The first clusters of Middle East respiratory syndrome coronavirus in Oman: Time to act
Identifieur interne : 000E60 ( Pmc/Corpus ); précédent : 000E59; suivant : 000E61The first clusters of Middle East respiratory syndrome coronavirus in Oman: Time to act
Auteurs : Salah T. Al Awaidy ; Ali Abdullah Al Maqbali ; Iyad Omer ; Suad Al Mukhaini ; Mohammed Ali Al Risi ; Majed Sultan Al Maqbali ; Ali Al Reesi ; Mujahid Al Busaidi ; Fatma Hashim Al Hashmi ; Talib Khamis Al Maqbali ; Vidyanand Vaidya ; Elham Said Ahmed Al Risi ; Talib Khamis Al Maqbali ; Ahmed Abdullah Rashid ; Maryam Abdullah Hassan Al Beloshi ; Arash Etemadi ; Faryal KhamisSource :
- Journal of Infection and Public Health [ 1876-0341 ] ; 2020.
Abstract
Middle East respiratory syndrome coronavirus (MERS-CoV), is an emerging infectious disease of growing global importance. This review describes the latest MERS-CoV clusters and the first cases of nosocomial transmission within health care facilities in Oman. We have highlighted lessons learned and proposed steps to prevent healthcare-associated infections.
A descriptive analysis of MERS-CoV cases was conducted between January 23 and February 16, 2019. The data from officials and other published sources used.
Thirteen laboratory-confirmed cases of MERS-CoV were reported from three simultaneous clusters from two governorates without an epidemiological link between the clusters. Two clusters were reported from North Al Batinah Governorate, with nine cases (69%) and 1 cluster from South Ash Sharqiyah Governorate with four cases (31%). In total, four deaths were reported (case fatality rate 31%). Four cases (31%) reported were household contacts from the first cluster, 3 (23%) were nosocomial transmission in health care facilities (two for first and one from the second cluster) and 7 (54%) were community-acquired cases.
The first local clusters of MERS-CoV reported with evidence suggestive of healthcare and household-associated transmission. Early diagnosis and strict implementation of infection control measures remain fundamental in preventing and managing MERS-CoV infection.
Url:
DOI: 10.1016/j.jiph.2020.03.002
PubMed: NONE
PubMed Central: 7162632
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PMC:7162632Le document en format XML
<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">The first clusters of Middle East respiratory syndrome coronavirus in Oman: Time to act</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="aff0005">Office of Health Affairs, Ministry of Health, Oman</nlm:aff></affiliation></author><author><name sortKey="Al Maqbali, Ali Abdullah" sort="Al Maqbali, Ali Abdullah" uniqKey="Al Maqbali A" first="Ali Abdullah" last="Al Maqbali">Ali Abdullah Al Maqbali</name><affiliation><nlm:aff id="aff0010">Directorate Health Services, North Al Batinah Governorate, Ministry of Health, Oman</nlm:aff></affiliation></author><author><name sortKey="Omer, Iyad" sort="Omer, Iyad" uniqKey="Omer I" first="Iyad" last="Omer">Iyad Omer</name><affiliation><nlm:aff id="aff0015">Directorate Health Services, South Ash Sharqiyah Governorate, Ministry of Health, Oman</nlm:aff></affiliation></author><author><name sortKey="Al Mukhaini, Suad" sort="Al Mukhaini, Suad" uniqKey="Al Mukhaini S" first="Suad" last="Al Mukhaini">Suad Al Mukhaini</name><affiliation><nlm:aff id="aff0020">Sur Hospital, South ASharqiyah Governorate, Ministry of Health, Oman</nlm:aff></affiliation></author><author><name sortKey="Al Risi, Mohammed Ali" sort="Al Risi, Mohammed Ali" uniqKey="Al Risi M" first="Mohammed Ali" last="Al Risi">Mohammed Ali Al Risi</name><affiliation><nlm:aff id="aff0025">Sohar Hospital, North Al Batinah Governorate, Ministry of Health, Oman</nlm:aff></affiliation></author><author><name sortKey="Al Maqbali, Majed Sultan" sort="Al Maqbali, Majed Sultan" uniqKey="Al Maqbali M" first="Majed Sultan" last="Al Maqbali">Majed Sultan Al Maqbali</name><affiliation><nlm:aff id="aff0025">Sohar Hospital, North Al Batinah Governorate, Ministry of Health, Oman</nlm:aff></affiliation></author><author><name sortKey="Al Reesi, Ali" sort="Al Reesi, Ali" uniqKey="Al Reesi A" first="Ali" last="Al Reesi">Ali Al Reesi</name><affiliation><nlm:aff id="aff0025">Sohar Hospital, North Al Batinah Governorate, Ministry of Health, Oman</nlm:aff></affiliation></author><author><name sortKey="Al Busaidi, Mujahid" sort="Al Busaidi, Mujahid" uniqKey="Al Busaidi M" first="Mujahid" last="Al Busaidi">Mujahid Al Busaidi</name><affiliation><nlm:aff id="aff0030">Sultan Qabous University Hospital, Oman</nlm:aff></affiliation></author><author><name sortKey="Al Hashmi, Fatma Hashim" sort="Al Hashmi, Fatma Hashim" uniqKey="Al Hashmi F" first="Fatma Hashim" last="Al Hashmi">Fatma Hashim Al Hashmi</name><affiliation><nlm:aff id="aff0025">Sohar Hospital, North Al Batinah Governorate, Ministry of Health, Oman</nlm:aff></affiliation></author><author><name sortKey="Al Maqbali, Talib Khamis" sort="Al Maqbali, Talib Khamis" uniqKey="Al Maqbali T" first="Talib Khamis" last="Al Maqbali">Talib Khamis Al Maqbali</name><affiliation><nlm:aff id="aff0025">Sohar Hospital, North Al Batinah Governorate, Ministry of Health, Oman</nlm:aff></affiliation></author><author><name sortKey="Vaidya, Vidyanand" sort="Vaidya, Vidyanand" uniqKey="Vaidya V" first="Vidyanand" last="Vaidya">Vidyanand Vaidya</name><affiliation><nlm:aff id="aff0010">Directorate Health Services, North Al Batinah Governorate, Ministry of Health, Oman</nlm:aff></affiliation></author><author><name sortKey="Al Risi, Elham Said Ahmed" sort="Al Risi, Elham Said Ahmed" uniqKey="Al Risi E" first="Elham Said Ahmed" last="Al Risi">Elham Said Ahmed Al Risi</name><affiliation><nlm:aff id="aff0025">Sohar Hospital, North Al Batinah Governorate, Ministry of Health, Oman</nlm:aff></affiliation></author><author><name sortKey="Al Maqbali, Talib Khamis" sort="Al Maqbali, Talib Khamis" uniqKey="Al Maqbali T" first="Talib Khamis" last="Al Maqbali">Talib Khamis Al Maqbali</name><affiliation><nlm:aff id="aff0025">Sohar Hospital, North Al Batinah Governorate, Ministry of Health, Oman</nlm:aff></affiliation></author><author><name sortKey="Rashid, Ahmed Abdullah" sort="Rashid, Ahmed Abdullah" uniqKey="Rashid A" first="Ahmed Abdullah" last="Rashid">Ahmed Abdullah Rashid</name><affiliation><nlm:aff id="aff0025">Sohar Hospital, North Al Batinah Governorate, Ministry of Health, Oman</nlm:aff></affiliation></author><author><name sortKey="Al Beloshi, Maryam Abdullah Hassan" sort="Al Beloshi, Maryam Abdullah Hassan" uniqKey="Al Beloshi M" first="Maryam Abdullah Hassan" last="Al Beloshi">Maryam Abdullah Hassan Al Beloshi</name><affiliation><nlm:aff id="aff0025">Sohar Hospital, North Al Batinah Governorate, Ministry of Health, Oman</nlm:aff></affiliation></author><author><name sortKey="Etemadi, Arash" sort="Etemadi, Arash" uniqKey="Etemadi A" first="Arash" last="Etemadi">Arash Etemadi</name><affiliation><nlm:aff id="aff0025">Sohar Hospital, North Al Batinah Governorate, Ministry of Health, 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="aff0035">Royal Hospital, Ministry of Health, Oman</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmc">7162632</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7162632</idno><idno type="RBID">PMC:7162632</idno><idno type="doi">10.1016/j.jiph.2020.03.002</idno><idno type="pmid">NONE</idno><date when="2020">2020</date><idno type="wicri:Area/Pmc/Corpus">000E60</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000E60</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">The first clusters of Middle East respiratory syndrome coronavirus in Oman: Time to act</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="aff0005">Office of Health Affairs, Ministry of Health, Oman</nlm:aff></affiliation></author><author><name sortKey="Al Maqbali, Ali Abdullah" sort="Al Maqbali, Ali Abdullah" uniqKey="Al Maqbali A" first="Ali Abdullah" last="Al Maqbali">Ali Abdullah Al Maqbali</name><affiliation><nlm:aff id="aff0010">Directorate Health Services, North Al Batinah Governorate, Ministry of Health, Oman</nlm:aff></affiliation></author><author><name sortKey="Omer, Iyad" sort="Omer, Iyad" uniqKey="Omer I" first="Iyad" last="Omer">Iyad Omer</name><affiliation><nlm:aff id="aff0015">Directorate Health Services, South Ash Sharqiyah Governorate, Ministry of Health, Oman</nlm:aff></affiliation></author><author><name sortKey="Al Mukhaini, Suad" sort="Al Mukhaini, Suad" uniqKey="Al Mukhaini S" first="Suad" last="Al Mukhaini">Suad Al Mukhaini</name><affiliation><nlm:aff id="aff0020">Sur Hospital, South ASharqiyah Governorate, Ministry of Health, Oman</nlm:aff></affiliation></author><author><name sortKey="Al Risi, Mohammed Ali" sort="Al Risi, Mohammed Ali" uniqKey="Al Risi M" first="Mohammed Ali" last="Al Risi">Mohammed Ali Al Risi</name><affiliation><nlm:aff id="aff0025">Sohar Hospital, North Al Batinah Governorate, Ministry of Health, Oman</nlm:aff></affiliation></author><author><name sortKey="Al Maqbali, Majed Sultan" sort="Al Maqbali, Majed Sultan" uniqKey="Al Maqbali M" first="Majed Sultan" last="Al Maqbali">Majed Sultan Al Maqbali</name><affiliation><nlm:aff id="aff0025">Sohar Hospital, North Al Batinah Governorate, Ministry of Health, Oman</nlm:aff></affiliation></author><author><name sortKey="Al Reesi, Ali" sort="Al Reesi, Ali" uniqKey="Al Reesi A" first="Ali" last="Al Reesi">Ali Al Reesi</name><affiliation><nlm:aff id="aff0025">Sohar Hospital, North Al Batinah Governorate, Ministry of Health, Oman</nlm:aff></affiliation></author><author><name sortKey="Al Busaidi, Mujahid" sort="Al Busaidi, Mujahid" uniqKey="Al Busaidi M" first="Mujahid" last="Al Busaidi">Mujahid Al Busaidi</name><affiliation><nlm:aff id="aff0030">Sultan Qabous University Hospital, Oman</nlm:aff></affiliation></author><author><name sortKey="Al Hashmi, Fatma Hashim" sort="Al Hashmi, Fatma Hashim" uniqKey="Al Hashmi F" first="Fatma Hashim" last="Al Hashmi">Fatma Hashim Al Hashmi</name><affiliation><nlm:aff id="aff0025">Sohar Hospital, North Al Batinah Governorate, Ministry of Health, Oman</nlm:aff></affiliation></author><author><name sortKey="Al Maqbali, Talib Khamis" sort="Al Maqbali, Talib Khamis" uniqKey="Al Maqbali T" first="Talib Khamis" last="Al Maqbali">Talib Khamis Al Maqbali</name><affiliation><nlm:aff id="aff0025">Sohar Hospital, North Al Batinah Governorate, Ministry of Health, Oman</nlm:aff></affiliation></author><author><name sortKey="Vaidya, Vidyanand" sort="Vaidya, Vidyanand" uniqKey="Vaidya V" first="Vidyanand" last="Vaidya">Vidyanand Vaidya</name><affiliation><nlm:aff id="aff0010">Directorate Health Services, North Al Batinah Governorate, Ministry of Health, Oman</nlm:aff></affiliation></author><author><name sortKey="Al Risi, Elham Said Ahmed" sort="Al Risi, Elham Said Ahmed" uniqKey="Al Risi E" first="Elham Said Ahmed" last="Al Risi">Elham Said Ahmed Al Risi</name><affiliation><nlm:aff id="aff0025">Sohar Hospital, North Al Batinah Governorate, Ministry of Health, Oman</nlm:aff></affiliation></author><author><name sortKey="Al Maqbali, Talib Khamis" sort="Al Maqbali, Talib Khamis" uniqKey="Al Maqbali T" first="Talib Khamis" last="Al Maqbali">Talib Khamis Al Maqbali</name><affiliation><nlm:aff id="aff0025">Sohar Hospital, North Al Batinah Governorate, Ministry of Health, Oman</nlm:aff></affiliation></author><author><name sortKey="Rashid, Ahmed Abdullah" sort="Rashid, Ahmed Abdullah" uniqKey="Rashid A" first="Ahmed Abdullah" last="Rashid">Ahmed Abdullah Rashid</name><affiliation><nlm:aff id="aff0025">Sohar Hospital, North Al Batinah Governorate, Ministry of Health, Oman</nlm:aff></affiliation></author><author><name sortKey="Al Beloshi, Maryam Abdullah Hassan" sort="Al Beloshi, Maryam Abdullah Hassan" uniqKey="Al Beloshi M" first="Maryam Abdullah Hassan" last="Al Beloshi">Maryam Abdullah Hassan Al Beloshi</name><affiliation><nlm:aff id="aff0025">Sohar Hospital, North Al Batinah Governorate, Ministry of Health, Oman</nlm:aff></affiliation></author><author><name sortKey="Etemadi, Arash" sort="Etemadi, Arash" uniqKey="Etemadi A" first="Arash" last="Etemadi">Arash Etemadi</name><affiliation><nlm:aff id="aff0025">Sohar Hospital, North Al Batinah Governorate, Ministry of Health, 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="aff0035">Royal Hospital, Ministry of Health, Oman</nlm:aff></affiliation></author></analytic><series><title level="j">Journal of Infection and Public Health</title><idno type="ISSN">1876-0341</idno><idno type="eISSN">1876-035X</idno><imprint><date when="2020">2020</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec><title>Introduction</title><p>Middle East respiratory syndrome coronavirus (MERS-CoV), is an emerging infectious disease of growing global importance. This review describes the latest MERS-CoV clusters and the first cases of nosocomial transmission within health care facilities in Oman. We have highlighted lessons learned and proposed steps to prevent healthcare-associated infections.</p></sec><sec><title>Methods</title><p>A descriptive analysis of MERS-CoV cases was conducted between January 23 and February 16, 2019. The data from officials and other published sources used.</p></sec><sec><title>Results</title><p>Thirteen laboratory-confirmed cases of MERS-CoV were reported from three simultaneous clusters from two governorates without an epidemiological link between the clusters. Two clusters were reported from North Al Batinah Governorate, with nine cases (69%) and 1 cluster from South Ash Sharqiyah Governorate with four cases (31%). In total, four deaths were reported (case fatality rate 31%). Four cases (31%) reported were household contacts from the first cluster, 3 (23%) were nosocomial transmission in health care facilities (two for first and one from the second cluster) and 7 (54%) were community-acquired cases.</p></sec><sec><title>Conclusions</title><p>The first local clusters of MERS-CoV reported with evidence suggestive of healthcare and household-associated transmission. Early diagnosis and strict implementation of infection control measures remain fundamental in preventing and managing MERS-CoV infection.