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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Detection of the Middle East Respiratory Syndrome Coronavirus Genome in an Air Sample Originating from a Camel Barn Owned by an Infected Patient</title><author><name sortKey="Azhar, Esam I" sort="Azhar, Esam I" uniqKey="Azhar E" first="Esam I." last="Azhar">Esam I. Azhar</name></author><author><name sortKey="Hashem, Anwar M" sort="Hashem, Anwar M" uniqKey="Hashem A" first="Anwar M." last="Hashem">Anwar M. Hashem</name></author><author><name sortKey="El Kafrawy, Sherif A" sort="El Kafrawy, Sherif A" uniqKey="El Kafrawy S" first="Sherif A." last="El-Kafrawy">Sherif A. El-Kafrawy</name><affiliation><nlm:aff id="aff1"></nlm:aff></affiliation></author><author><name sortKey="Sohrab, Sayed Sartaj" sort="Sohrab, Sayed Sartaj" uniqKey="Sohrab S" first="Sayed Sartaj" last="Sohrab">Sayed Sartaj Sohrab</name><affiliation><nlm:aff id="aff1"></nlm:aff></affiliation></author><author><name sortKey="Aburizaiza, Asad S" sort="Aburizaiza, Asad S" uniqKey="Aburizaiza A" first="Asad S." last="Aburizaiza">Asad S. Aburizaiza</name><affiliation><nlm:aff id="aff4"></nlm:aff></affiliation></author><author><name sortKey="Farraj, Suha A" sort="Farraj, Suha A" uniqKey="Farraj S" first="Suha A." last="Farraj">Suha A. Farraj</name><affiliation><nlm:aff id="aff1"></nlm:aff></affiliation></author><author><name sortKey="Hassan, Ahmed M" sort="Hassan, Ahmed M" uniqKey="Hassan A" first="Ahmed M." last="Hassan">Ahmed M. Hassan</name><affiliation><nlm:aff id="aff1"></nlm:aff></affiliation></author><author><name sortKey="Al Saeed, Muneera S" sort="Al Saeed, Muneera S" uniqKey="Al Saeed M" first="Muneera S." last="Al-Saeed">Muneera S. Al-Saeed</name><affiliation><nlm:aff id="aff1"></nlm:aff></affiliation></author><author><name sortKey="Jamjoom, Ghazi A" sort="Jamjoom, Ghazi A" uniqKey="Jamjoom G" first="Ghazi A." last="Jamjoom">Ghazi A. Jamjoom</name><affiliation><nlm:aff id="aff1"></nlm:aff></affiliation></author><author><name sortKey="Madani, Tariq A" sort="Madani, Tariq A" uniqKey="Madani T" first="Tariq A." last="Madani">Tariq A. Madani</name></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">25053787</idno><idno type="pmc">4120199</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4120199</idno><idno type="RBID">PMC:4120199</idno><idno type="doi">10.1128/mBio.01450-14</idno><date when="2014">2014</date><idno type="wicri:Area/Pmc/Corpus">000755</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000755</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Detection of the Middle East Respiratory Syndrome Coronavirus Genome in an Air Sample Originating from a Camel Barn Owned by an Infected Patient</title><author><name sortKey="Azhar, Esam I" sort="Azhar, Esam I" uniqKey="Azhar E" first="Esam I." last="Azhar">Esam I. Azhar</name></author><author><name sortKey="Hashem, Anwar M" sort="Hashem, Anwar M" uniqKey="Hashem A" first="Anwar M." last="Hashem">Anwar M. Hashem</name></author><author><name sortKey="El Kafrawy, Sherif A" sort="El Kafrawy, Sherif A" uniqKey="El Kafrawy S" first="Sherif A." last="El-Kafrawy">Sherif A. El-Kafrawy</name><affiliation><nlm:aff id="aff1"></nlm:aff></affiliation></author><author><name sortKey="Sohrab, Sayed Sartaj" sort="Sohrab, Sayed Sartaj" uniqKey="Sohrab S" first="Sayed Sartaj" last="Sohrab">Sayed Sartaj Sohrab</name><affiliation><nlm:aff id="aff1"></nlm:aff></affiliation></author><author><name sortKey="Aburizaiza, Asad S" sort="Aburizaiza, Asad S" uniqKey="Aburizaiza A" first="Asad S." last="Aburizaiza">Asad S. Aburizaiza</name><affiliation><nlm:aff id="aff4"></nlm:aff></affiliation></author><author><name sortKey="Farraj, Suha A" sort="Farraj, Suha A" uniqKey="Farraj S" first="Suha A." last="Farraj">Suha