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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Middle East Respiratory Syndrome Coronavirus (MERS-CoV) in Oman: Current Situation and Going Forward</title>
<author><name sortKey="Al Awaidy, Salah T" sort="Al Awaidy, Salah T" uniqKey="Al Awaidy S" first="Salah T." last="Al Awaidy">Salah T. Al Awaidy</name>
<affiliation><nlm:aff id="aff1">Office of Health Affairs, Ministry of Health, Muscat, Oman</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Khamis, Faryal" sort="Khamis, Faryal" uniqKey="Khamis F" first="Faryal" last="Khamis">Faryal Khamis</name>
<affiliation><nlm:aff id="aff2">Department of Infectious Diseases, Royal Hospital, Muscat, Oman</nlm:aff>
</affiliation>
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<idno type="pmid">31110623</idno>
<idno type="pmc">6505341</idno>
<idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6505341</idno>
<idno type="RBID">PMC:6505341</idno>
<idno type="doi">10.5001/omj.2019.36</idno>
<date when="2019">2019</date>
<idno type="wicri:Area/Pmc/Corpus">000850</idno>
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<sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Middle East Respiratory Syndrome Coronavirus (MERS-CoV) in Oman: Current Situation and Going Forward</title>
<author><name sortKey="Al Awaidy, Salah T" sort="Al Awaidy, Salah T" uniqKey="Al Awaidy S" first="Salah T." last="Al Awaidy">Salah T. Al Awaidy</name>
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</affiliation>
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<author><name sortKey="Khamis, Faryal" sort="Khamis, Faryal" uniqKey="Khamis F" first="Faryal" last="Khamis">Faryal Khamis</name>
<affiliation><nlm:aff id="aff2">Department of Infectious Diseases, Royal Hospital, Muscat, Oman</nlm:aff>
</affiliation>
</author>
</analytic>
<series><title level="j">Oman Medical Journal</title>
<idno type="ISSN">1999-768X</idno>
<idno type="eISSN">2070-5204</idno>
<imprint><date when="2019">2019</date>
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<pmc article-type="editorial"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">Oman Med J</journal-id>
<journal-id journal-id-type="iso-abbrev">Oman Med J</journal-id>
<journal-id journal-id-type="publisher-id">OMJ</journal-id>
<journal-title-group><journal-title>Oman Medical Journal</journal-title>
</journal-title-group>
<issn pub-type="ppub">1999-768X</issn>
<issn pub-type="epub">2070-5204</issn>
<publisher><publisher-name>OMJ</publisher-name>
</publisher>
</journal-meta>
<article-meta><article-id pub-id-type="pmid">31110623</article-id>
<article-id pub-id-type="pmc">6505341</article-id>
<article-id pub-id-type="publisher-id">OMJ-D-19-00063</article-id>
<article-id pub-id-type="doi">10.5001/omj.2019.36</article-id>
<article-categories><subj-group subj-group-type="heading"><subject>Editorial</subject>
</subj-group>
<subj-group subj-group-type="first-page-heading"><subject>Editorial</subject>
</subj-group>
</article-categories>
<title-group><article-title>Middle East Respiratory Syndrome Coronavirus (MERS-CoV) in Oman: Current Situation and Going Forward</article-title>
</title-group>
<contrib-group><contrib contrib-type="author"><name><surname>Al Awaidy</surname>
<given-names>Salah T.</given-names>
</name>
<xref ref-type="aff" rid="aff1"><sup>1</sup>
</xref>
<xref ref-type="corresp" rid="cor1">*</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Khamis</surname>
<given-names>Faryal</given-names>
</name>
<xref ref-type="aff" rid="aff2"><sup>2</sup>
</xref>
</contrib>
<aff id="aff1"><label>1</label>
Office of Health Affairs, Ministry of Health, Muscat, Oman</aff>
<aff id="aff2"><label>2</label>
Department of Infectious Diseases, Royal Hospital, Muscat, Oman</aff>
</contrib-group>
<author-notes><corresp id="cor1"><label>*</label>
<italic>Address correspondence and reprints request to: Salah T. Al Awaidy,</italic>
Office of Health Affairs, Ministry of Health, Muscat, Oman. E-mail: <italic><email xlink:href="salah.awaidy@gmail.com">salah.awaidy@gmail.com</email>
</italic>
</corresp>
</author-notes>
<pub-date pub-type="ppub"><month>5</month>
<year>2019</year>
</pub-date>
<volume>34</volume>
<issue>3</issue>
<fpage>181</fpage>
<lpage>183</lpage>
<history><date date-type="received"><day>10</day>
<month>3</month>
<year>2019</year>
</date>
<date date-type="accepted"><day>28</day>
<month>3</month>
<year>2019</year>
</date>
</history>
<permissions><copyright-statement>The OMJ is Published Bimonthly and Copyrighted 2019 by the OMSB.</copyright-statement>
<copyright-year>2019</copyright-year>
<copyright-holder>Oman Medical Specialty Board</copyright-holder>
<license license-type="open-access"><license-p>This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License (CC BY-NC 4.0).