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Zaki, A M" uniqKey="Zaki A">A.M. Zaki</name></author><author><name sortKey="Van Boheemen, S" uniqKey="Van Boheemen S">S. van Boheemen</name></author><author><name sortKey="Bestebroer, T M" uniqKey="Bestebroer T">T.M. Bestebroer</name></author><author><name sortKey="Osterhaus, A D" uniqKey="Osterhaus A">A.D. Osterhaus</name></author><author><name sortKey="Fouchier, R A" uniqKey="Fouchier R">R.A. Fouchier</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Azhar, Esam I" uniqKey="Azhar E">Esam I. Azhar</name></author><author><name sortKey="El Kafrawy, Sherif A" uniqKey="El Kafrawy S">Sherif A. El-Kafrawy</name></author><author><name sortKey="Farraj, Suha A" uniqKey="Farraj S">Suha A. Farraj</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Conzade, R" uniqKey="Conzade R">R. Conzade</name></author><author><name sortKey="Grant, R" uniqKey="Grant R">R. Grant</name></author><author><name sortKey="Malik, M R" uniqKey="Malik M">M.R. Malik</name></author><author><name sortKey="Elkholy, A" uniqKey="Elkholy A">A. Elkholy</name></author><author><name sortKey="Elhakim, M" uniqKey="Elhakim M">M. Elhakim</name></author><author><name sortKey="Samhouri, D" uniqKey="Samhouri D">D. Samhouri</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Drosten, C" uniqKey="Drosten C">C. Drosten</name></author><author><name sortKey="Muth, D" uniqKey="Muth D">D. Muth</name></author><author><name sortKey="Corman, V M" uniqKey="Corman V">V.M. Corman</name></author><author><name sortKey="Hussain, R" uniqKey="Hussain R">R. Hussain</name></author><author><name sortKey="Al Masri, M" uniqKey="Al Masri M">M. Al Masri</name></author><author><name sortKey="Hajomar, W" uniqKey="Hajomar W">W. HajOmar</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Hijawi, B" uniqKey="Hijawi B">B. Hijawi</name></author><author><name sortKey="Abdallat, M" uniqKey="Abdallat M">M. Abdallat</name></author><author><name sortKey="Sayaydeh, A" uniqKey="Sayaydeh A">A. Sayaydeh</name></author><author><name sortKey="Alqasrawi, S" uniqKey="Alqasrawi S">S. Alqasrawi</name></author><author><name sortKey="Haddadin, A" uniqKey="Haddadin A">A. Haddadin</name></author><author><name sortKey="Jaarour, N" uniqKey="Jaarour N">N. Jaarour</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Assiri, A" uniqKey="Assiri A">A. Assiri</name></author><author><name sortKey="Mcgeer, A" uniqKey="Mcgeer A">A. McGeer</name></author><author><name sortKey="Perl, T M" uniqKey="Perl T">T.M. Perl</name></author><author><name sortKey="Price, C S" uniqKey="Price C">C.S. Price</name></author><author><name sortKey="Al Rabeeah, A A" uniqKey="Al Rabeeah A">A.A. Al Rabeeah</name></author><author><name sortKey="Cummings, D A" uniqKey="Cummings D">D.A. Cummings</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Al Abdallat, M M" uniqKey="Al Abdallat M">M.M. Al-Abdallat</name></author><author><name sortKey="Payne, D C" uniqKey="Payne D">D.C. Payne</name></author><author><name sortKey="Alqasrawi, S" uniqKey="Alqasrawi S">S. Alqasrawi</name></author><author><name sortKey="Rha, B" uniqKey="Rha B">B. Rha</name></author><author><name sortKey="Tohme, R A" uniqKey="Tohme R">R.A. Tohme</name></author><author><name sortKey="Abedi, G R" uniqKey="Abedi G">G.R. Abedi</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Al Hosani, F I" uniqKey="Al Hosani F">F.I. Al Hosani</name></author><author><name sortKey="Pringle, K" uniqKey="Pringle K">K. Pringle</name></author><author><name sortKey="Al Mulla, M" uniqKey="Al Mulla M">M. Al Mulla</name></author><author><name sortKey="Kim, L" uniqKey="Kim L">L. Kim</name></author><author><name sortKey="Pham, H" uniqKey="Pham H">H. Pham</name></author><author><name sortKey="Alami, N N" uniqKey="Alami N">N.N. Alami</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Park, H Y" uniqKey="Park H">H.Y. Park</name></author><author><name sortKey="Lee, E J" uniqKey="Lee E">E.J. Lee</name></author><author><name sortKey="Ryu, Y W" uniqKey="Ryu Y">Y.W. Ryu</name></author><author><name sortKey="Kim, Y" uniqKey="Kim Y">Y. Kim</name></author><author><name sortKey="Kim, H" uniqKey="Kim H">H. Kim</name></author><author><name sortKey="Lee, H" uniqKey="Lee H">H. Lee</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Omrani, A S" uniqKey="Omrani A">A.S. Omrani</name></author><author><name sortKey="Abdul Matin, M" uniqKey="Abdul Matin M">M. Abdul Matin</name></author><author><name sortKey="Haddad, Q" uniqKey="Haddad Q">Q. Haddad</name></author><author><name sortKey="Al Nakhli, D" uniqKey="Al Nakhli D">D. Al-Nakhli</name></author><author><name sortKey="Memish, Z A" uniqKey="Memish Z">Z.A. Memish</name></author><author><name sortKey="Albarraka, A M" uniqKey="Albarraka A">A.M. Albarraka</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Oboho, I K" uniqKey="Oboho I">I.K. Oboho</name></author><author><name sortKey="Tomczyk, S M" uniqKey="Tomczyk S">S.M. Tomczyk</name></author><author><name sortKey="Al Asmari, A M" uniqKey="Al Asmari A">A.M. Al-Asmari</name></author><author><name sortKey="Banjar, A A" uniqKey="Banjar A">A.A. Banjar</name></author><author><name sortKey="Al Mugti, H" uniqKey="Al Mugti H">H. Al-Mugti</name></author><author><name sortKey="Aloraini, M S" uniqKey="Aloraini M">M.S. Aloraini</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Killerby, M E" uniqKey="Killerby M">M.E. Killerby</name></author><author><name sortKey="Biggs, H M" uniqKey="Biggs H">H.M. Biggs</name></author><author><name sortKey="Midgley, C M" uniqKey="Midgley C">C.M. Midgley</name></author><author><name sortKey="Gerber, S I" uniqKey="Gerber S">S.I. Gerber</name></author><author><name sortKey="Watson, J T" uniqKey="Watson J">J.T. Watson</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Van Kerkhove, M D" uniqKey="Van Kerkhove M">M.D. Van Kerkhove</name></author><author><name sortKey="Alaswad, S" uniqKey="Alaswad S">S. Alaswad</name></author><author><name sortKey="Assiri, A" uniqKey="Assiri A">A. Assiri</name></author><author><name sortKey="Perera, R A P M" uniqKey="Perera R">R.A.P.M. Perera</name></author><author><name sortKey="Peiris, M" uniqKey="Peiris M">M. Peiris</name></author><author><name sortKey="El Bushra, H E" uniqKey="El Bushra H">H.E. El Bushra</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Al Hosani, F I" uniqKey="Al Hosani F">F.I. Al Hosani</name></author><author><name sortKey="Kim, L" uniqKey="Kim L">L. Kim</name></author><author><name sortKey="Khudhair, A" uniqKey="Khudhair A">A. Khudhair</name></author><author><name sortKey="Pham, H" uniqKey="Pham H">H. Pham</name></author><author><name sortKey="Al Mulla, M" uniqKey="Al Mulla M">M. Al Mulla</name></author><author><name sortKey="Al Bandar, Z" uniqKey="Al Bandar Z">Z. Al Bandar</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Hui, D S" uniqKey="Hui D">D.S. Hui</name></author><author><name sortKey="Azhar, E I" uniqKey="Azhar E">E.I. Azhar</name></author><author><name sortKey="Kim, Y J" uniqKey="Kim Y">Y.-J. Kim</name></author><author><name sortKey="Memish, Z A" uniqKey="Memish Z">Z.A. Memish</name></author><author><name sortKey="Oh, M D" uniqKey="Oh M">M.-d. Oh</name></author><author><name sortKey="Zumla, A" uniqKey="Zumla A">A. Zumla</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Arwady, M A" uniqKey="Arwady M">M.A. Arwady</name></author><author><name sortKey="Alraddadi, B" uniqKey="Alraddadi B">B. Alraddadi</name></author><author><name sortKey="Basler, C" uniqKey="Basler C">C. Basler</name></author><author><name sortKey="Azhar, E I" uniqKey="Azhar E">E.I. Azhar</name></author><author><name sortKey="Abuelzein, E" uniqKey="Abuelzein E">E. Abuelzein</name></author><author><name sortKey="Sindy, A I" uniqKey="Sindy A">A.I. Sindy</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Drosten, C" uniqKey="Drosten C">C. Drosten</name></author><author><name sortKey="Meyer, B" uniqKey="Meyer B">B. Meyer</name></author><author><name sortKey="Muller, M A" uniqKey="Muller M">M.A. Müller</name></author><author><name sortKey="Corman, V M" uniqKey="Corman V">V.M. Corman</name></author><author><name sortKey="Al Masri, M" uniqKey="Al Masri M">M. Al-Masri</name></author><author><name sortKey="Hossain, R" uniqKey="Hossain R">R. Hossain</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Jahan, Firdous" uniqKey="Jahan F">Firdous Jahan</name></author><author><name sortKey="Maqbali, Ali Abdullah Al" uniqKey="Maqbali A">Ali Abdullah Al Maqbali</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Awaidy, Salah T Al" uniqKey="Awaidy S">Salah T. Al Awaidy</name></author><author><name sortKey="Khamis, Faryal" uniqKey="Khamis F">Faryal Khamis</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Reusken, C B E M" uniqKey="Reusken C">C.B.E.M. Reusken</name></author><author><name sortKey="Haagmans, B L" uniqKey="Haagmans B">B.L. Haagmans</name></author><author><name sortKey="Muller, M A" uniqKey="Muller M">M.A. Müller</name></author><author><name sortKey="Gutierrez, C" uniqKey="Gutierrez C">C. Gutierrez</name></author><author><name sortKey="Godeke, G J" uniqKey="Godeke G">G.J. Godeke</name></author><author><name sortKey="Meyer, B" uniqKey="Meyer B">B. Meyer</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Sikkema, R S" uniqKey="Sikkema R">R.S. Sikkema</name></author><author><name sortKey="Farag, E A B A" uniqKey="Farag E">E.A.B.A. Farag</name></author><author><name sortKey="Islam, M" uniqKey="Islam M">M. Islam</name></author><author><name sortKey="Atta, M" uniqKey="Atta M">M. Atta</name></author><author><name sortKey="Reusken, C B E M" uniqKey="Reusken C">C.B.E.M. Reusken</name></author><author><name sortKey="Al Hajri, M M" uniqKey="Al Hajri M">M.M. Al-Hajri</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Al Abaidani, I S" uniqKey="Al Abaidani I">I.S. Al Abaidani</name></author><author><name sortKey="Al Maani, A S" uniqKey="Al Maani A">A.S. Al Maani</name></author><author><name sortKey="Al Kindy, H S" uniqKey="Al Kindy H">H.S. Al Kindy</name></author><author><name sortKey="Al Jardani, A K" uniqKey="Al Jardani A">A.K. Al-Jardani</name></author><author><name sortKey="Abdel Hady, D M" uniqKey="Abdel Hady D">D.M. Abdel-Hady</name></author><author><name sortKey="Zayed, B E" uniqKey="Zayed B">B.E. Zayed</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Balkhair, A" uniqKey="Balkhair A">A. Balkhair</name></author><author><name sortKey="Al Maamari, K" uniqKey="Al Maamari K">K. Al Maamari</name></author><author><name sortKey="Ba Alawi, F" uniqKey="Ba Alawi F">F. Ba Alawi</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Nassar, M S" uniqKey="Nassar M">M.S. Nassar</name></author><author><name sortKey="Bakhrebah, M A" uniqKey="Bakhrebah M">M.A. Bakhrebah</name></author><author><name sortKey="Meo, S A" uniqKey="Meo S">S.A. Meo</name></author><author><name sortKey="Alsuabey, M S" uniqKey="Alsuabey M">M.S. Alsuabey</name></author><author><name sortKey="Zaher, W A" uniqKey="Zaher W">W.A. Zaher</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Al Harthy, K" uniqKey="Al Harthy K">K. Al Harthy</name></author><author><name sortKey="Al Maani, A" uniqKey="Al Maani A">A. Al Maani</name></author><author><name sortKey="Elsheikh, M" uniqKey="Elsheikh M">M. Elsheikh</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Ghazal, H S" uniqKey="Ghazal H">H.S. Ghazal</name></author><author><name sortKey="Ghazal, S" uniqKey="Ghazal S">S. Ghazal</name></author><author><name sortKey="Alharbi, T M" uniqKey="Alharbi T">T.M. Alharbi</name></author><author><name sortKey="Al Nujaidi, M" uniqKey="Al Nujaidi M">M. Al Nujaidi</name></author><author><name sortKey="Memish, Z A" uniqKey="Memish Z">Z.A. Memish</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Al Tawfiq, J A" uniqKey="Al Tawfiq J">J.A. Al-Tawfiq</name></author><author><name sortKey="Omrani, A S" uniqKey="Omrani A">A.S. Omrani</name></author><author><name sortKey="Memish, Z A" uniqKey="Memish Z">Z.A. Memish</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Al Tawfiq, J A" uniqKey="Al Tawfiq J">J.A. Al-Tawfiq</name></author><author><name sortKey="Memish, Z A" uniqKey="Memish Z">Z.A. Memish</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Al Tawfiq, J A" uniqKey="Al Tawfiq J">J.A. Al-Tawfiq</name></author><author><name sortKey="Memish, Z A" uniqKey="Memish Z">Z.A. Memish</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="World Health Organization" uniqKey="World Health Organization">World Health Organization</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Abroug, Fekri" uniqKey="Abroug F">Fekri Abroug</name></author><author><name sortKey="Slim, Amine" uniqKey="Slim A">Amine Slim</name></author><author><name sortKey="Ouanes Besbes, Lamia" uniqKey="Ouanes Besbes L">Lamia Ouanes-Besbes</name></author><author><name sortKey="Kacem, Mohamed Ali Hadj" uniqKey="Kacem M">Mohamed-Ali Hadj Kacem</name></author><author><name sortKey="Dachraoui, Fahmi" uniqKey="Dachraoui F">Fahmi Dachraoui</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Sikkema, R S" uniqKey="Sikkema R">R.S. Sikkema</name></author><author><name sortKey="Farag, E A" uniqKey="Farag E">E.A. Farag</name></author><author><name sortKey="Himatt, S" uniqKey="Himatt S">S. Himatt</name></author><author><name sortKey="Ibrahim, A K" uniqKey="Ibrahim A">A.K. Ibrahim</name></author><author><name sortKey="Al Romaihi, H" uniqKey="Al Romaihi H">H. Al-Romaihi</name></author><author><name sortKey="Al Marri, S A" uniqKey="Al Marri S">S.A. Al-Marri</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Al Tawfiq, J A" uniqKey="Al Tawfiq J">J.A. Al-Tawfiq</name></author><author><name sortKey="Abdrabalnabi, R" uniqKey="Abdrabalnabi R">R. Abdrabalnabi</name></author><author><name sortKey="Taher, A" uniqKey="Taher A">A. Taher</name></author><author><name sortKey="Mathew, S" uniqKey="Mathew S">S. Mathew</name></author><author><name sortKey="Rahman, K A" uniqKey="Rahman K">K.A. Rahman</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Alfaraj, S H" uniqKey="Alfaraj S">S.H. Alfaraj</name></author><author><name sortKey="Al Tawfiq, J A" uniqKey="Al Tawfiq J">J.A. Al Tawfiq</name></author><author><name sortKey="Altuwaijri, T A" uniqKey="Altuwaijri T">T.A. Altuwaijri</name></author><author><name sortKey="Alanazi, M" uniqKey="Alanazi M">M. Alanazi</name></author><author><name sortKey="Alzahrani, N" uniqKey="Alzahrani N">N. Alzahrani</name></author><author><name sortKey="Memish, Z A" uniqKey="Memish Z">Z.A. Memish</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Ki, M" uniqKey="Ki M">M. Ki</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Cowling, B" uniqKey="Cowling B">B. Cowling</name></author><author><name sortKey="Park, M" uniqKey="Park M">M. Park</name></author><author><name sortKey="Fang, V" uniqKey="Fang V">V. Fang</name></author><author><name sortKey="Wu, P" uniqKey="Wu P">P. Wu</name></author><author><name sortKey="Leung, G M" uniqKey="Leung G">G.M. Leung</name></author><author><name sortKey="Wu, J T" uniqKey="Wu J">J.T. Wu</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct></listBibl></div1></back></TEI><pmc article-type="research-article"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">J Infect Public Health</journal-id><journal-id journal-id-type="iso-abbrev">J Infect Public Health</journal-id><journal-title-group><journal-title>Journal of Infection and Public Health</journal-title></journal-title-group><issn pub-type="ppub">1876-0341</issn><issn pub-type="epub">1876-035X</issn><publisher><publisher-name>The Authors. Published by Elsevier Ltd on behalf of King Saud Bin Abdulaziz University for Health Sciences.