A. Farraj</name><affiliation><nlm:aff id="aff1"></nlm:aff></affiliation></author><author><name sortKey="Hassan, Ahmed M" sort="Hassan, Ahmed M" uniqKey="Hassan A" first="Ahmed M." last="Hassan">Ahmed M. Hassan</name><affiliation><nlm:aff id="aff1"></nlm:aff></affiliation></author><author><name sortKey="Al Saeed, Muneera S" sort="Al Saeed, Muneera S" uniqKey="Al Saeed M" first="Muneera S." last="Al-Saeed">Muneera S. Al-Saeed</name><affiliation><nlm:aff id="aff1"></nlm:aff></affiliation></author><author><name sortKey="Jamjoom, Ghazi A" sort="Jamjoom, Ghazi A" uniqKey="Jamjoom G" first="Ghazi A." last="Jamjoom">Ghazi A. Jamjoom</name><affiliation><nlm:aff id="aff1"></nlm:aff></affiliation></author><author><name sortKey="Madani, Tariq A" sort="Madani, Tariq A" uniqKey="Madani T" first="Tariq A." last="Madani">Tariq A. Madani</name></author></analytic><series><title level="j">mBio</title><idno type="eISSN">2150-7511</idno><imprint><date when="2014">2014</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><title>ABSTRACT</title><p>Middle East respiratory syndrome coronavirus (MERS-CoV) is a novel betacoronavirus that has been circulating in the Arabian Peninsula since 2012 and causing severe respiratory infections in humans. While bats were suggested to be involved in human MERS-CoV infections, a direct link between bats and MERS-CoV is uncertain. On the other hand, serological and virological data suggest dromedary camels as the potential animal reservoirs of MERS-CoV. Recently, we isolated MERS-CoV from a camel and its infected owner and provided evidence for the direct transmission of MERS-CoV from the infected camel to the patient. Here, we extend this work and show that identical MERS-CoV RNA fragments were detected in an air sample collected from the same barn that sheltered the infected camel in our previous study. These data indicate that the virus was circulating in this farm concurrently with its detection in the camel and in the patient, which warrants further investigations for the possible airborne transmission of MERS-CoV.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Bermingham, A" uniqKey="Bermingham A">A Bermingham</name></author><author><name sortKey="Chand, Ma" uniqKey="Chand M">MA Chand</name></author><author><name sortKey="Brown, Cs" uniqKey="Brown C">CS Brown</name></author><author><name sortKey="Aarons, E" uniqKey="Aarons E">E Aarons</name></author><author><name sortKey="Tong, C" uniqKey="Tong C">C Tong</name></author><author><name sortKey="Langrish, C" uniqKey="Langrish C">C Langrish</name></author><author><name sortKey="Hoschler, K" uniqKey="Hoschler K">K Hoschler</name></author><author><name sortKey="Brown, K" uniqKey="Brown K">K Brown</name></author><author><name sortKey="Galiano, M" uniqKey="Galiano M">M 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<front><journal-meta><journal-id journal-id-type="nlm-ta">mBio</journal-id><journal-id journal-id-type="iso-abbrev">MBio</journal-id><journal-id journal-id-type="hwp">mbio</journal-id><journal-id journal-id-type="pmc">mbio</journal-id><journal-id journal-id-type="publisher-id">mBio</journal-id><journal-title-group><journal-title>mBio</journal-title></journal-title-group><issn pub-type="epub">2150-7511</issn><publisher><publisher-name>American Society of Microbiology</publisher-name><publisher-loc>1752 N St., N.W., Washington, DC</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">25053787</article-id><article-id pub-id-type="pmc">4120199</article-id><article-id pub-id-type="publisher-id">mBio01450-14</article-id><article-id pub-id-type="doi">10.1128/mBio.01450-14</article-id><article-categories><subj-group subj-group-type="heading"><subject>Observation</subject></subj-group></article-categories><title-group><article-title>Detection of the Middle East Respiratory Syndrome Coronavirus Genome in an Air Sample Originating from a Camel Barn Owned by an Infected Patient</article-title><alt-title>Detection of Airborne MERS-CoV Genome in a Camel Barn</alt-title></title-group><contrib-group><contrib contrib-type="author" corresp="yes"><name><surname>Azhar</surname><given-names>Esam I.