(<ext-link ext-link-type="uri" xlink:href="https://creativecommons.org/licenses/by-nc/4.0/">https://creativecommons.org/licenses/by-nc/4.0/</ext-link>
).</license-p>
</license>
</permissions>
</article-meta>
</front>
<body><p>Middle East respiratory syndrome coronavirus (MERS-CoV) is a zoonotic viral respiratory illness caused by a novel betacoronavirus, which was first reported in Saudi Arabia in 2012.<sup><xref rid="r1" ref-type="bibr">1</xref>
</sup>
Since, MERS-CoV cases have been reported across the Arabian Peninsula, with occasional cases exported among travelers to other continents.<sup><xref rid="r2" ref-type="bibr">2</xref>
</sup>
Dromedary camels are a major reservoir host, in which the virus causes negligible disease.<sup><xref rid="r3" ref-type="bibr">3</xref>
</sup>
The virus can spread from dromedary camels to humans, through direct or indirect contact, causing significant morbidity and mortality.<sup><xref rid="r4" ref-type="bibr">4</xref>
</sup>
The clinical spectrum ranges from asymptomatic illness to septic shock and multiorgan failure.<sup><xref rid="r5" ref-type="bibr">5</xref>
</sup>
</p>
<p>As of January 2019, a total of 2298 laboratory-confirmed human cases of MERS-CoV from 27 countries have been reported, including 811 associated deaths giving a fatality rate of 35.2%. Eighty percent of cases have been reported from countries of the World Health Organization Eastern Mediterranean Region.<sup><xref rid="r2" ref-type="bibr">2</xref>
</sup>
</p>
<p>Human-to-human transmission of MERS-CoV has been described in several closed clusters of cases, including a small family cluster of mild disease.<sup><xref rid="r5" ref-type="bibr">5</xref>
</sup>
Two major healthcare-associated outbreaks due to super-spreading events led to massive numbers of cases and excessive morbidity and mortality in several countries.<sup><xref rid="r2" ref-type="bibr">2</xref>
,<xref rid="r6" ref-type="bibr">6</xref>
</sup>
Currently, there has been no evidence of sustained human-to-human transmission.<sup><xref rid="r2" ref-type="bibr">2</xref>
,<xref rid="r6" ref-type="bibr">6</xref>
</sup>
</p>
<p>In Oman, the first laboratory-confirmed case of MERS-CoV was reported in June 2013.<sup><xref rid="r7" ref-type="bibr">7</xref>
,<xref rid="r8" ref-type="bibr">8</xref>
</sup>
Up to March 2018, a total of 11 laboratory-confirmed cases have been reported sporadically.<sup><xref rid="r5" ref-type="bibr">5</xref>
</sup>
Ten (91%) cases were males with a mean age of 52±17.7 years (range: 20–75 years). Nine cases (82%) were primary and two cases (18%) were secondary. Patients were predominately from the North Al Batinah governorate (average rate: 1 per 100 000 population) with a fatality rate of 9%. Eight cases (73%) reported domestic camel exposure. Uncontrolled diabetes mellitus was the most common comorbidity in eight cases (73%). No secondary cases were reported among healthcare workers. Seroprevalence studies revealed MERS-CoV exposure among all sampled domestic camels across Oman.<sup><xref rid="r9" ref-type="bibr">9</xref>
,<xref rid="r10" ref-type="bibr">10</xref>
</sup>
</p>
<p>Between 27 January and 12 February 2019, a total of 13 additional human cases of laboratory-confirmed MERS-CoV using real-time polymerase chain reaction (RT-PCR) were reported in Oman. Eight (61%) and four (39%) cases were residents of North Al Batinah and A'South Sharqiyah governorates, respectively.<sup><xref rid="r11" ref-type="bibr">11</xref>
</sup>
The first cluster of five females (four from the same family), reported on 27 and 28 January 2019 were residents of North Al Batinah. Their mean age was 42±10.8 years (range: 30–59 years). Three of the five cases were probably secondary cases exposed to the index case who reported a history of direct contact with camels. None of the other cases had contact with camels. However, four cases resided on a farm where camels were kept, and the fifth case had a history of contact with one of the patient’s with MERS-CoV at the hospital. Two of the five cases died (40% fatality rate). Uncontrolled diabetes mellitus and hypertension were the most common comorbidities reported among three of the cases.</p>