</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmc">7162632</article-id><article-id pub-id-type="publisher-id">S1876-0341(20)30402-0</article-id><article-id pub-id-type="doi">10.1016/j.jiph.2020.03.002</article-id><article-categories><subj-group subj-group-type="heading"><subject>Article</subject></subj-group></article-categories><title-group><article-title>The first clusters of Middle East respiratory syndrome coronavirus in Oman: Time to act</article-title></title-group><contrib-group><contrib contrib-type="author" id="aut0005"><name><surname>Al Awaidy</surname><given-names>Salah T.</given-names></name><email>salah.awaidy@gmail.com</email><xref rid="aff0005" ref-type="aff">a</xref><xref rid="cor0005" ref-type="corresp">⁎</xref></contrib><contrib contrib-type="author" id="aut0010"><name><surname>Al Maqbali</surname><given-names>Ali Abdullah</given-names></name><xref rid="aff0010" ref-type="aff">b</xref></contrib><contrib contrib-type="author" id="aut0015"><name><surname>Omer</surname><given-names>Iyad</given-names></name><xref rid="aff0015" ref-type="aff">c</xref></contrib><contrib contrib-type="author" id="aut0020"><name><surname>Al Mukhaini</surname><given-names>Suad</given-names></name><xref rid="aff0020" ref-type="aff">d</xref></contrib><contrib contrib-type="author" id="aut0025"><name><surname>Al Risi</surname><given-names>Mohammed Ali</given-names></name><xref rid="aff0025" ref-type="aff">e</xref></contrib><contrib contrib-type="author" id="aut0030"><name><surname>Al Maqbali</surname><given-names>Majed Sultan</given-names></name><xref rid="aff0025" ref-type="aff">e</xref></contrib><contrib contrib-type="author" id="aut0035"><name><surname>Al Reesi</surname><given-names>Ali</given-names></name><xref rid="aff0025" ref-type="aff">e</xref></contrib><contrib contrib-type="author" id="aut0040"><name><surname>Al Busaidi</surname><given-names>Mujahid</given-names></name><xref rid="aff0030" ref-type="aff">f</xref></contrib><contrib contrib-type="author" id="aut0045"><name><surname>Al Hashmi</surname><given-names>Fatma Hashim</given-names></name><xref rid="aff0025" ref-type="aff">e</xref></contrib><contrib contrib-type="author" id="aut0050"><name><surname>Al Maqbali</surname><given-names>Talib Khamis</given-names></name><xref rid="aff0025" ref-type="aff">e</xref></contrib><contrib contrib-type="author" id="aut0055"><name><surname>Vaidya</surname><given-names>Vidyanand</given-names></name><xref rid="aff0010" ref-type="aff">b</xref></contrib><contrib contrib-type="author" id="aut0060"><name><surname>Al Risi</surname><given-names>Elham Said Ahmed</given-names></name><xref rid="aff0025" ref-type="aff">e</xref></contrib><contrib contrib-type="author" id="aut0065"><name><surname>Al Maqbali</surname><given-names>Talib Khamis</given-names></name><xref rid="aff0025" ref-type="aff">e</xref></contrib><contrib contrib-type="author" id="aut0070"><name><surname>Rashid</surname><given-names>Ahmed Abdullah</given-names></name><xref rid="aff0025" ref-type="aff">e</xref></contrib><contrib contrib-type="author" id="aut0075"><name><surname>Al Beloshi</surname><given-names>Maryam Abdullah Hassan</given-names></name><xref rid="aff0025" ref-type="aff">e</xref></contrib><contrib contrib-type="author" id="aut0080"><name><surname>Etemadi</surname><given-names>Arash</given-names></name><xref rid="aff0025" ref-type="aff">e</xref></contrib><contrib contrib-type="author" id="aut0085"><name><surname>Khamis</surname><given-names>Faryal</given-names></name><email>khami001@gmail.com</email><xref rid="aff0035" ref-type="aff">g</xref><xref rid="cor0010" ref-type="corresp">⁎⁎</xref></contrib></contrib-group><aff id="aff0005"><label>a</label>Office of Health Affairs, Ministry of Health, Oman</aff><aff id="aff0010"><label>b</label>Directorate Health Services, North Al Batinah Governorate, Ministry of Health, Oman</aff><aff id="aff0015"><label>c</label>Directorate Health Services, South Ash Sharqiyah Governorate, Ministry of Health, Oman</aff><aff id="aff0020"><label>d</label>Sur Hospital, South ASharqiyah Governorate, Ministry of Health, Oman</aff><aff id="aff0025"><label>e</label>Sohar Hospital, North Al Batinah Governorate, Ministry of Health, Oman</aff><aff id="aff0030"><label>f</label>Sultan Qabous University Hospital, Oman</aff><aff id="aff0035"><label>g</label>Royal Hospital, Ministry of Health, Oman</aff><author-notes><corresp id="cor0005"><label>⁎</label>Corresponding author at: P.O. Box 393 PC 100, Muscat, Oman. <email>salah.awaidy@gmail.com</email></corresp><corresp id="cor0010"><label>⁎⁎</label>Corresponding author at: P.O. Box 1331 PC 111, Muscat Oman. <email>khami001@gmail.com</email></corresp></author-notes><pub-date pub-type="pmc-release"><day>16</day><month>4</month><year>2020</year></pub-date><pmc-comment> PMC Release delay is 0 months and 0 days and was based on .</pmc-comment>
<pub-date pub-type="epub"><day>16</day><month>4</month><year>2020</year></pub-date><history><date date-type="received"><day>12</day><month>2</month><year>2020</year></date><date date-type="accepted"><day>2</day><month>3</month><year>2020</year></date></history><permissions><copyright-statement>© 2020 The Authors</copyright-statement><copyright-year>2020</copyright-year><license><license-p>Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.</license-p></license></permissions><abstract id="abs0005"><sec><title>Introduction</title><p>Middle East respiratory syndrome coronavirus (MERS-CoV), is an emerging infectious disease of growing global importance. This review describes the latest MERS-CoV clusters and the first cases of nosocomial transmission within health care facilities in Oman. We have highlighted lessons learned and proposed steps to prevent healthcare-associated infections.</p></sec><sec><title>Methods</title><p>A descriptive analysis of MERS-CoV cases was conducted between January 23 and February 16, 2019. The data from officials and other published sources used.</p></sec><sec><title>Results</title><p>Thirteen laboratory-confirmed cases of MERS-CoV were reported from three simultaneous clusters from two governorates without an epidemiological link between the clusters. Two clusters were reported from North Al Batinah Governorate, with nine cases (69%) and 1 cluster from South Ash Sharqiyah Governorate with four cases (31%). In total, four deaths were reported (case fatality rate 31%). Four cases (31%) reported were household contacts from the first cluster, 3 (23%) were nosocomial transmission in health care facilities (two for first and one from the second cluster) and 7 (54%) were community-acquired cases.</p></sec><sec><title>Conclusions</title><p>The first local clusters of MERS-CoV reported with evidence suggestive of healthcare and household-associated transmission. Early diagnosis and strict implementation of infection control measures remain fundamental in preventing and managing MERS-CoV infection.</p></sec></abstract><kwd-group id="kwd0005"><title>Keywords</title><kwd>Middle East respiratory syndrome coronavirus</kwd><kwd>MERS</kwd><kwd>MERS-CoV</kwd><kwd>Healthcare associated transmission</kwd><kwd>Household-associated transmission</kwd><kwd>Nosocomial infection</kwd><kwd>Infection control</kwd><kwd>Oman</kwd></kwd-group></article-meta></front><body><sec id="sec0005"><title>Introduction</title><p id="par0005">The Middle East respiratory syndrome (MERS) is caused by a zoonotic respiratory pathogen, coronavirus, which causes a non-specific respiratory illness that was first reported in Saudi Arabia in 2012 [<xref rid="bib0005" ref-type="bibr">1</xref>]. Following reports of MERS-CoV infections from the Arabian Peninsula, cases were likewise reported from travelers visiting other continents [<xref rid="bib0010" ref-type="bibr">2</xref>]. Dromedary camels, in which the virus does not cause disease, are believed to be the major host reservoir [<xref rid="bib0015" ref-type="bibr">3</xref>,<xref rid="bib0020" ref-type="bibr">4</xref>]. The virus can spread from dromedary camels to humans through direct or indirect contact, causing significant morbidity and mortality [<xref rid="bib0020" ref-type="bibr">4</xref>]. The clinical spectrum ranges from asymptomatic illness to septic shock, multi-organ failure and death in severe cases [<xref rid="bib0025" ref-type="bibr">5</xref>]. Evidence suggests that the average incubation period in an infected human host is 5.5–6.5 days with a maximum of 10–14 days [<xref rid="bib0030" ref-type="bibr">6</xref>].</p><p id="par0010">As of the end of December 2019, a total of 2499 laboratory-confirmed human cases of MERS-CoV from 27 countries have been reported, with 861 associated deaths (fatality rate of 34.2%). Ninety percent of the cases have been reported from countries of the Eastern Mediterranean Region (EMR) by WHO (2). Eighty-four percent (1106) of total global cases were reported from Saudi Arabia and resulted in at least 770 related deaths with a case fatality rate of close to 37.2% [<xref rid="bib0010" ref-type="bibr">2</xref>].</p><p id="par0015">Limited human-to-human transmission of MERS-CoV has been described mostly in health care setting [<xref rid="bib0010" ref-type="bibr">2</xref>,<xref rid="bib0030" ref-type="bibr">[6]</xref>, <xref rid="bib0035" ref-type="bibr">[7]</xref>, <xref rid="bib0040" ref-type="bibr">[8]</xref>, <xref rid="bib0045" ref-type="bibr">[9]</xref>, <xref rid="bib0050" ref-type="bibr">[10]</xref>, <xref rid="bib0055" ref-type="bibr">[11]</xref>, <xref rid="bib0060" ref-type="bibr">[12]</xref>, <xref rid="bib0065" ref-type="bibr">[13]</xref>] and small household clusters of community-acquired cases, including a family cluster of mild disease [<xref rid="bib0070" ref-type="bibr">[14]</xref>, <xref rid="bib0075" ref-type="bibr">[15]</xref>, <xref rid="bib0080" ref-type="bibr">[16]</xref>, <xref rid="bib0085" ref-type="bibr">[17]</xref>, <xref rid="bib0090" ref-type="bibr">[18]</xref>, <xref rid="bib0095" ref-type="bibr">[19]</xref>]. Larger outbreaks have been reported in healthcare settings, which have led to multiple chains of limited transmission, as a result of contact with index cases or inadequate infection prevention and control measures causing excessive morbidity and mortality in several countries [<xref rid="bib0010" ref-type="bibr">2</xref>,<xref rid="bib0025" ref-type="bibr">[5]</xref>, <xref rid="bib0030" ref-type="bibr">[6]</xref>, <xref rid="bib0035" ref-type="bibr">[7]</xref>, <xref rid="bib0040" ref-type="bibr">[8]</xref>, <xref rid="bib0045" ref-type="bibr">[9]</xref>, <xref rid="bib0050" ref-type="bibr">[10]</xref>, <xref rid="bib0055" ref-type="bibr">[11]</xref>]. Currently, there is no evidence of sustained human-to-human transmission [<xref rid="bib0010" ref-type="bibr">2</xref>].</p><p id="par0020">In Oman, the first laboratory-confirmed case of MERS-CoV was reported in June 2013 [<xref rid="bib0030" ref-type="bibr">6</xref>,<xref rid="bib0040" ref-type="bibr">8</xref>,<xref rid="bib0100" ref-type="bibr">[20]</xref>, <xref rid="bib0105" ref-type="bibr">[21]</xref>, <xref rid="bib0110" ref-type="bibr">[22]</xref>]. Sporadic cases were then reported until March 2018, with limited human-to-human transmission and secondary transmission. No secondary cases were reported among health care workers (HCWs).</p><p id="par0025">In 2013, a countrywide MERS survey among dromedary camels showed MERS-CoV neutrilasing antibodies were detected in all (50) surveyed camels [<xref rid="bib0115" ref-type="bibr">23</xref>]. In addition, phylogenetic analysis and high MERS-CoV viral loads in dromedary camels suggested local zoonotic transmission through the respiratory route. However, MERS-CoV isolates from camels did not have sequences closely related to MERS-CoV strains recovered from human cases [<xref rid="bib0120" ref-type="bibr">24</xref>].</p><p id="par0030">This review describes the latest MERS-CoV clusters and the first cases of nosocomial transmission within health care facilities in Oman. We have highlighted lessons learned and proposed steps to prevent future community and healthcare-associated infections.