</given-names></name><xref ref-type="aff" rid="aff1 aff2"><sup>a,b</sup></xref></contrib><contrib contrib-type="author"><name><surname>Hashem</surname><given-names>Anwar M.</given-names></name><xref ref-type="aff" rid="aff1 aff3"><sup>a,c</sup></xref></contrib><contrib contrib-type="author"><name><surname>El-Kafrawy</surname><given-names>Sherif A.</given-names></name><xref ref-type="aff" rid="aff1"><sup>a</sup></xref></contrib><contrib contrib-type="author"><name><surname>Sohrab</surname><given-names>Sayed Sartaj</given-names></name><xref ref-type="aff" rid="aff1"><sup>a</sup></xref></contrib><contrib contrib-type="author"><name><surname>Aburizaiza</surname><given-names>Asad S.</given-names></name><xref ref-type="aff" rid="aff4"><sup>d</sup></xref></contrib><contrib contrib-type="author"><name><surname>Farraj</surname><given-names>Suha A.</given-names></name><xref ref-type="aff" rid="aff1"><sup>a</sup></xref></contrib><contrib contrib-type="author"><name><surname>Hassan</surname><given-names>Ahmed M.</given-names></name><xref ref-type="aff" rid="aff1"><sup>a</sup></xref></contrib><contrib contrib-type="author"><name><surname>Al-Saeed</surname><given-names>Muneera S.</given-names></name><xref ref-type="aff" rid="aff1"><sup>a</sup></xref></contrib><contrib contrib-type="author"><name><surname>Jamjoom</surname><given-names>Ghazi A.</given-names></name><xref ref-type="aff" rid="aff1"><sup>a</sup></xref></contrib><contrib contrib-type="author"><name><surname>Madani</surname><given-names>Tariq A.</given-names></name><xref ref-type="aff" rid="aff5 aff6"><sup>e,f</sup></xref></contrib><aff id="aff1"><label><sup>a</sup></label>Special Infectious Agents Unit, King Fahd Medical Research Center, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia</aff><aff id="aff2"><label><sup>b</sup></label>Department of Medical Laboratory Technology, Faculty of Applied Medical Sciences, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia</aff><aff id="aff3"><label><sup>c</sup></label>Department of Medical Microbiology and Parasitology, Faculty of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia</aff><aff id="aff4"><label><sup>d</sup></label>Environmental Science Department, Faculty of Metrology, Environmental Science & Arid Land Agriculture, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia</aff><aff id="aff5"><label><sup>e</sup></label>Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia</aff><aff id="aff6"><label><sup>f</sup></label>Scientific Chair of Mohammad Hussein Alamoudi for Viral Hemorrhagic Fever, King Fahd Medical Research Center, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia</aff></contrib-group><author-notes><corresp id="cor1">Address correspondence to Esam I. Azhar, <email>eazhar@kau.edu.sa</email>.</corresp><fn fn-type="edited-by"><p><bold>Editor</bold> Michael Katze, University of Washington</p></fn></author-notes><pub-date pub-type="epub"><day>22</day><month>7</month><year>2014</year></pub-date><pub-date pub-type="collection"><season>Jul-Aug</season><year>2014</year></pub-date><volume>5</volume><issue>4</issue><elocation-id>e01450-14</elocation-id><history><date date-type="received"><day>10</day><month>6</month><year>2014</year></date><date date-type="accepted"><day>27</day><month>6</month><year>2014</year></date></history><permissions><copyright-statement>Copyright © 2014 Azhar et al.</copyright-statement><copyright-year>2014</copyright-year><copyright-holder>Azhar et al.