<p>Between 12 and 18 February 2019, North Al Batinah and South A'Sharqiyah governorates each reported four additional cases (n = 8). These were sporadic cases with no epidemiological link to the previous cluster. Seven cases (88%) were Omani nationals. The mean age of cases was 55±17.5 years (range: 30–77 years) with an equal number of males and females. Cases from both governorates had a history of contact with camels (community). Two cases from South A'Sharqiyah were admitted to intensive care units. Uncontrolled diabetes mellitus, hypertension, and ischemic heart diseases were the most common comorbidities present and were reported among three cases including the deceased. The case fatality rate was 25%.</p>
<p>Through contact screening, two asymptomatic healthcare workers, one from each governate tested positive for MERS-CoV. Both were involved in the care of MERS-CoV patient (one was involved in intubation). A total of 60 familial contacts from both clusters and 119 healthcare worker contacts were screened for MERS-CoV and monitored for 14 days from the final date of exposure. All tested negative except two.</p>
<p>Between January and March, the season of dromedary camels breeding, races take place in these governorates. It is possible that during these months there is increased MERS-CoV circulation in the animal reservoir. The index cases were in contact with or resided on a farm where camels were kept. Individuals in close contact with dromedary camels are at an increased risk of acquiring the infection compared with the general population.<sup><xref rid="r12" ref-type="bibr">12</xref>
</sup>
The transmission from camels to humans can be via direct contact with camels through respiratory droplets or saliva, or the use of camel products.<sup><xref rid="r12" ref-type="bibr">12</xref>
</sup>
In the current outbreaks, we observed non-linked clusters and sporadic cases, in addition to nosocomial transmission in healthcare facilities with no evidence of sustained human-to-human transmission.<sup><xref rid="r13" ref-type="bibr">13</xref>
</sup>
</p>
<p>Although most MERS-CoV infected healthcare workers are asymptomatic,<sup><xref rid="r13" ref-type="bibr">13</xref>
</sup>
serious infections can occur, and healthcare workers might play a critical role in spreading the virus within their area of practice in healthcare facilities.<sup><xref rid="r14" ref-type="bibr">14</xref>
</sup>
Several factors could have contributed to the current transmission within healthcare facilities, including delays in suspicion and case detection, and providing close patient care without adherence to infection prevention and control (IPC) measures. Hospital transmission of MERS-CoV has been attributed to suboptimal infection control practices such as lack of personal protective equipment use, poor hand hygiene, delay in timely index case isolation, lack of negative pressure rooms, and performing aerosolizing procedures without appropriate personal protective equipment. Thus, there is an urgent need to reinforce the execution of basic IPC measures at all times in all healthcare facilities. Other pivotal interventions in reducing nosocomial transmission include prompt triaging, staff cohorting, and excluding non-essential staff and visitors.<sup><xref rid="r6" ref-type="bibr">6</xref>
,<xref rid="r15" ref-type="bibr">15</xref>
</sup>
</p>
<p>The current outbreak highlights the need for increased awareness among the public, particularly in individuals with comorbidities, who are at higher risk of complications and death. Awareness among this group should focus on avoiding close contact with camels or camel products, particularly in camel race festivals and breeding areas.<sup><xref rid="r12" ref-type="bibr">12</xref>
</sup>
</p>
<p>Stringent efforts are required to improve IPC to prevent transmission of the virus within healthcare facilities, to reduce mortality rates, and minimize community transmission. Institutional monitoring and training of healthcare workers remain the mainstay of disease prevention in healthcare facilities.<sup><xref rid="r15" ref-type="bibr">15</xref>
</sup>
Furthermore, urgent adoption of the 'One Health' strategic approach (the collaboration of multiple disciplines and sectors working locally, nationally, and globally to attain optimal health for people, animals, and the environment), including establishing a robust, timely, integrated surveillance system, and strengthening the governorates capabilities for rapid and efficient investigation of the disease is critical in minimizing the risk of disease spread.</p>
</body>
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