</p></sec><sec id="sec0010"><title>Methodology</title><p id="par0035">Between January 23 and February 16, 2019, a review of the MERS-CoV data were collected from the following sources: the MOH Communicable Diseases Weekly Surveillance Updates, WHO/EMRO Weekly Epidemiological Monitor for MERS cluster in Oman [<xref rid="bib0125" ref-type="bibr">25</xref>]. The information collected included baseline demographic characteristics (time, place, gender, age, residency and nationality), risk factors including history of previous exposure to camels, co-morbidities, laboratory investigations, clinical management and outcomes including mortality rates. A comprehensive investigation of close contacts, including health care personnel who may have been exposed to patients infected with MERS-CoV was conducted. Close contacts were defined as any person who provided care for the patient, including a healthcare worker or family member, or had another similarly close physical contact, for example, someone with whom the patient had resided or visited [<xref rid="bib0130" ref-type="bibr">26</xref>]. Close contacts of confirmed or probable cases were identified and monitored for the appearance of respiratory symptoms for 14 days after their last exposure to the confirmed or suspected case, while the index case remained symptomatic. Any contact that became ill during that period of time was tested for MERS-CoV using real-time polymerase chain reaction (RT-PCR) [<xref rid="bib0135" ref-type="bibr">27</xref>] to detect viral RNA from patient blood samples. RT-PCR was also used to test the camels, starting with RNA extracted from nasal and conjunctive swabs. The ethical approval was obtained based on Ministry of Health regulation.</p></sec><sec id="sec0015"><title>Results</title><sec id="sec0020"><title>Cluster description</title><p id="par0040">Between January 23 and February 16, 2019, a total of 13 human cases of laboratory-confirmed MERS-CoV were reported in Oman [<xref rid="fig0005" ref-type="fig">Fig. 1</xref>]. Nine cases (69%) were residents of North Al Batinah, and four cases (31%) were from South Ash Sharqiyah Governorates (23) [<xref rid="fig0010" ref-type="fig">Fig. 2</xref>]. Eleven cases (85%) were Omani nationals.<fig id="fig0005"><label>Fig. 1</label><caption><p>MERS-CoV notified cases and death by year of report, Oman, 2013-2019.</p></caption><alt-text id="at0005">Fig. 1</alt-text><graphic xlink:href="gr1_lrg"></graphic></fig><fig id="fig0010"><label>Fig. 2</label><caption><p>MERS-CoV cases, by month of report and Governorate (province), Oman, 2013-2019.</p></caption><alt-text id="at0010">Fig. 2</alt-text><graphic xlink:href="gr2_lrg"></graphic></fig></p><p id="par0045">The first cluster of five females (Four from the same family), reported on January 23 and 28, 2019, were residents of North Al Batinah (<xref rid="fig0010" ref-type="fig">Fig. 2</xref>). Their median age was 42 ± SD 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 [<xref rid="bib0140" ref-type="bibr">28</xref>]. These secondary cases had neither a recent history of travel outside of Oman nor a history of a recent hospitalization or direct contact with camels. There is also a history of sleeping in an index case-patient’s room and spending time in the same room and assisting the possible index case during his illness. Three cases (60%) were admitted to ICU [<xref rid="tbl0005" ref-type="table">Table 1</xref>]. Two of the five cases died (Case fatality rate: 40%).<table-wrap position="float" id="tbl0005"><label>Table 1</label><caption><p>Demographic and clinical characteristics of clusters MERS-CoV cases, Oman, 2019.</p></caption><alt-text id="at0020">Table 1</alt-text><table frame="hsides" rules="groups"><thead><tr><th align="left">Characteristics</th><th align="left">SouthAsh Sharquia (1 cluster) (n = 4)</th><th align="left">North Al Batinah (2 clasters) (n = 9)</th><th align="left">Total, n (%) (n = 13)</th></tr></thead><tbody><tr><td align="left">Age (years)</td><td align="left"></td><td align="left"></td><td align="left"></td></tr><tr><td align="left"> 30–40</td><td align="left">1</td><td align="left">3</td><td align="left">4 (30)</td></tr><tr><td align="left"> 40–50</td><td align="left">1</td><td align="left">1</td><td align="left">2 (15)</td></tr><tr><td align="left"> 50−60</td><td align="left">0</td><td align="left">1</td><td align="left">1 (8)</td></tr><tr><td align="left"> ≥60</td><td align="left">2</td><td align="left">4</td><td align="left">6 (46)</td></tr><tr><td align="left">Gender</td><td align="left"></td><td align="left"></td><td align="left"></td></tr><tr><td align="left"> Male</td><td align="left">2</td><td align="left">7</td><td align="left">9 (69)</td></tr><tr><td align="left"> Female</td><td align="left">2</td><td align="left">2</td><td align="left">4 (31)</td></tr><tr><td align="left">Health Care Workers infected with MERS-CoV</td><td align="left">1</td><td align="left">1</td><td align="left">2 (15)</td></tr><tr><td align="left">Patients admitted to ICU</td><td align="left"></td><td align="left"></td><td align="left"></td></tr><tr><td align="left"> Yes</td><td align="left">3</td><td align="left">4</td><td align="left">7 (53)</td></tr><tr><td align="left"> No</td><td align="left">1</td><td align="left">5</td><td align="left">6 (47)</td></tr><tr><td align="left">Average number of days admitted</td><td colspan="3" align="left">15 days (Range 1−99days)</td></tr><tr><td align="left">Clinical outcome</td><td align="left"></td><td align="left"></td><td align="left"></td></tr><tr><td align="left"> Survived</td><td align="left">2</td><td align="left">7</td><td align="left">9 (69)</td></tr><tr><td align="left"> Died</td><td align="left">2</td><td align="left">2</td><td align="left">4 (31)</td></tr><tr><td align="left">Possible cause of death</td><td align="left"></td><td align="left"></td><td align="left"></td></tr><tr><td align="left"> Bronchopneumonia with Septic shock</td><td align="left">1</td><td align="left"></td><td align="left">1/4<xref rid="tblfn0005" ref-type="table-fn">*</xref> (25)</td></tr><tr><td align="left"> Septic shock</td><td align="left">1</td><td align="left"></td><td align="left">1/4<xref rid="tblfn0005" ref-type="table-fn">*</xref> (25)</td></tr><tr><td align="left"> Bronchopeumonia</td><td align="left"></td><td align="left">2</td><td align="left">2/4<xref rid="tblfn0005" ref-type="table-fn">*</xref> (50)</td></tr><tr><td align="left"> Multi-organ failure</td><td align="left"></td><td align="left">1</td><td align="left">1/4<xref rid="tblfn0005" ref-type="table-fn">*</xref> (25)</td></tr><tr><td align="left"> Heart failure</td><td align="left">1</td><td align="left"></td><td align="left">1/4<xref rid="tblfn0005" ref-type="table-fn">*</xref> (25)</td></tr><tr><td align="left">Comorbidities</td><td align="left"></td><td align="left"></td><td align="left"></td></tr><tr><td align="left"> DM</td><td align="left">2</td><td align="left">3</td><td align="left">5 (38)</td></tr><tr><td align="left"> HTN</td><td align="left">1</td><td align="left">5</td><td align="left">6 (46)</td></tr><tr><td align="left"> IHD</td><td align="left">1</td><td align="left">1</td><td align="left">2 (15)</td></tr><tr><td align="left">Chronic Kidney disease</td><td align="left">1</td><td align="left">1</td><td align="left">2 (15)</td></tr><tr><td align="left">Chronic lung disease</td><td align="left"></td><td align="left"></td><td align="left"></td></tr><tr><td align="left">Others</td><td colspan="2" align="left">Cardiomyopathy CVA, Dementia, Alzheimer, Asthma</td><td align="left">7 (53)</td></tr><tr><td align="left">Exposure to:</td><td align="left"></td><td align="left"></td><td align="left"></td></tr><tr><td align="left"> Camels</td><td align="left">1</td><td align="left">1</td><td align="left">2 (15)</td></tr><tr><td align="left"> MERS-CoV cases</td><td align="left">3</td><td align="left"></td><td align="left">3 (23)</td></tr><tr><td align="left"> (Household)</td><td align="left">3</td><td align="left"></td><td align="left">3 (23)</td></tr><tr><td align="left"> Hospital-acquired</td><td align="left">2</td><td align="left">1</td><td align="left">3 (23)</td></tr><tr><td align="left"> Community-acquired</td><td align="left">3</td><td align="left">2</td><td align="left">5 (38)</td></tr><tr><td align="left">General clinical characteristics</td><td align="left"></td><td align="left"></td><td align="left"></td></tr><tr><td align="left"> Fever >38 °C</td><td align="left">2</td><td align="left">2</td><td align="left">4 (31)</td></tr><tr><td align="left"> Malaise</td><td align="left">1</td><td align="left">2</td><td align="left">3 (23)</td></tr><tr><td align="left"> Confusion</td><td align="left">1</td><td align="left"></td><td align="left">1 (7)</td></tr><tr><td align="left"> Rhinorrhea</td><td align="left">1</td><td align="left"></td><td align="left">1 (7)</td></tr><tr><td align="left"> Sore throat</td><td align="left">1</td><td align="left"></td><td align="left">1 (7)</td></tr><tr><td align="left"> Haemoptysis</td><td align="left">1</td><td align="left"></td><td align="left">1 (7)</td></tr><tr><td align="left">Pulmonary clinical characteristics</td><td align="left"></td><td align="left"></td><td align="left"></td></tr><tr><td align="left"> Cough</td><td align="left">1</td><td align="left">7</td><td align="left">8 (62)</td></tr><tr><td align="left"> Shortness of breath</td><td align="left">1</td><td align="left">2</td><td align="left">3 (23)</td></tr><tr><td align="left"> Pneumonia</td><td align="left">1</td><td align="left">1</td><td align="left">2 (15)</td></tr><tr><td align="left">Extra-pulmonary clinical characteristics</td><td align="left"></td><td align="left"></td><td align="left"></td></tr><tr><td align="left"> Abdominal pain</td><td align="left"></td><td align="left">3</td><td align="left">3 (23)</td></tr><tr><td align="left"> Nausea and vomiting</td><td align="left">2</td><td align="left">3</td><td align="left">5 (38)</td></tr><tr><td align="left"> Diarrhea</td><td align="left"></td><td align="left">1</td><td align="left">1 (7)</td></tr><tr><td align="left"> Acute renal failure</td><td align="left"></td><td align="left">1</td><td align="left">1 (7)</td></tr><tr><td align="left">Blood analysis</td><td align="left"></td><td align="left"></td><td align="left"></td></tr><tr><td align="left">Leukopenia</td><td colspan="3" align="left">2 (15)</td></tr><tr><td align="left">Thrombocytopenia</td><td colspan="3" align="left">1 (7)</td></tr><tr><td align="left">Anaemia</td><td colspan="3" align="left">2 (15)</td></tr><tr><td align="left">c-reactive protein</td><td colspan="3" align="left">12 (92)</td></tr><tr><td align="left">Alanine Aminotrasferase</td><td colspan="3" align="left">3 (23)</td></tr><tr><td align="left">Elevetaed creatinine</td><td colspan="3" align="left">4 (31)</td></tr><tr><td align="left">Hyponatremia</td><td colspan="3" align="left">8 (61)</td></tr></tbody></table><table-wrap-foot><fn id="tblfn0005"><label>*</label><p id="npar0005">Total deaths.</p></fn></table-wrap-foot></table-wrap></p><p id="par0050">The second and third clusters were reported between January 27 and February 12, 2019, from North Al Batinah and South Ash Sharqiyah Governorates each reported 4 additional cases (Eight totals). These two additional clustered cases had no epidemiological link to the previous cluster. The median age was 55 ± SD 17.5 years (range: 30–77 years), with an equal number of males and females. Two cases (50%) from South Ash Sharqiyah and one case (25%) from North Al Batinah were admitted to ICU [<xref rid="tbl0005" ref-type="table">Table 1</xref>]. In total, uncontrolled diabetes mellitus (Five cases, 38%), hypertension (Six cases, 46%) and ischemic heart diseases (Two cases, 15%) were the most common co-morbidities and were reported in all clusters. Three of the four cases (75%) had septic shock, and bronchopneumonia was the most common cause of death. The overall case-fatality rate was 4 (31%) [<xref rid="tbl0005" ref-type="table">Table 1</xref>].</p><p id="par0055">Eleven cases (85%) presented with the typical MERS-CoV symptoms, including fever, cough, and shortness of breath. Four cases (31%) presented with gastrointestinal symptoms and diarrhoea. A total of 2 cases (15%) were asymptomatic and 4 (30%) had a mild illness. The two asymptomatic cases were health care workers detected by contact screening. The median time from symptom onset to hospitalization was 4 days (range 1–13 days) and from hospitalization to case notification was 12 days (range 1–22 days).</p><p id="par0060">The two index cases (15%) from North Al Batinah and South Ash Sharqiyah Governorates had a history of contact with camels, and 6 of the 13 cases (46%) had a history of contact with MERS-CoV patients either within the household or nosocomial [<xref rid="fig0015" ref-type="fig">Fig. 3</xref>]. Community-acquired cases were reported during the winter month of January with a peak number of cases (46%) reported on January 11 [<xref rid="fig0010" ref-type="fig">Fig. 2</xref>].<fig id="fig0015"><label>Fig. 3</label><caption><p>MERS-CoV confirmed cases by date of onset of symptoms, type of case, and Governorate, Oman, 2019.</p></caption><alt-text id="at0015">Fig. 3</alt-text><graphic xlink:href="gr3_lrg"></graphic></fig></p><p id="par0065">Laboratory investigations revealed that 5 cases (38%) presented with anaemia, and 2 cases and 1 case (15% and 8%) with leukopenia and thrombocytopenia, respectively. C-reactive protein was high in all except 1 patient. Alanine aminotransferase was elevated in 3 cases (23%). Hyponatremia was observed in 8 cases (61%) and creatinine was elevated in 4 cases (31%) [<xref rid="tbl0005" ref-type="table">Table 1</xref>]. Three cases (23%) had co-infection with other respiratory viruses and 6 cases (46%) had bacterial infections. The antibiotics and antiviral drugs used to manage the patients during hospitalization has been shown in [<xref rid="tbl0010" ref-type="table">Table 2</xref>].<table-wrap position="float" id="tbl0010"><label>Table 2</label><caption><p>Characteristic of confirmed MERs-CoV Cases, Oman, 2019.