</copyright-holder><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by-nc-sa/3.0/"><license-p>This is an open-access article distributed under the terms of the <ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by-nc-sa/3.0/">Creative Commons Attribution-Noncommercial-ShareAlike 3.0 Unported license</ext-link>, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original author and source are credited.</license-p></license></permissions><abstract><title>ABSTRACT</title><p>Middle East respiratory syndrome coronavirus (MERS-CoV) is a novel betacoronavirus that has been circulating in the Arabian Peninsula since 2012 and causing severe respiratory infections in humans. While bats were suggested to be involved in human MERS-CoV infections, a direct link between bats and MERS-CoV is uncertain. On the other hand, serological and virological data suggest dromedary camels as the potential animal reservoirs of MERS-CoV. Recently, we isolated MERS-CoV from a camel and its infected owner and provided evidence for the direct transmission of MERS-CoV from the infected camel to the patient. Here, we extend this work and show that identical MERS-CoV RNA fragments were detected in an air sample collected from the same barn that sheltered the infected camel in our previous study. These data indicate that the virus was circulating in this farm concurrently with its detection in the camel and in the patient, which warrants further investigations for the possible airborne transmission of MERS-CoV.</p></abstract><abstract abstract-type="executive-summary"><title>IMPORTANCE</title><p>This work clearly highlights the importance of continuous surveillance and infection control measures to control the global public threat of MERS-CoV. While current MERS-CoV transmission appears to be limited, we advise minimal contact with camels, especially for immunocompromised individuals, and the use of appropriate health, safety, and infection prevention and control measures when dealing with infected patients. Also, detailed clinical histories of any MERS-CoV cases with epidemiological and laboratory investigations carried out for any animal exposure must be considered to identify any animal source.</p></abstract><counts><page-count count="4"></page-count></counts><custom-meta-group><custom-meta><meta-name>cover-date</meta-name><meta-value>July/August 2014</meta-value></custom-meta></custom-meta-group></article-meta></front><body><sec id="h0.0"><title>Observation</title><p>The Middle East respiratory syndrome coronavirus (MERS-CoV) is a novel human pathogen associated with severe respiratory symptoms and renal failure (<xref rid="B1" ref-type="bibr">1</xref>, <xref rid="B2" ref-type="bibr">2</xref>). Since its emergence in 2012, there has been up to 536 laboratory-confirmed infections and 145 deaths in at least 17 countries in Asia, Africa, Europe, and North America (<xref rid="B3" ref-type="bibr">3</xref>). Most of these cases originated from countries in or around the Arabian Peninsula, particularly Saudi Arabia (<xref rid="B3" ref-type="bibr">3</xref>). The ability of this virus to infect those in close contact with an infected individual, such as family members and health care personnel, as well as the associated high mortality rate may represent a global public health threat (<xref rid="B4" ref-type="bibr">4</xref><xref ref-type="bibr" rid="B5">–</xref><xref rid="B7" ref-type="bibr">7</xref>).