,952,817</td><td valign="top" align="center" rowspan="1" colspan="1">0/888</td><td valign="top" align="center" rowspan="1" colspan="1">4.5</td><td valign="top" align="center" rowspan="1" colspan="1">0</td><td valign="top" align="center" rowspan="1" colspan="1">0</td></tr></tbody></table><table-wrap-foot><p>*Population data from (<xref rid="R10" ref-type="bibr"><italic>10</italic></xref>).</p></table-wrap-foot></table-wrap><p>In addition, surveillance during the annual Hajj pilgrimage included 888 tested persons during September 2015, representing 4.5 tested persons/10,000 among 1,952,817 pilgrims. None tested positive for MERS-CoV.</p><p>Among 8,032 children <underline><</underline>14 years of age, 10 (0.1%) tested positive, including 5 who were <1 year of age. At least 7 of the 10 children were tested because of exposure to a MERS case-patient. The number of tests among children <underline><</underline>14 years of age temporarily dropped after the case definition revision in June 2015, which introduced more stringent criteria for testing.</p></sec><sec sec-type="conclusions"><title>Conclusions</title><p>Surveillance and testing for MERS-CoV infection is extensive and widespread in Saudi Arabia. During our study, an average of >5,000 persons per month were identified as being at high risk for infection due to clinical or epidemiologic criteria and were subsequently tested. MERS was first recognized in 2012, and as of November 3, 2016, Saudi Arabia has reported 80.9% of the cases reported worldwide (<xref rid="R11" ref-type="bibr"><italic>11</italic></xref>); this distinction may be partly due to the country’s robust implementation of surveillance practices and the ready availability of testing, which is facilitated by HESN. We found few other published descriptions of surveillance practices for MERS-CoV (<xref rid="R12" ref-type="bibr"><italic>12</italic></xref>,<xref rid="R13" ref-type="bibr"><italic>13</italic></xref>).</p><p>Confirmed MERS case-patients represented <1% of all tested persons in Saudi Arabia. Most tests were conducted for persons with community-acquired pneumonia, among whom the positivity rate was predictably low. Positivity rates were highest among persons tested because of presumed exposure to MERS case-patients (i.e., those tested because of healthcare-acquired pneumonia or onset of symptoms following contact with a confirmed case-patient).</p><p>Only 0.1% of children <underline><</underline>14 years of age tested positive for MERS-CoV; this was the lowest rate among all age groups. Most MERS-CoV–positive children <underline><</underline>14 years of age were tested because of high-risk exposures, not because they met clinical criteria. Although the proportion of positive tests was highest among persons <underline>></underline>35 years of age, the number of tests was highest among persons 18–34 years of age, perhaps because of widespread testing of healthcare workers during outbreaks.</p><p>The largest number of tests was conducted in November, coinciding with the winter respiratory virus season. In comparison, the proportion of positive tests peaked in May and August, coinciding with outbreaks that occurred in Ahsa (<xref rid="R14" ref-type="bibr"><italic>14</italic></xref>) and Riyadh (<xref rid="R15" ref-type="bibr"><italic>15</italic></xref>), respectively.</p><p>Our analysis had limitations. Variations were probably present in the reporting practices of the various data reporters, in the clinical diagnostic practices used across Saudi Arabia, and among investigation teams. Such variations could affect the completeness, accuracy, and timeliness of the data used for this assessment.</p><p>Surveillance and testing for MERS-CoV throughout Saudi Arabia is extensive, as documented by HESN; in a single month during this study, >9,000 patients at high risk for MERS were investigated. A continued robust approach to the early detection of patients with MERS is critical for the prompt implementation of infection-control precautions and the prevention of healthcare-associated transmission of MERS-CoV.</p></sec><sec sec-type="supplementary-material"><title></title><supplementary-material content-type="local-data" id="SD1"><caption><title>Technical Appendix</title><p>Definitions for suspected cases of Middle East respiratory syndrome coronavirus in Saudi Arabia.