</p></caption><alt-text id="at0025">Table 2</alt-text><table frame="hsides" rules="groups"><thead><tr><th align="left">No</th><th align="left">Sex</th><th align="left">Age</th><th align="left">Nationality</th><th align="left">Symptoms</th><th align="left">Co-morbidities</th><th align="left">Exposure camels/ Camel products Y/N</th><th align="left">Type of contact</th><th align="left">Date of onset of symptoms</th><th align="left">Date of admission</th><th align="left">Date of Isolation</th><th align="left">Duration of hospitalization</th><th align="left">Intubation Y/N</th><th align="left">Antibiotics received on admission</th><th align="left">Antibiotics received during hospitalization</th><th align="left">Organisms grown during hospitalization</th><th align="left">Outcome</th></tr></thead><tbody><tr><td align="left">1</td><td align="left">F</td><td align="left">43</td><td align="left">Omani</td><td align="left">Headaches, Nauseaabdominal pain</td><td align="left">HTN</td><td align="left">N</td><td align="left">Index case</td><td align="left">15/1/19</td><td align="left">18/1/19</td><td align="left">23/1/19</td><td align="left">16 days</td><td align="left">Y</td><td align="left">CRO<break></break>CRL<break></break>OTV</td><td align="left">TZP<break></break>LVX<break></break>TGC<break></break>CS</td><td align="left">BC:<break></break><italic>A.baumannii</italic></td><td align="left">Died<break></break>Septic shock</td></tr><tr><td align="left">2</td><td align="left">F</td><td align="left">30</td><td align="left">Omani</td><td align="left">Cough<break></break>Nauseaabdominal pain</td><td align="left">DKA</td><td align="left">N</td><td align="left">Household of index case</td><td align="left">22/1/19</td><td align="left">25/1/19</td><td align="left">25/1/19</td><td align="left">8 days</td><td align="left">Y</td><td align="left">CRO<break></break>CRL</td><td align="left">TZP<break></break>MEM<break></break>LVX<break></break>TGC</td><td align="left">No growth</td><td align="left">Died<break></break>Septic shock</td></tr><tr><td align="left">3</td><td align="left">F</td><td align="left">39</td><td align="left">Omani</td><td align="left">Fever</td><td align="left">cardiomyopathy</td><td align="left">N</td><td align="left">Household of index case</td><td align="left">26/1/19</td><td align="left">26/1/19</td><td align="left">29/1/19</td><td align="left">19 days</td><td align="left">N</td><td align="left">CRO<break></break>CRL<break></break>OTV</td><td align="left">TZP</td><td align="left">No growth</td><td align="left">Alive</td></tr><tr><td align="left">4</td><td align="left">F</td><td align="left">59</td><td align="left">Omani</td><td align="left">Severe respiratory distress</td><td align="left">CKD<break></break>DM,<break></break>HTN<break></break>IHD<break></break>Hypothyroidism</td><td align="left">N</td><td align="left">Nosocomial</td><td align="left">26/1/19</td><td align="left">26/1/19</td><td align="left">28/1/19</td><td align="left">48 days</td><td align="left">Y</td><td align="left">CIP<break></break>OTV</td><td align="left">TZP<break></break>MEM<break></break>LZD<break></break>AN</td><td align="left">UC: <italic>E.coli</italic><break></break>BC: <italic>Candida spps.</italic></td><td align="left">Alive</td></tr><tr><td align="left">5</td><td align="left">F</td><td align="left">37</td><td align="left">Omani</td><td align="left">Nausea<break></break>Abdominal pain</td><td align="left"></td><td align="left">N</td><td align="left">Household of index case</td><td align="left">26/1/19</td><td align="left">29/1/19</td><td align="left">1/2/19</td><td align="left">16 days</td><td align="left">N</td><td align="left">CRO<break></break>CRL<break></break>OTV</td><td align="left"></td><td align="left">No growth</td><td align="left">Alive</td></tr><tr><td align="left">6</td><td align="left">F</td><td align="left">77</td><td align="left">Omani</td><td align="left">Asymptomatic</td><td align="left">CVA<break></break>DM<break></break>HTN Alzheimer</td><td align="left">N</td><td align="left">Unknown</td><td align="left">Unknown</td><td align="left">27/1/19</td><td align="left">13/2/19</td><td align="left">17 days</td><td align="left"></td><td align="left">CRO<break></break>CRL</td><td align="left">TZP<break></break>LZD</td><td align="left">BC: <italic>Enterococcus spps.</italic></td><td align="left">Alive</td></tr><tr><td align="left">7</td><td align="left">F</td><td align="left">65</td><td align="left">Omani</td><td align="left">SOB</td><td align="left">DM<break></break>HTN<break></break>CVA</td><td align="left">N</td><td align="left">Nosocomial</td><td align="left">9/2/19</td><td align="left">12/2/19</td><td align="left">12/2/19</td><td align="left">99 days</td><td align="left">Y</td><td align="left">AMP</td><td align="left">CIP, GEN, CAZ, MEM, TZP</td><td align="left">BC:<break></break><italic>P mirabilis</italic><break></break><italic>A. baumannii</italic></td><td align="left">Alive</td></tr><tr><td align="left">8</td><td align="left">F</td><td align="left">61</td><td align="left">Omani</td><td align="left">Fever<break></break>Cough</td><td align="left">DM<break></break>HTN<break></break>CVA<break></break>Dementia</td><td align="left">N</td><td align="left">Nosocomial</td><td align="left">12/2/19</td><td align="left">12/2/19</td><td align="left">15/2/19</td><td align="left">12 days</td><td align="left">N</td><td align="left">TZP<break></break>CRL<break></break>OTV</td><td align="left">TGC</td><td align="left">UC: <italic>ESBL</italic><break></break><italic>E. coli, A. baumannii</italic><break></break><italic>ESBL K. pneumonia</italic></td><td align="left">Alive</td></tr><tr><td align="left">9</td><td align="left">F</td><td align="left">31</td><td align="left">Indian</td><td align="left">Asymptomatic</td><td align="left">N</td><td align="left">N</td><td align="left">HCW<break></break>Nurse</td><td align="left">16/2/19</td><td align="left">16/2/19</td><td align="left">16/2/19</td><td align="left">7 days</td><td align="left">N</td><td align="left">OTV</td><td align="left"></td><td align="left">No growth</td><td align="left">Alive</td></tr><tr><td align="left">10</td><td align="left">M</td><td align="left">63</td><td align="left">Omani</td><td align="left">Fever cough</td><td align="left">DM<break></break>IHD<break></break>CKD</td><td align="left">Y</td><td align="left">Index case</td><td align="left">26/1/2019</td><td align="left">29/1/2019</td><td align="left">No isolation</td><td align="left">10 days</td><td align="left">Y</td><td align="left">TZP<break></break>CLR</td><td align="left">MEM, CS,<break></break>LZD, LVX</td><td align="left">UC:<break></break><italic>CRE</italic><break></break><italic>K. pneumonia</italic></td><td align="left">Died<break></break>Septic shock<break></break>Broncho<break></break>Pneumonia</td></tr><tr><td align="left">11</td><td align="left">M</td><td align="left">68</td><td align="left">Omani</td><td align="left">SOB</td><td align="left">DM<break></break>HTN<break></break>CKD</td><td align="left">No</td><td align="left">Nosocomial</td><td align="left">9/2/19</td><td align="left">9/2/19</td><td align="left">9/2/19</td><td align="left">3 days</td><td align="left">Y</td><td align="left">TZP<break></break>OTV</td><td align="left">VAN, MEM,<break></break>CS</td><td align="left">No growth</td><td align="left">Died<break></break>Broncho<break></break>Pneumonia</td></tr><tr><td align="left">12</td><td align="left">M</td><td align="left">30</td><td align="left">Sudanese</td><td align="left">Runny nose<break></break>sore throat</td><td align="left">Asthma</td><td align="left">No</td><td align="left">Nosocomial-<break></break>Physician</td><td align="left">10/2/19</td><td align="left">13/2/19</td><td align="left">13/2/19</td><td align="left">1 day</td><td align="left">N</td><td align="left">No</td><td align="left"></td><td align="left">13/2<break></break>Rhinovirus positive</td><td align="left">Alive</td></tr><tr><td align="left">13</td><td align="left">M</td><td align="left">48</td><td align="left">Bangladeshi</td><td align="left">Fever<break></break>hemoptysis</td><td align="left">Cardiomyopathy</td><td align="left">No</td><td align="left">Nosocomial</td><td align="left">14/2/19</td><td align="left">14/2/19</td><td align="left">18/2/19</td><td align="left">10 days</td><td align="left">N</td><td align="left">TZP<break></break>OTV</td><td align="left"></td><td align="left">No growth</td><td align="left">Died<break></break>Cardiomyo<break></break>pathy</td></tr></tbody></table></table-wrap></p></sec></sec><sec id="sec0025"><title>Contact and active case tracing</title><p id="par0070">A total of 761 close contacts from the clusters were identified and screened. In South Ash Sharquia, 294 contacts were screened, of which 151 (51%) were HCWs and 24 (8%) were close household contacts. In North Al Batinah, 467 contacts, 234 (50%) HCWs, and 114 (24%) household contacts were screened. Contacts were monitored for 14 days from their final date of exposure. MERS-CoV was not detected by RT-PCR, except in two HCWs, one from each Governorate. These HCWs were a female nurse and a female physician. One had a single encounter with the patient during intubation, and the other was involved in providing care for a patient for over a week in a high-dependency ward. Both were asymptomatic. Screening for MERS-CoV was not repeated if the first sample tested negative. Almost all other HCWs who attended the MERS-CoV patients were females, aged between 30 and 40 years. None of these HCWs exhibited co-morbidities.</p><p id="par0075">Two cases (15%) from South Ash Sharquia rapidly progressed to acute respiratory distress syndrome (ARDS), with a median of 3 days from hospitalization to ICU admission. At the time of submitting this manuscript, there are no epidemiological data to suggest further propagation of the outbreak.</p><p id="par0080">The index cases’ source of exposure was investigated by the Oman Ministry of Agriculture (MOA) less than a week after case notification and a total of 86 camels were tested (nasal and conjunctival swabs) in the vicinity and found to be negative for the virus. None of the camels in North Al Batinah Governorate tested positive for the virus and only one camel in South Ash Sharqiyah Governorate tested positive.</p></sec><sec id="sec0030"><title>Discussion</title><p id="par0085">To the best of our knowledge, this is the first healthcare and household-associated transmission cluster of MERS-CoV infection in the country. The current three clusters are different than what has been previously reported: the total number of cases in a single month exceeds the total number of cases from the previous 6 years [<xref rid="bib0015" ref-type="bibr">3</xref>]. It would have been advantageous in order to confirm the household transmission to perform a whole-genome sequencing of the virus isolated from individuals and analyze the sera from close contacts to cluster cases at 3–4 weeks after contact with index case [<xref rid="bib0145" ref-type="bibr">29</xref>].</p><p id="par0090">In Oman, sporadic MERS-CoV cases have been reported [<xref rid="bib0105" ref-type="bibr">[21]</xref>, <xref rid="bib0110" ref-type="bibr">[22]</xref>, <xref rid="bib0115" ref-type="bibr">[23]</xref>,<xref rid="bib0150" ref-type="bibr">30</xref>,<xref rid="bib0155" ref-type="bibr">31</xref>] with limited human-to-human transmission until the time of this clustered outbreak. Most of the community-acquired cases were reported during the winter month of January 2019, which is consistent with data from other countries in the EMR [<xref rid="bib0160" ref-type="bibr">32</xref>]. No healthcare-associated MERS-CoV infections have been previously reported. This has been mainly attributed to an effective triage system and HCWs awareness [<xref rid="bib0165" ref-type="bibr">33</xref>].</p><p id="par0095">In the current report, we observed three distinct clusters occurring at the same time without any epidemiological link between them (two clusters from North Al Batinah and 1 cluster from South Ash Sharqiyah Governorates).</p><p id="par0100">In the first cluster, we suspect that 3 out of 5 patients in the household–associated transmission acquired infection secondarily. Though the family lived on a camel farm and the index case reported a history of contact with camels, these 3 family members reported no direct contact with camels or camel products, neither a history of travel outside Oman nor recent hospitalizations. Risk factor for the household-associated cluster infection was direct contact with a confirmed case. The three secondary cases were caring for or sharing a room with a confirmed case. Therefore the possible source of their infection is the index case. Inaddition, the date of onset of illness of the three cases suggested that they are secondary cases with a link to the index case [<xref rid="fig0015" ref-type="fig">Fig. 3</xref>,<xref rid="tbl0010" ref-type="table">Table 2</xref>].</p><p id="par0105">The clustered cases showed three remarkable features. Firstly, the cases reported from the North Al Batinah cluster were household contacts, indicating that for the first time in the country human-to-human transmission occurred at the household level. Similar family clusters were reported in Saudi Arabia [<xref rid="bib0070" ref-type="bibr">14</xref>,<xref rid="bib0075" ref-type="bibr">15</xref>,<xref rid="bib0085" ref-type="bibr">17</xref>,<xref rid="bib0170" ref-type="bibr">[34]</xref>, <xref rid="bib0175" ref-type="bibr">[35]</xref>, <xref rid="bib0180" ref-type="bibr">[36]</xref>, <xref rid="bib0185" ref-type="bibr">[37]</xref>, <xref rid="bib0190" ref-type="bibr">[38]</xref>, <xref rid="bib0195" ref-type="bibr">[39]</xref>], Tunisia [<xref rid="bib0200" ref-type="bibr">40</xref>] and the UK [<xref rid="bib0195" ref-type="bibr">39</xref>]. Secondly, the epidemiological characteristics of these 13 cases are different from what has been observed in cases reported from other countries [<xref rid="bib0025" ref-type="bibr">5</xref>,<xref rid="bib0050" ref-type="bibr">10</xref>,<xref rid="bib0055" ref-type="bibr">11</xref>,<xref rid="bib0195" ref-type="bibr">39</xref>,<xref rid="bib0200" ref-type="bibr">40</xref>]. The age is skewed towards younger age groups while the reported global median age of MERS-CoV cases acquired through community transmission is 55 and above [<xref rid="bib0025" ref-type="bibr">5</xref>,<xref rid="bib0050" ref-type="bibr">10</xref>,<xref rid="bib0055" ref-type="bibr">11</xref>,<xref rid="bib0195" ref-type="bibr">39</xref>,<xref rid="bib0200" ref-type="bibr">40</xref>]. Thirdly, most of the cases are females (69%) and not males, as reported elsewhere [<xref rid="bib0010" ref-type="bibr">2</xref>,<xref rid="bib0160" ref-type="bibr">32</xref>]. The reason for the strong female predominance of the outbreak remains unexplained.