</p><p>Although the source of MERS-CoV and its mode of transmission are not fully understood, zoonotic transmission from an unknown reservoir or through an intermediate host to humans was suggested (<xref rid="B7" ref-type="bibr">7</xref><xref ref-type="bibr" rid="B8">–</xref><xref rid="B9" ref-type="bibr">9</xref>). Phylogenetic analysis showed that MERS-CoV belongs to bat-associated clade 2c betacoronaviruses (<xref rid="B2" ref-type="bibr">2</xref>, <xref rid="B9" ref-type="bibr">9</xref>, <xref rid="B10" ref-type="bibr">10</xref>). Detection of MERS-CoV-related viruses in Old World insectivorous bats from the family <italic>Vespertilionidae</italic> (<xref rid="B11" ref-type="bibr">11</xref>, <xref rid="B12" ref-type="bibr">12</xref>) and the isolation of small genomic fragments identical to the sequence of the Erasmus Medical Center (EMC)/2012 MERS-CoV Essen isolate (GenBank accession number <ext-link ext-link-type="NCBI:nucleotide" xlink:href="KC875821">KC875821</ext-link>) from a <italic>Taphozous perforatus</italic> bat in Saudi Arabia (<xref rid="B13" ref-type="bibr">13</xref>) suggested that insectivorous bats could be the original source of MERS-CoV. However, due to the limited direct contact between humans and bats and to the detection of neutralizing antibodies to MERS-CoV in dromedary camels from countries like Oman, the United Arab Emirates, Qatar, Egypt, and Saudi Arabia (<xref rid="B8" ref-type="bibr">8</xref>, <xref rid="B14" ref-type="bibr">14</xref><xref ref-type="bibr" rid="B15">–</xref><xref rid="B16" ref-type="bibr">16</xref>), dromedary camels were proposed to be involved in the cross-species transmission of MERS-CoV. This was further supported by the detection and partial genome sequencing of MERS-CoV RNA in samples collected from camels in Qatar and Saudi Arabia (<xref rid="B17" ref-type="bibr">17</xref>, <xref rid="B18" ref-type="bibr">18</xref>). Anti-MERS-CoV antibodies have also been detected in samples collected from dromedary camels in Saudi Arabia since 1992 (<xref rid="B18" ref-type="bibr">18</xref>). While these studies provide a convincing link between humans, camels, and MERS-CoV and indicate that MERS-CoV has been circulating in dromedary camels for a long time, they do not prove that camels passed the virus to humans.</p><p>Recently, several MERS-CoV isolates were obtained from nasal samples from dromedary camels in Saudi Arabia, and their consensus genome sequences were found to be similar to published human MERS-CoV sequences, supporting the role of dromedary camels in human MERS-CoV infections (<xref rid="B19" ref-type="bibr">19</xref>). In another report, we also provided evidence for the direct cross-species transmission of MERS-CoV from infected camels to their owner (<xref rid="B20" ref-type="bibr">20</xref>). Serological data suggested that the virus was circulating in the herd before infecting the patient. Additionally, we showed based on reverse transcription-PCR (RT-PCR), viral isolation, and full-genome sequencing that both MERS-CoV-Jeddah-human-1 (accession number <ext-link ext-link-type="NCBI:nucleotide" xlink:href="KF958702">KF958702</ext-link>) and MERS-CoV-Jeddah-camel-1 (accession number <ext-link ext-link-type="NCBI:nucleotide" xlink:href="KF917527">KF917527</ext-link>) isolates were 100% identical and contain characteristic mutations compared to other reported sequences, suggesting direct cross-species transmission from the camels to the patient.</p><p>Here, we tried to extend our previous study and to examine whether air could play a role in MERS-CoV transmission. To this end, three air samples were collected from the camels’ barn on three consecutive days as shown in <xref ref-type="fig" rid="fig1">Fig. 1</xref>. All samples were screened by real-time RT-PCR targeting the upstream region of the E gene (UpE region) of MERS-CoV. Interestingly, only the air sample collected on 7 November 2013, the same day that one of the nine camels in the same barn tested positive for MERS-CoV (<xref ref-type="fig" rid="fig1">Fig. 1</xref>), tested positive for the UpE region. The two other air samples were negative for UpE by RT-PCR. Two other confirmatory real-time RT-PCR assays targeting the open reading frame 1a (ORF1a) and ORF1b regions confirmed the UpE-positive result of the first air sample, as shown in <xref ref-type="table" rid="tab1">Table 1</xref>.