</p></caption><media mimetype="application" mime-subtype="pdf" xlink:href="16-1793-Techapp-s1.pdf" xlink:type="simple" id="d35e1147" position="anchor"></media></supplementary-material></sec></body><back><fn-group><fn fn-type="citation"><p><italic>Suggested citation for this article</italic>: Bin Saeed AA, Abedi GR, Alzahrani AG, Salameh I, Abdirizak F, Alhakeem R, et al. Surveillance and testing for Middle East respiratory syndrome coronavirus, Saudi Arabia, April 2015–February 2016. Emerg Infect Dis. 2017 Apr [<italic>date cited</italic>]. <ext-link ext-link-type="uri" xlink:href="https://dx.doi.org/10.3201/eid2304.161793">https://dx.doi.org/10.3201/eid2304.161793</ext-link></p></fn></fn-group><bio id="d35e1160"><p>Dr. Bin Saeed served as Deputy Minister for Preventive Health at the Saudi Arabia Ministry of Health from October 2014 through October 2016 and is currently a professor of epidemiology in the Department of Family and Community Medicine at King Saud University College of Medicine in Riyadh. His research interests include epidemiologic methodologies, infection control, and outbreak investigations.</p></bio><ref-list><title>References</title><ref id="R1"><label>1. </label><mixed-citation publication-type="webpage">Situation update on Middle East respiratory syndrome coronavirus September–October <year>2016</year> MERS situation update 2016 Oct 2016 [cited 2016 Dec 21]. <ext-link ext-link-type="uri" xlink:href="http://www.emro.who.int/images/stories/csr/documents/MERS-CoV_Sep_October_2016.pdf?ua=1">http://www.emro.who.int/images/stories/csr/documents/MERS-CoV_Sep_October_2016.pdf?ua=1</ext-link></mixed-citation></ref><ref id="R2"><label>2. </label><mixed-citation publication-type="journal"><string-name><surname>Oboho</surname><given-names>IK</given-names></string-name>, <string-name><surname>Tomczyk</surname><given-names>SM</given-names></string-name>, <string-name><surname>Al-Asmari</surname><given-names>AM</given-names></string-name>, <string-name><surname>Banjar</surname><given-names>AA</given-names></string-name>, <string-name><surname>Al-Mugti</surname><given-names>H</given-names></string-name>, <string-name><surname>Aloraini</surname><given-names>MS</given-names></string-name>, <etal>et al.</etal><article-title>2014 MERS-CoV outbreak in Jeddah—a link to health care facilities.</article-title><source>N Engl J Med</source>. <year>2015</year>;<volume>372</volume>:<fpage>846</fpage>–<lpage>54</lpage>. <pub-id pub-id-type="doi">10.1056/NEJMoa1408636</pub-id><pub-id pub-id-type="pmid">25714162</pub-id></mixed-citation></ref><ref id="R3"><label>3. </label><mixed-citation publication-type="journal"><string-name><surname>Drosten</surname><given-names>C</given-names></string-name>, <string-name><surname>Meyer</surname><given-names>B</given-names></string-name>, <string-name><surname>Müller</surname><given-names>MA</given-names></string-name>, <string-name><surname>Corman</surname><given-names>VM</given-names></string-name>, <string-name><surname>Al-Masri</surname><given-names>M</given-names></string-name>, <string-name><surname>Hossain</surname><given-names>R</given-names></string-name>, <etal>et al.</etal><article-title>Transmission of MERS-coronavirus in household contacts.</article-title><source>N Engl J Med</source>. <year>2014</year>;<volume>371</volume>:<fpage>828</fpage>–<lpage>35</lpage>. <pub-id pub-id-type="doi">10.1056/NEJMoa1405858</pub-id><pub-id pub-id-type="pmid">25162889</pub-id></mixed-citation></ref><ref id="R4"><label>4. </label><mixed-citation publication-type="journal"><string-name><surname>Alraddadi</surname><given-names>BM</given-names></string-name>, <string-name><surname>Watson</surname><given-names>JT</given-names></string-name>, <string-name><surname>Almarashi</surname><given-names>A</given-names></string-name>, <string-name><surname>Abedi</surname><given-names>GR</given-names></string-name>, <string-name><surname>Turkistani</surname><given-names>A</given-names></string-name>, <string-name><surname>Sadran</surname><given-names>M</given-names></string-name>, <etal>et al.</etal><article-title>Risk factors for primary Middle East respiratory syndrome coronavirus illness in humans, Saudi Arabia, 2014.</article-title><source>Emerg Infect Dis</source>. <year>2016</year>;<volume>22</volume>:<fpage>49</fpage>–<lpage>55</lpage>. <pub-id pub-id-type="doi">10.3201/eid2201.151340</pub-id><pub-id pub-id-type="pmid">26692185</pub-id></mixed-citation></ref><ref id="R5"><label>5. </label><mixed-citation publication-type="webpage"><collab>World Health Organization</collab>. 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