</p><p id="par0110">The season of dromedary camel breeding and racing is from January to March in these governorates and the camel farms may become a source of MERS-CoV circulation and transmission during this time [<xref rid="bib0160" ref-type="bibr">32</xref>]. Two of the index cases had a history of contact with dromedary camels. At this time, evidence suggests that dromedary camels (<italic>Camelus dromedarius</italic>) are the main source of transmission of MERS-CoV to humans [<xref rid="bib0120" ref-type="bibr">24</xref>]. It is known that individuals in close contact with dromedary camels are at an increased risk of acquiring MERS-CoV infection compared to the general population [<xref rid="bib0205" ref-type="bibr">41</xref>]. The transmission from camels to humans can be via direct contact with respiratory secretions or indirect contact through the use of camel products [<xref rid="bib0205" ref-type="bibr">41</xref>].</p><p id="par0115">In these clustered outbreaks, we observed non-linked clusters and sporadic cases, in addition to nosocomial transmission in health care facilities with neither evidence of sustained human-to-human transmission nor community transmission. A similar situation was observed in Saudi Arabia, where up to 50% of MERS-CoV cases were classified as secondary, due to possible human-to-human transmission through contact with asymptomatic or symptomatic individuals infected with MERS-CoV [<xref rid="bib0210" ref-type="bibr">42</xref>]. Furthermore, limited human-to-human transmission of MERS-CoV was observed in several other clusters in other countries, including family members [<xref rid="bib0070" ref-type="bibr">[14]</xref>, <xref rid="bib0075" ref-type="bibr">[15]</xref>, <xref rid="bib0080" ref-type="bibr">[16]</xref>, <xref rid="bib0085" ref-type="bibr">[17]</xref>, <xref rid="bib0090" ref-type="bibr">[18]</xref>, <xref rid="bib0095" ref-type="bibr">[19]</xref>] and patients in health care facilities [<xref rid="bib0195" ref-type="bibr">39</xref>,<xref rid="bib0200" ref-type="bibr">40</xref>,<xref rid="bib0210" ref-type="bibr">[42]</xref>, <xref rid="bib0215" ref-type="bibr">[43]</xref>, <xref rid="bib0220" ref-type="bibr">[44]</xref>].</p><p id="par0120">The current outbreak highlights the significant challenges associated with suspecting and diagnosing MERS-CoV infection. The median time from hospitalization to case notification was 12 days, which is relatively long, reflecting the need for increased awareness among health care workers and the community. However, a study conducted in from Saudi Arabia showed the median time to notification was 2 days [<xref rid="bib0225" ref-type="bibr">45</xref>].</p><p id="par0125">The general clinical characteristics of the MERS-CoV clustered cases observed in this study were consistent with data from other countries in the EMR [<xref rid="bib0195" ref-type="bibr">39</xref>,<xref rid="bib0200" ref-type="bibr">40</xref>,<xref rid="bib0210" ref-type="bibr">[42]</xref>, <xref rid="bib0215" ref-type="bibr">[43]</xref>, <xref rid="bib0220" ref-type="bibr">[44]</xref>, <xref rid="bib0225" ref-type="bibr">[45]</xref>]. Healthcare-associated MERS-CoV outbreaks have been reported in several countries, with the largest outbreaks in Saudi Arabia, the United Arab Emirates and the Republic of Korea [<xref rid="bib0010" ref-type="bibr">[2]</xref>, <xref rid="bib0015" ref-type="bibr">[3]</xref>, <xref rid="bib0020" ref-type="bibr">[4]</xref>, <xref rid="bib0025" ref-type="bibr">[5]</xref>,<xref rid="bib0035" ref-type="bibr">[7]</xref>, <xref rid="bib0040" ref-type="bibr">[8]</xref>, <xref rid="bib0045" ref-type="bibr">[9]</xref>,<xref rid="bib0160" ref-type="bibr">[32]</xref>, <xref rid="bib0165" ref-type="bibr">[33]</xref>, <xref rid="bib0170" ref-type="bibr">[34]</xref>, <xref rid="bib0175" ref-type="bibr">[35]</xref>, <xref rid="bib0180" ref-type="bibr">[36]</xref>, <xref rid="bib0185" ref-type="bibr">[37]</xref>, <xref rid="bib0190" ref-type="bibr">[38]</xref>, <xref rid="bib0195" ref-type="bibr">[39]</xref>, <xref rid="bib0200" ref-type="bibr">[40]</xref>, <xref rid="bib0205" ref-type="bibr">[41]</xref>, <xref rid="bib0210" ref-type="bibr">[42]</xref>, <xref rid="bib0215" ref-type="bibr">[43]</xref>, <xref rid="bib0220" ref-type="bibr">[44]</xref>]. Although most MERS-CoV-infected HCWs were asymptomatic [<xref rid="bib0210" ref-type="bibr">42</xref>], serious infections have occurred, and HCWs might have played a critical role in spreading the virus [<xref rid="bib0215" ref-type="bibr">43</xref>]. Several factors could have contributed to transmission in the current outbreak within the healthcare facilities, including delays in suspicion and case detection, delays in timely index case isolation and most importantly, lack of adherence to optimal infection control measures such as: using proper personal protective equipment (PPE) while providing care to the infected patients, proper hand hygiene and lack of proper isolation facilities like negative pressure rooms.</p><p id="par0130">The execution of basic infection control measures must be continuous and the efforts should be sustained whether there is an outbreak or not. The majority of the responsibility lies with the staff and the leadership of a healthcare facility to ensure adherence to existing infection control practices at all times.</p><p id="par0135">Three patients (27%) exhibited noticeable gastrointestinal symptoms, including abdominal pain and diarrhoea. Two of these 3 patients (75%) occurred in persons with underlying chronic medical conditions. Several other countries have reported similar co-morbidities (7–10). Fifteen percent (2) of our MERS-CoV patients had severe pneumonia, complicated by ARDS, septic shock, or multi-organ failure leading to death. A similar situation was observed in a number of countries [<xref rid="bib0035" ref-type="bibr">7</xref>,<xref rid="bib0220" ref-type="bibr">44</xref>]. These patients had several underlying comorbidities including diabetes, hypertension, chronic heart disease, and chronic kidney disease. Individuals with co-morbidities and on immunosuppressive treatments are at high risk of severe disease [<xref rid="bib0230" ref-type="bibr">46</xref>]. The high fatality rates (31%) observed in our patients with these co-morbidities are in line with what has been reported globally (approximately 35%) [<xref rid="bib0235" ref-type="bibr">47</xref>]. The high fatality rate may also be attributed to a delay in seeking medical care, as the mean date of the onset of symptoms to hospitalization was 4 days, and a delay was seen mostly in those with underlying chronic medical conditions.</p><p id="par0140">The current outbreak highlights the need for increased awareness among the public as well, particularly in individuals with co-morbidities, 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. Encouraging regular hand washing, especially following contact with camels [<xref rid="bib0205" ref-type="bibr">41</xref>] and early presentation to health care facilities when feeling unwell are also important messages. Practicing safe hygiene habits around dromedaries could reduce further transmission and prevent community clustered outbreaks.</p><p id="par0145">Many patients received multiple courses of antimicrobials and may have developed resistance during therapy. The present MERS-CoV management approach, with regards to antimicrobial use, is not standardized. There is an urgent need to develop regional and national treatment guidelines addressing MERS-CoV antiviral drugs and certain adjunct treatments including antibiotics among patients infected with MERS-CoV according to current WHO guidelines [<xref rid="bib0240" ref-type="bibr">48</xref>].</p><p id="par0150">In order to better understand future MERS-CoV transmission dynamics, we recommend a series of clinical steps. a) Perform whole-genome sequencing of the virus isolated from individuals. Also, conduct a serological investigation in order to see if silent transmission had occurred at the household level and to determine the extent of infection, i.e., sub-clinical or asymptomatic amongst high and low risk contacts of the cases. b) Sera collection should be repeated in close contacts 3–4 weeks after contact with the index case, regardless of whether close contacts have developed symptoms [<xref rid="bib0130" ref-type="bibr">26</xref>]. Close contacts include family members and health care worker contacts of the infected patients, including family member contacts that previously tested negative as per the WHO guideline [<xref rid="bib0130" ref-type="bibr">26</xref>]. c) It would have been advantageous to consider implementation of a study design using inferential methods, from which evidence-based conclusions can be drawn as the review limitation.</p><p id="par0155">The timing of this investigation is critical and should be initiated as soon as the first patient with MERS-CoV (the index case) is identified. MERS-CoV-specific antibodies take 14–21 days to develop in infected individuals [<xref rid="bib0130" ref-type="bibr">26</xref>]. Therefore, it is ideal to wait 21 days from the day the index case was reported to be sure that anti-MERS-CoV IgG is not missed in the serum of the contact cases as many mild or asymptomatic cases of MERS-CoV do not seroconvert.</p><p id="par0160">The agenda to address existing knowledge gaps in relation to MERS-CoV infection should include the following technical areas: virus origin and characteristics, epidemiology and transmission and infection prevention and control [<xref rid="bib0235" ref-type="bibr">47</xref>]. Oman can contribute to the research agenda by addressing key fundamental issues associated with public and animal health. We should focus on the primary source of MERS-CoV infections, which remains unclear, as does the transmission pattern from dromedary camels to humans. Special attention should be particularly paid to the types of behaviour or exposure that result in human infections, even asymptomatic infections that elicit immune responses.</p><p id="par0165">Efforts are required to improve infection prevention and control in order to minimize nosocomial transmission. Institutional monitoring and evaluation and training of HCWs remain the mainstays of disease prevention in healthcare facilities. Furthermore, the urgent adoption of a “One Health” strategic approach, including the establishment of a robust, timely, integrated surveillance system and strengthening the governorates' capabilities for rapid and efficient investigation of the disease is critical for minimizing the spread of disease. This is the first local clusters of MERS-CoV ever reported in Oman with evidence suggestive of healthcare transmission and limited household-associated transmission. Early diagnosis and strict implementation of infection control measures remain fundamental in preventing and managing MERS-CoV infection.</p></sec><sec id="sec0035"><title>Conflicts of interest</title><p id="par0170">All authors declare no conflicts of interest.</p></sec><sec id="sec0040"><title>Funding information</title><p id="par0175">No sources of funding were used in the preparation of this manuscript.</p></sec><sec id="sec0045"><title>Previous presentations statement</title><p id="par0180">None.</p></sec></body><back><ref-list id="bibl0005"><title>References</title><ref id="bib0005"><label>1</label><element-citation publication-type="journal" id="sbref0005"><person-group person-group-type="author"><name><surname>Zaki</surname><given-names>A.M.</given-names></name><name><surname>van Boheemen</surname><given-names>S.</given-names></name><name><surname>Bestebroer</surname><given-names>T.M.</given-names></name><name><surname>Osterhaus</surname><given-names>A.D.</given-names></name><name><surname>Fouchier</surname><given-names>R.A.</given-names></name></person-group><article-title>Isolation of a novel coronavirus from a man with pneumonia in Saudi Arabia</article-title><source>N Engl J Med</source><volume>367</volume><year>2012</year><fpage>1814</fpage><lpage>1820</lpage><pub-id pub-id-type="pmid">23075143</pub-id></element-citation></ref><ref id="bib0010"><label>2</label><mixed-citation publication-type="other" id="oref0010">MERS situation. (Update, June 2019). WHO. [Available from] <ext-link ext-link-type="uri" xlink:href="http://www.emro.who.int/health-topics/mers-cov/mers-outbreaks.html" id="intr0005">http://www.emro.who.int/health-topics/mers-cov/mers-outbreaks.html</ext-link>.</mixed-citation></ref><ref id="bib0015"><label>3</label><element-citation publication-type="journal" id="sbref0015"><person-group person-group-type="author"><name><surname>Azhar</surname><given-names>Esam I.</given-names></name><name><surname>El-Kafrawy</surname><given-names>Sherif A.</given-names></name><name><surname>Farraj</surname><given-names>Suha A.</given-names></name></person-group><article-title>Evidence for camel-to-human transmission of MERS coronavirus</article-title><source>N Engl J Med</source><volume>370</volume><year>2014</year><fpage>2499</fpage><lpage>2505</lpage><pub-id pub-id-type="doi">10.1056/NEJMoa1401505</pub-id><pub-id pub-id-type="pmid">24896817</pub-id></element-citation></ref><ref id="bib0020"><label>4</label><element-citation publication-type="journal" id="sbref0020"><person-group person-group-type="author"><name><surname>Conzade</surname><given-names>R.</given-names></name><name><surname>Grant</surname><given-names>R.</given-names></name><name><surname>Malik</surname><given-names>M.R.</given-names></name><name><surname>Elkholy</surname><given-names>A.</given-names></name><name><surname>Elhakim</surname><given-names>M.</given-names></name><name><surname>Samhouri</surname><given-names>D.