</p><fig id="fig1" position="float"><label>FIG 1 </label><caption><p>Timeline of the main events in the study. ICU, intensive care unit; Abs, antibodies.</p></caption><graphic xlink:href="mbo0041419190001"></graphic></fig><table-wrap id="tab1" position="float"><label>TABLE 1 </label><caption><p>Results of a real-time RT-PCR for MERS-CoV RNA in air samples</p></caption><table frame="hsides" rules="groups"><thead valign="bottom"><tr><th rowspan="2" align="left" colspan="1">Day of air sample collection<sup><xref rid="ngtab1.1"><italic>a</italic></xref></sup></th><th colspan="3" align="left" rowspan="1">Threshold cycle of the real-time RT-PCR for detection of indicated MERS-CoV RNA<sup><xref rid="ngtab1.2"><italic>b</italic></xref></sup><hr></hr></th></tr><tr><th align="left" rowspan="1" colspan="1">UpE</th><th align="left" rowspan="1" colspan="1">ORF1a</th><th align="left" rowspan="1" colspan="1">ORF1b</th></tr></thead><tbody valign="top"><tr><td align="left" rowspan="1" colspan="1">1</td><td align="left" rowspan="1" colspan="1">34.7</td><td align="left" rowspan="1" colspan="1">34.4</td><td align="left" rowspan="1" colspan="1">33.3</td></tr><tr><td align="left" rowspan="1" colspan="1">2</td><td align="left" rowspan="1" colspan="1">ND</td><td align="left" rowspan="1" colspan="1">ND</td><td align="left" rowspan="1" colspan="1">ND</td></tr><tr><td align="left" rowspan="1" colspan="1">3</td><td align="left" rowspan="1" colspan="1">ND</td><td align="left" rowspan="1" colspan="1">ND</td><td align="left" rowspan="1" colspan="1">ND</td></tr></tbody></table><table-wrap-foot><fn id="ngtab1.1"><label><sup>a</sup></label><p>Samples were collected starting on 7 November 2013.</p></fn><fn id="ngtab1.2"><label><sup>b</sup></label><p>ND, not detected.</p></fn></table-wrap-foot></table-wrap><p>To further confirm these results, extracted RNA was subjected to partial genome sequencing of a 665-nucleotide (nt) segment in ORF1a (accession number <ext-link ext-link-type="NCBI:nucleotide" xlink:href="KJ740999">KJ740999</ext-link>), a 706-nt segment in the RNA-dependent RNA polymerase (RdRp) (accession number <ext-link ext-link-type="NCBI:nucleotide" xlink:href="KJ741000">KJ741000</ext-link>), a 688-nt segment in ORF1b (accession number <ext-link ext-link-type="NCBI:nucleotide" xlink:href="KJ741001">KJ741001</ext-link>), a 452-nt segment in UpE (accession number <ext-link ext-link-type="NCBI:nucleotide" xlink:href="KJ741002">KJ741002</ext-link>), and a 403-nt segment in the nucleocapsid (N) region (accession number <ext-link ext-link-type="NCBI:nucleotide" xlink:href="KJ741003">KJ741003</ext-link>) of the viral genome. Here, we confirmed the presence of MERS-CoV-specific sequences in the first air sample and found that these fragments are 100% identical to the corresponding regions in our previous isolates MERS-CoV-Jeddah-human-1 and MERS-CoV-Jeddah-camel-1, obtained from the patient and the infected camel in this barn, respectively (see <xref ref-type="supplementary-material" rid="figS1">Fig. S1</xref> in the supplemental material). Of note, further partial genome sequencing of a 697-nt segment of the viral RNA in the ORF1a region (accession number <ext-link ext-link-type="NCBI:nucleotide" xlink:href="KJ740998">KJ740998</ext-link>) from the air sample showed that the virus is identical to the original isolates obtained from the nasal samples collected from the patient and the infected camel, without the cell culture-adapted mutation (T10154C) observed in our earlier report (see <xref ref-type="supplementary-material" rid="figS2">Fig. S2</xref> in the supplemental material).