</given-names></name></person-group><article-title>Reported direct and indirect contact with dromedary camels among laboratory-confirmed MERS-CoV cases</article-title><source>Viruses</source><volume>10</volume><year>2018</year><fpage>425</fpage><pub-id pub-id-type="doi">10.3390/v10080425</pub-id><comment>[Available from]:</comment><ext-link ext-link-type="uri" xlink:href="arxiv:/www.mdpi.com/journal/viruses" id="intr0010">www.mdpi.com/journal/viruses</ext-link></element-citation></ref><ref id="bib0025"><label>5</label><mixed-citation publication-type="other" id="oref0025">Surveillance for human infection with Middle East respiratory syndrome coronavirus (MERS- CoV), WHO. (Updated June 2018). [Available from] <ext-link ext-link-type="uri" xlink:href="https://apps.who.int/iris/bitstream/handle/10665/177869/WHO_MERS_SUR_15.1_eng.pdf?ua=1" id="intr0015">https://apps.who.int/iris/bitstream/handle/10665/177869/WHO_MERS_SUR_15.1_eng.pdf?ua=1</ext-link>.</mixed-citation></ref><ref id="bib0030"><label>6</label><element-citation publication-type="journal" id="sbref0030"><person-group person-group-type="author"><name><surname>Drosten</surname><given-names>C.</given-names></name><name><surname>Muth</surname><given-names>D.</given-names></name><name><surname>Corman</surname><given-names>V.M.</given-names></name><name><surname>Hussain</surname><given-names>R.</given-names></name><name><surname>Al Masri</surname><given-names>M.</given-names></name><name><surname>HajOmar</surname><given-names>W.</given-names></name></person-group><article-title>An observational, laboratory-based study of outbreaks of Middle East Respiratory Syndrome coronavirus in Jeddah and Riyadh, Kingdom of Saudi Arabia, 2014</article-title><source>Clin Infect Dis</source><volume>60</volume><year>2015</year><fpage>369</fpage><lpage>377</lpage><pub-id pub-id-type="pmid">25323704</pub-id></element-citation></ref><ref id="bib0035"><label>7</label><element-citation publication-type="journal" id="sbref0035"><person-group person-group-type="author"><name><surname>Hijawi</surname><given-names>B.</given-names></name><name><surname>Abdallat</surname><given-names>M.</given-names></name><name><surname>Sayaydeh</surname><given-names>A.</given-names></name><name><surname>Alqasrawi</surname><given-names>S.</given-names></name><name><surname>Haddadin</surname><given-names>A.</given-names></name><name><surname>Jaarour</surname><given-names>N.</given-names></name></person-group><article-title>Novel coronavirus infections in Jordan, April 2012: epidemiological findings from a retrospective investigation</article-title><source>East Mediterr Health J</source><volume>19</volume><issue>Suppl. 1</issue><year>2013</year><fpage>S12</fpage><lpage>S18</lpage><pub-id pub-id-type="pmid">23888790</pub-id></element-citation></ref><ref id="bib0040"><label>8</label><element-citation publication-type="journal" id="sbref0040"><person-group person-group-type="author"><name><surname>Assiri</surname><given-names>A.</given-names></name><name><surname>McGeer</surname><given-names>A.</given-names></name><name><surname>Perl</surname><given-names>T.M.</given-names></name><name><surname>Price</surname><given-names>C.S.</given-names></name><name><surname>Al Rabeeah</surname><given-names>A.A.</given-names></name><name><surname>Cummings</surname><given-names>D.A.</given-names></name></person-group><article-title>Hospital outbreak of Middle East Respiratory Syndrome coronavirus</article-title><source>N Engl J Med</source><volume>369</volume><year>2013</year><fpage>407</fpage><lpage>416</lpage><pub-id pub-id-type="pmid">23782161</pub-id></element-citation></ref><ref id="bib0045"><label>9</label><element-citation publication-type="journal" id="sbref0045"><person-group person-group-type="author"><name><surname>Al-Abdallat</surname><given-names>M.M.</given-names></name><name><surname>Payne</surname><given-names>D.C.</given-names></name><name><surname>Alqasrawi</surname><given-names>S.</given-names></name><name><surname>Rha</surname><given-names>B.</given-names></name><name><surname>Tohme</surname><given-names>R.A.</given-names></name><name><surname>Abedi</surname><given-names>G.R.</given-names></name></person-group><article-title>Hospital-associated outbreak of Middle East Respiratory Syndrome coronavirus: a serologic, epidemiologic, and clinical description</article-title><source>Clin Infect Dis</source><volume>59</volume><year>2014</year><fpage>1225</fpage><lpage>1233</lpage><pub-id pub-id-type="pmid">24829216</pub-id></element-citation></ref><ref id="bib0050"><label>10</label><element-citation publication-type="journal" id="sbref0050"><person-group person-group-type="author"><name><surname>Al Hosani</surname><given-names>F.I.</given-names></name><name><surname>Pringle</surname><given-names>K.</given-names></name><name><surname>Al Mulla</surname><given-names>M.</given-names></name><name><surname>Kim</surname><given-names>L.</given-names></name><name><surname>Pham</surname><given-names>H.</given-names></name><name><surname>Alami</surname><given-names>N.N.</given-names></name></person-group><article-title>Response to emergence of Middle East Respiratory Syndrome coronavirus, Abu Dhabi, United Arab Emirates, 2013–2014</article-title><source>Emerg Infect Dis</source><volume>22</volume><year>2016</year><fpage>1162</fpage><lpage>1168</lpage><pub-id pub-id-type="pmid">27314227</pub-id></element-citation></ref><ref id="bib0055"><label>11</label><element-citation publication-type="journal" id="sbref0055"><person-group person-group-type="author"><name><surname>Park</surname><given-names>H.Y.</given-names></name><name><surname>Lee</surname><given-names>E.J.</given-names></name><name><surname>Ryu</surname><given-names>Y.W.</given-names></name><name><surname>Kim</surname><given-names>Y.</given-names></name><name><surname>Kim</surname><given-names>H.</given-names></name><name><surname>Lee</surname><given-names>H.</given-names></name></person-group><article-title>Epidemiological investigation of MERS-CoV spread in a single hospital in South Korea, May to June 2015</article-title><source>Euro Surveill.</source><volume>20</volume><year>2015</year><fpage>1</fpage><lpage>6</lpage><pub-id pub-id-type="pmid">26132766</pub-id></element-citation></ref><ref id="bib0060"><label>12</label><element-citation publication-type="journal" id="sbref0060"><person-group person-group-type="author"><name><surname>Omrani</surname><given-names>A.S.</given-names></name><name><surname>Abdul Matin</surname><given-names>M.</given-names></name><name><surname>Haddad</surname><given-names>Q.</given-names></name><name><surname>Al-Nakhli</surname><given-names>D.</given-names></name><name><surname>Memish</surname><given-names>Z.A.</given-names></name><name><surname>Albarraka</surname><given-names>A.M.</given-names></name></person-group><article-title>A family cluster of Middle East Respiratory Syndrome Coronavirus infections related to a likely unrecognized asymptomatic or mild case</article-title><source>Int J Infect Dis</source><volume>17</volume><issue>September (9)</issue><year>2013</year><fpage>e668</fpage><lpage>e672</lpage><pub-id pub-id-type="pmid">23916548</pub-id></element-citation></ref><ref id="bib0065"><label>13</label><element-citation publication-type="journal" id="sbref0065"><person-group person-group-type="author"><name><surname>Oboho</surname><given-names>I.K.</given-names></name><name><surname>Tomczyk</surname><given-names>S.M.</given-names></name><name><surname>Al-Asmari</surname><given-names>A.M.</given-names></name><name><surname>Banjar</surname><given-names>A.A.</given-names></name><name><surname>Al-Mugti</surname><given-names>H.</given-names></name><name><surname>Aloraini</surname><given-names>M.S.</given-names></name></person-group><article-title>2014 MERS-CoV outbreak in Jeddah—a link to health care facilities</article-title><source>N Engl J Med</source><volume>372</volume><year>2015</year><fpage>846</fpage><lpage>854</lpage><pub-id pub-id-type="doi">10.1056/NEJMoa1408636</pub-id><comment>[Available from]:</comment><pub-id pub-id-type="pmid">25714162</pub-id></element-citation></ref><ref id="bib0070"><label>14</label><element-citation publication-type="journal" id="sbref0070"><person-group person-group-type="author"><name><surname>Killerby</surname><given-names>M.E.</given-names></name><name><surname>Biggs</surname><given-names>H.M.</given-names></name><name><surname>Midgley</surname><given-names>C.M.</given-names></name><name><surname>Gerber</surname><given-names>S.I.</given-names></name><name><surname>Watson</surname><given-names>J.T.</given-names></name></person-group><article-title>Middle East Respiratory Syndrome coronavirus transmission</article-title><source>Emerging Infect Dis</source><volume>26</volume><issue>February (2)</issue><year>2020</year><pub-id pub-id-type="doi">10.3201/eid2602.190697</pub-id><comment>[Available from]</comment><ext-link ext-link-type="uri" xlink:href="https://wwwnc.cdc.gov/eid/article/26/2/19-0697_article" id="intr0020">https://wwwnc.cdc.gov/eid/article/26/2/19-0697_article</ext-link></element-citation></ref><ref id="bib0075"><label>15</label><element-citation publication-type="journal" id="sbref0075"><person-group person-group-type="author"><name><surname>Van Kerkhove</surname><given-names>M.D.</given-names></name><name><surname>Alaswad</surname><given-names>S.</given-names></name><name><surname>Assiri</surname><given-names>A.</given-names></name><name><surname>Perera</surname><given-names>R.A.P.M.</given-names></name><name><surname>Peiris</surname><given-names>M.</given-names></name><name><surname>El Bushra</surname><given-names>H.E.</given-names></name></person-group><article-title>Transmissibility of MERS-CoV infection in closed setting, Riyadh, Saudi Arabia, 2015</article-title><source>Emerg Infect Dis</source><volume>25</volume><year>2019</year><fpage>1802</fpage><lpage>1809</lpage><pub-id pub-id-type="doi">10.3201/eid2510.190130</pub-id><pub-id pub-id-type="pmid">31423971</pub-id></element-citation></ref><ref id="bib0080"><label>16</label><element-citation publication-type="journal" id="sbref0080"><person-group person-group-type="author"><name><surname>Al Hosani</surname><given-names>F.I.</given-names></name><name><surname>Kim</surname><given-names>L.</given-names></name><name><surname>Khudhair</surname><given-names>A.</given-names></name><name><surname>Pham</surname><given-names>H.</given-names></name><name><surname>Al Mulla</surname><given-names>M.</given-names></name><name><surname>Al Bandar</surname><given-names>Z.</given-names></name></person-group><article-title>Serologic follow-up of Middle East Respiratory Syndrome coronavirus cases and contacts–Abu Dhabi, United Arab Emirates</article-title><source>Clin Infect Dis</source><volume>68</volume><year>2019</year><fpage>409</fpage><lpage>418</lpage><pub-id pub-id-type="doi">10.1093/cid/ciy503</pub-id><pub-id pub-id-type="pmid">29905769</pub-id></element-citation></ref><ref id="bib0085"><label>17</label><element-citation publication-type="journal" id="sbref0085"><person-group person-group-type="author"><name><surname>Hui</surname><given-names>D.S.</given-names></name><name><surname>Azhar</surname><given-names>E.I.</given-names></name><name><surname>Kim</surname><given-names>Y.-J.</given-names></name><name><surname>Memish</surname><given-names>Z.A.</given-names></name><name><surname>Oh</surname><given-names>M.-d.</given-names></name><name><surname>Zumla</surname><given-names>A.</given-names></name></person-group><article-title>Middle East Respiratory Syndrome coronavirus: risk factors and determinants of primary, household, and nosocomial transmission</article-title><source>Lancet Infect Dis</source><volume>18</volume><year>2018</year><fpage>e217</fpage><lpage>27</lpage><pub-id pub-id-type="pmid">29680581</pub-id></element-citation></ref><ref id="bib0090"><label>18</label><element-citation publication-type="journal" id="sbref0090"><person-group person-group-type="author"><name><surname>Arwady</surname><given-names>M.A.</given-names></name><name><surname>Alraddadi</surname><given-names>B.</given-names></name><name><surname>Basler</surname><given-names>C.</given-names></name><name><surname>Azhar</surname><given-names>E.I.</given-names></name><name><surname>Abuelzein</surname><given-names>E.</given-names></name><name><surname>Sindy</surname><given-names>A.I.</given-names></name></person-group><article-title>Middle East Respiratory Syndrome coronavirus transmission in extended family, Saudi Arabia, 2014</article-title><source>Emerg Infect Dis</source><volume>22</volume><year>2016</year><fpage>1395</fpage><lpage>1402</lpage><pub-id pub-id-type="doi">10.3201/eid2208.152015</pub-id><pub-id pub-id-type="pmid">27191038</pub-id></element-citation></ref><ref id="bib0095"><label>19</label><element-citation publication-type="journal" id="sbref0095"><person-group person-group-type="author"><name><surname>Drosten</surname><given-names>C.</given-names></name><name><surname>Meyer</surname><given-names>B.</given-names></name><name><surname>Müller</surname><given-names>M.A.</given-names></name><name><surname>Corman</surname><given-names>V.M.</given-names></name><name><surname>Al-Masri</surname><given-names>M.</given-names></name><name><surname>Hossain</surname><given-names>R.