</p><p>These data confirm our previous report (<xref rid="B20" ref-type="bibr">20</xref>) and show evidence for the presence of the airborne MERS-CoV genome in the same barn that was owned by the patient and housed the infected camels. The detection of viral RNA in the air sample collected on the same day that one of the camels’ samples tested positive for MERS-CoV and the fact that all genome sequences obtained from the air sample were identical to those from the camel and the patient samples suggest that the detected viral RNA originated from the camels.</p><p>MERS-CoV was reported to be more stable than influenza A H1N1 virus under different environmental conditions on surfaces or in aerosols (<xref rid="B21" ref-type="bibr">21</xref>). Specifically, viable MERS-CoV was recovered from surfaces after 48 h at 20°C and 40% relative humidity and after 24 h at 30°C and 30% relative humidity. Similarly, the viability of MERS-CoV decreased by 7% only in aerosols when the virus was incubated at 20°C with 40% relative humidity. However, virus isolation in cell culture was unsuccessful from the air sample collected in the current study, which may be due to a loss of viral infectivity in the collected air sample. Therefore, further studies are clearly needed to confirm the viability of MERS-CoV at different environmental conditions and to confirm its infectivity. Nonetheless, while other routes of transmission, such as droplet contact or fomite transmission, may be involved, the detection of MERS-CoV RNA in the air sample from this barn concurrently with its detection and isolation from the infected camel and the onset of symptoms in the patient warrants further investigations for the possible airborne transmission of MERS-CoV.</p><p>The shedding of MERS-CoV into the environment is supported by several reports, including report of the nosocomial infection of immunocompromised patients and the infection of those in close contact with patients, such as family members and health care workers (<xref rid="B4" ref-type="bibr">4</xref><xref ref-type="bibr" rid="B5">–</xref><xref rid="B7" ref-type="bibr">7</xref>). Furthermore, the detection of MERS-CoV-neutralizing antibodies and its genome in dromedary camels (<xref rid="B8" ref-type="bibr">8</xref>, <xref rid="B14" ref-type="bibr">14</xref><xref ref-type="bibr" rid="B15">–</xref><xref rid="B18" ref-type="bibr">18</xref>) clearly suggest that these animals may play an important role in MERS-CoV transmission to humans. To our knowledge, this is the first report on the possible risk of airborne transmission of MERS-CoV, especially to personnel working directly with infected patients or animals. Our data suggest that camels may be a source of infectious MERS-CoV, which can be transmitted to humans within confined spaces. These results also suggest that air sampling might be a useful approach to investigate the role of the airborne transmission of MERS-CoV spread and shedding. Further studies are urgently needed to fully understand the role of camels in the transmission of MERS-CoV and whether airborne transmission plays a role in MERS-CoV spread in order to implement control and prevention measures to prevent the transmission of this deadly virus.</p><sec id="h0.1"><title>Air sampling procedure.</title><p>Air samples were collected from the camels’ barn on three consecutive days, with day 1 (7 November 2013) being the same day that one of the nine camels was positive for MERS-CoV by real-time RT-PCR. Samples were collected using the MD8 airscan sampling device (Sartorius) and sterile gelatin filters (80 mm in diameter and 3-μm pore size; type 17528-80-ACD; Sartorius). Air was sampled at a speed of 50 liters/min for 20 min. Filters were dissolved in 5 ml viral transport medium (VTM) and stored at −80°C until analyzed.</p></sec><sec id="h0.2"><title>Real-time RT-PCR.</title><p>RNA was extracted from the dissolved filter solution using a QIAamp viral RNA minikit (Qiagen, Germany) according to manufacturer’s instructions. Eluted RNA was screened for the UpE region using the real-time RT-PCR assay on a Rotor-Gene Q real-time PCR machine (Qiagen, Germany) as previously described (<xref rid="B22" ref-type="bibr">22</xref>). Samples were also tested by real-time RT-PCR for the ORF1a and ORF1b regions for confirmation as described previously (<xref rid="B22" ref-type="bibr">22</xref>).</p></sec><sec id="h0.3"><title>Sequencing and alignment.</title><p>Further confirmation was performed by partially sequencing the UpE, ORF1a, ORF1b, RdRp, and N regions of the viral genome as per the WHO recommendations (<xref rid="B23" ref-type="bibr">23</xref>). In addition, one region containing unique mutations in isolates obtained in our previous report (<xref rid="B20" ref-type="bibr">20</xref>) were also sequenced. Sequencing was performed as described previously (<xref rid="B20" ref-type="bibr">20</xref>). Sequences were aligned with the genome of the MERS-CoV-Jeddah-camel-1isolate (KF917527) obtained in our pervious study using Geneious 7.0.6 software.</p></sec><sec id="h0.4"><title>Nucleotide sequence accession numbers.</title><p>Sequences obtained in this study were deposited in GenBank and given the following accession numbers: MERS-CoV-Jeddah-air-1-2014-ORF1a-partial cds-1, <ext-link ext-link-type="NCBI:nucleotide" xlink:href="KJ740998">KJ740998</ext-link>; MERS-CoV-Jeddah-air-1-2014-ORF1a-partial cds-2, <ext-link ext-link-type="NCBI:nucleotide" xlink:href="KJ740999">KJ740999</ext-link>; MERS-CoV-Jeddah-air-1-2014-RdRp-partial, <ext-link ext-link-type="NCBI:nucleotide" xlink:href="KJ741000">KJ741000</ext-link>; MERS-CoV-Jeddah-air-1-2014-ORF1b-partial, <ext-link ext-link-type="NCBI:nucleotide" xlink:href="KJ741001">KJ741001</ext-link>; MERS-CoV-Jeddah-air-1-2014-UpE-partial, <ext-link ext-link-type="NCBI:nucleotide" xlink:href="KJ741002">KJ741002</ext-link>; and MERS-CoV-Jeddah-air-1-2014-N protein-partial, <ext-link ext-link-type="NCBI:nucleotide" xlink:href="KJ741003">KJ741003</ext-link>.</p></sec></sec><sec sec-type="supplementary-material" id="h1"><title>SUPPLEMENTAL MATERIAL</title><supplementary-material id="figS1"><label>Figure S1</label><caption><p>Alignment of MERS-CoV genome sequences obtained from the air sample, the camel’s isolate, and the patient’s isolate. Partial genome sequences obtained from the air sample were aligned with corresponding regions from both isolates for the ORF1a (A), RdRp (B), ORF1b (C), UpE (D), and N (E) regions. Download </p></caption><media xlink:href="mbo004141919sf01.pdf"><caption><p>Figure S1, PDF file, 1.3 MB</p></caption></media></supplementary-material><supplementary-material id="figS2"><label>Figure S2</label><caption><p>The MERS-CoV genome in the air sample is identical to the original MERS-CoV-Jeddah-camel-1 isolate without the cell culture-adapted mutation. A partial genome sequence obtained from the air sample was aligned with the corresponding regions from the original camel nasal sample and the cell culture isolate sequences containing the cell culture-adapted mutation at position 10154. Download </p></caption><media xlink:href="mbo004141919sf02.pdf"><caption><p>Figure S2, PDF file, 0.1 MB</p></caption></media></supplementary-material></sec></body><back><fn-group><fn fn-type="other"><p><bold>Citation</bold> Azhar EI, Hashem AM, El-Kafrawy SA, Sohrab SS, Aburizaiza AS, Farraj SA, Hassan AM, Al-Saeed MS, Jamjoom GA, Madani TA. 2014. 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