</given-names></name></person-group><article-title>Transmission of MERS-coronavirus in household contacts</article-title><source>N Engl J Med</source><volume>371</volume><year>2014</year><fpage>828</fpage><lpage>835</lpage><pub-id pub-id-type="pmid">25162889</pub-id></element-citation></ref><ref id="bib0100"><label>20</label><element-citation publication-type="journal" id="sbref0100"><person-group person-group-type="author"><name><surname>Jahan</surname><given-names>Firdous</given-names></name><name><surname>Maqbali</surname><given-names>Ali Abdullah Al</given-names></name></person-group><article-title>The Middle East Respiratory Syndrome coronavirus (MERS-COV)</article-title><source>Middle East J Family Med</source><volume>13</volume><issue>1</issue><year>2015</year></element-citation></ref><ref id="bib0105"><label>21</label><element-citation publication-type="journal" id="sbref0105"><person-group person-group-type="author"><name><surname>Awaidy</surname><given-names>Salah T. Al</given-names></name><name><surname>Khamis</surname><given-names>Faryal</given-names></name></person-group><article-title>Middle East Respiratory Syndrome Coronavirus (MERS-CoV) in Oman: Current Situation and Going Forward</article-title><source>Oman Med J</source><volume>34</volume><issue>3</issue><year>2019</year><fpage>181</fpage><lpage>183</lpage><pub-id pub-id-type="pmid">31110623</pub-id></element-citation></ref><ref id="bib0110"><label>22</label><mixed-citation publication-type="other" id="oref0110">WHO-EMRO. MERS situation update March (Accessed 2 May 2018). [Available from: <ext-link ext-link-type="uri" xlink:href="http://www.emro.who.int/images/stories/mers-cov/MERS-CoV_March_2018.pdf?ua=1" id="intr0025">http://www.emro.who.int/images/stories/mers-cov/MERS-CoV_March_2018.pdf?ua=1</ext-link>].</mixed-citation></ref><ref id="bib0115"><label>23</label><element-citation publication-type="journal" id="sbref0115"><person-group person-group-type="author"><name><surname>Reusken</surname><given-names>C.B.E.M.</given-names></name><name><surname>Haagmans</surname><given-names>B.L.</given-names></name><name><surname>Müller</surname><given-names>M.A.</given-names></name><name><surname>Gutierrez</surname><given-names>C.</given-names></name><name><surname>Godeke</surname><given-names>G.J.</given-names></name><name><surname>Meyer</surname><given-names>B.</given-names></name></person-group><article-title>Middle East respiratory syndrome coronavirus neutralising serum antibodies in dromedary camels: a comparative serological study</article-title><source>Lancet Infect Dis</source><volume>13</volume><issue>10</issue><year>2013</year><fpage>859</fpage><lpage>866</lpage><pub-id pub-id-type="doi">10.1016/S1473-3099(13)70164-6</pub-id><comment>[Available from]:</comment><pub-id pub-id-type="pmid">23933067</pub-id></element-citation></ref><ref id="bib0120"><label>24</label><element-citation publication-type="journal" id="sbref0120"><person-group person-group-type="author"><name><surname>Sikkema</surname><given-names>R.S.</given-names></name><name><surname>Farag</surname><given-names>E.A.B.A.</given-names></name><name><surname>Islam</surname><given-names>M.</given-names></name><name><surname>Atta</surname><given-names>M.</given-names></name><name><surname>Reusken</surname><given-names>C.B.E.M.</given-names></name><name><surname>Al-Hajri</surname><given-names>M.M.</given-names></name></person-group><article-title>Global status of Middle East respiratory syndrome coronavirus in dromedary camels: a systematic review</article-title><source>Epidemiol Infect</source><volume>147</volume><year>2019</year><pub-id pub-id-type="doi">10.1017/S095026881800345X</pub-id><comment>e84, 1–13. [Available from]:</comment></element-citation></ref><ref id="bib0125"><label>25</label><mixed-citation publication-type="other" id="oref0125">Middle East respiratory syndrome coronavirus (MERS-CoV), Oman. WHO, EMR, Disease outbreak news (11 February 2019). [Available from]: <ext-link ext-link-type="uri" xlink:href="https://www.who.int/csr/don/11-february-2019-mers-oman/en/" id="intr0030">https://www.who.int/csr/don/11-february-2019-mers-oman/en/</ext-link>.</mixed-citation></ref><ref id="bib0130"><label>26</label><mixed-citation publication-type="other" id="oref0130">WHO guidelines for investigation of cases of human infection with Middle East Respiratory Syndrome Coronavirus (MERS-CoV) (July 2013). [Available from]: <ext-link ext-link-type="uri" xlink:href="https://www.who.int/csr/disease/coronavirus_infections/MERS_CoV_investigation_guideline_Jul13.pdf" id="intr0035">https://www.who.int/csr/disease/coronavirus_infections/MERS_CoV_investigation_guideline_Jul13.pdf</ext-link>.</mixed-citation></ref><ref id="bib0135"><label>27</label><mixed-citation publication-type="other" id="oref0135">MERS-CoV Preparedness & Response Plan (July) 2013, Ministry of Health, Oman. [Availablr from]: <ext-link ext-link-type="uri" xlink:href="https://www.moh.gov.om/documents/236878/0/MERS+COV+national+preparedness+plan+Oman+2013/e5f90be0-f90d-422b-94c8-0621190a7c34" id="intr0040">https://www.moh.gov.om/documents/236878/0/MERS+COV+national+preparedness+plan+Oman+2013/e5f90be0-f90d-422b-94c8-0621190a7c34</ext-link>.</mixed-citation></ref><ref id="bib0140"><label>28</label><mixed-citation publication-type="other" id="oref0140">MERS-CoV in Oman, WHO. 11 February 2019. Available from: <ext-link ext-link-type="uri" xlink:href="https://www.who.int/csr/don/11-february-2019-mers-oman/en/" id="intr0045">https://www.who.int/csr/don/11-february-2019-mers-oman/en/</ext-link>.</mixed-citation></ref><ref id="bib0145"><label>29</label><mixed-citation publication-type="other" id="oref0145">Laboratory testing of human suspected cases of novel coronavirus (nCoV) infection Interim guidance 10 January 2020. [Available from]: <ext-link ext-link-type="uri" xlink:href="https://www.who.int/iris/bitstream/handle/10665/330374/WHO-2019-nCoV-laboratory-2020.1-eng.pdf" id="intr0050">https://www.who.int/iris/bitstream/handle/10665/330374/WHO-2019-nCoV-laboratory-2020.1-eng.pdf</ext-link>.</mixed-citation></ref><ref id="bib0150"><label>30</label><element-citation publication-type="journal" id="sbref0150"><person-group person-group-type="author"><name><surname>Al Abaidani</surname><given-names>I.S.</given-names></name><name><surname>Al Maani</surname><given-names>A.S.</given-names></name><name><surname>Al Kindy</surname><given-names>H.S.</given-names></name><name><surname>Al-Jardani</surname><given-names>A.K.</given-names></name><name><surname>Abdel-Hady</surname><given-names>D.M.</given-names></name><name><surname>Zayed</surname><given-names>B.E.</given-names></name></person-group><article-title>Overview of preparedness and response for Middle East respiratory syndrome coronavirus (MERS-CoV) in Oman</article-title><source>Int J Infect Dis</source><volume>29</volume><year>2014</year><fpage>309</fpage><lpage>310</lpage><comment>[Available from]:</comment><ext-link ext-link-type="uri" xlink:href="https://www.sciencedirect.com/science/article/pii/S1201971214016488" id="intr0055">https://www.sciencedirect.com/science/article/pii/S1201971214016488</ext-link><pub-id pub-id-type="pmid">25447719</pub-id></element-citation></ref><ref id="bib0155"><label>31</label><element-citation publication-type="journal" id="sbref0155"><person-group person-group-type="author"><name><surname>Balkhair</surname><given-names>A.</given-names></name><name><surname>Al Maamari</surname><given-names>K.</given-names></name><name><surname>Ba Alawi</surname><given-names>F.</given-names></name></person-group><article-title>The struggle against MERS-CoV (The Novel Coronavirus)</article-title><source>Oman Med J</source><volume>28</volume><issue>July (4)</issue><year>2013</year><fpage>226</fpage><lpage>227</lpage><comment>[Available from]:</comment><ext-link ext-link-type="uri" xlink:href="http://www.omjournal.org/fultext_PDF.aspx?DetailsID=392%26type=fultext" id="intr0060">http://www.omjournal.org/fultext_PDF.aspx?DetailsID=392&type=fultext</ext-link><pub-id pub-id-type="pmid">23904912</pub-id></element-citation></ref><ref id="bib0160"><label>32</label><element-citation publication-type="journal" id="sbref0160"><person-group person-group-type="author"><name><surname>Nassar</surname><given-names>M.S.</given-names></name><name><surname>Bakhrebah</surname><given-names>M.A.</given-names></name><name><surname>Meo</surname><given-names>S.A.</given-names></name><name><surname>Alsuabey</surname><given-names>M.S.</given-names></name><name><surname>Zaher</surname><given-names>W.A.</given-names></name></person-group><article-title>Global seasonal occurrence of Middle East respiratory syndrome coronavirus (MERS-CoV) infection</article-title><source>Eur Rev Med Pharmacol Sci</source><volume>22</volume><year>2018</year><fpage>3913</fpage><lpage>3918</lpage><pub-id pub-id-type="pmid">29949167</pub-id></element-citation></ref><ref id="bib0165"><label>33</label><element-citation publication-type="journal" id="sbref0165"><person-group person-group-type="author"><name><surname>Al Harthy</surname><given-names>K.</given-names></name><name><surname>Al Maani</surname><given-names>A.</given-names></name><name><surname>Elsheikh</surname><given-names>M.</given-names></name></person-group><article-title>Infection prevention and control strategies for the Middle East respiratory syndrome coronavirus and outcome in Oman</article-title><source>Antimicrob Resist Infect Control</source><volume>4</volume><year>2015</year><fpage>O58</fpage><pub-id pub-id-type="doi">10.1186/2047-2994-4-S1-O58</pub-id><comment>[Available from]</comment></element-citation></ref><ref id="bib0170"><label>34</label><element-citation publication-type="journal" id="sbref0170"><person-group person-group-type="author"><name><surname>Ghazal</surname><given-names>H.S.</given-names></name><name><surname>Ghazal</surname><given-names>S.</given-names></name><name><surname>Alharbi</surname><given-names>T.M.</given-names></name><name><surname>Al Nujaidi</surname><given-names>M.</given-names></name><name><surname>Memish</surname><given-names>Z.A.</given-names></name></person-group><article-title>Middle-East respiratory syndrome-coronavirus: putting emergency departments in the spotlight</article-title><source>J Health Spec</source><volume>5</volume><year>2017</year><fpage>51</fpage><lpage>54</lpage></element-citation></ref><ref id="bib0175"><label>35</label><element-citation publication-type="journal" id="sbref0175"><person-group person-group-type="author"><name><surname>Al-Tawfiq</surname><given-names>J.A.</given-names></name><name><surname>Omrani</surname><given-names>A.S.</given-names></name><name><surname>Memish</surname><given-names>Z.A.</given-names></name></person-group><article-title>Middle East respiratory syndrome coronavirus: current situation and travel-associated concerns</article-title><source>Front Med</source><volume>10</volume><year>2016</year><fpage>111</fpage><lpage>119</lpage><pub-id pub-id-type="pmid">27146399</pub-id></element-citation></ref><ref id="bib0180"><label>36</label><element-citation publication-type="journal" id="sbref0180"><person-group person-group-type="author"><name><surname>Al-Tawfiq</surname><given-names>J.A.</given-names></name><name><surname>Memish</surname><given-names>Z.A.</given-names></name></person-group><article-title>Drivers of MERS-CoV transmission: what do we know?</article-title><source>Expert Rev Respir Med</source><volume>10</volume><year>2016</year><fpage>331</fpage><lpage>338</lpage><pub-id pub-id-type="pmid">26848513</pub-id></element-citation></ref><ref id="bib0185"><label>37</label><element-citation publication-type="journal" id="sbref0185"><person-group person-group-type="author"><name><surname>Al-Tawfiq</surname><given-names>J.A.</given-names></name><name><surname>Memish</surname><given-names>Z.A.</given-names></name></person-group><article-title>Infection control measures for the prevention of MERS coronavirus transmission in healthcare settings</article-title><source>Expert Rev Anti Infect Ther</source><volume>14</volume><year>2016</year><fpage>281</fpage><lpage>283</lpage><pub-id pub-id-type="pmid">26687211</pub-id></element-citation></ref><ref id="bib0190"><label>38</label><element-citation publication-type="book" id="sbref0190"><person-group person-group-type="author"><name><surname>World Health Organization</surname></name></person-group><chapter-title>Global Alert and Response (GAR): novel coronavirus infection - update (Middle East respiratory syndrome coronavirus)</chapter-title><comment>[Available from]:</comment><year>2013</year><publisher-name>World Health Organization</publisher-name><publisher-loc>Geneva, Switzerland</publisher-loc><ext-link ext-link-type="uri" xlink:href="http://www.who.int/csr/don/2013_05_23_ncov/en/index.html" id="intr0065">http://www.who.int/csr/don/2013_05_23_ncov/en/index.html</ext-link></element-citation></ref><ref id="bib0195"><label>39</label><mixed-citation publication-type="other" id="oref0195">Donnelly CA, Malik MR, Elkholy A, Cauchemez S, Van Kerkhove MD. Worldwide reduction in MERS cases and deaths since 2016. Emerg Infect Dis. (2019 Sep). Available from: <pub-id pub-id-type="doi">10.3201/eid2509.190143</pub-id>.</mixed-citation></ref><ref id="bib0200"><label>40</label><element-citation publication-type="journal" id="sbref0200"><person-group person-group-type="author"><name><surname>Abroug</surname><given-names>Fekri</given-names></name><name><surname>Slim</surname><given-names>Amine</given-names></name><name><surname>Ouanes-Besbes</surname><given-names>Lamia</given-names></name><name><surname>Kacem</surname><given-names>Mohamed-Ali Hadj</given-names></name><name><surname>Dachraoui</surname><given-names>Fahmi</given-names></name></person-group><article-title>Family cluster of middle east respiratory syndrome coronavirus infections, Tunisia, 2013</article-title><source>Emerging Infect Dis</source><volume>20</volume><issue>9</issue><year>2014</year><fpage>1527</fpage><lpage>1530</lpage><pub-id pub-id-type="pmid">25148113</pub-id></element-citation></ref><ref id="bib0205"><label>41</label><element-citation publication-type="journal" id="sbref0205"><person-group person-group-type="author"><name><surname>Sikkema</surname><given-names>R.S.</given-names></name><name><surname>Farag</surname><given-names>E.A.</given-names></name><name><surname>Himatt</surname><given-names>S.</given-names></name><name><surname>Ibrahim</surname><given-names>A.K.</given-names></name><name><surname>Al-Romaihi</surname><given-names>H.</given-names></name><name><surname>Al-Marri</surname><given-names>S.A.</given-names></name></person-group><article-title>Risk factors for primary Middle East respiratory syndrome coronavirus infection in camel workers in Qatar during 2013–2014: a case-control study</article-title><source>J Infect Dis</source><volume>215</volume><year>2017</year><fpage>1702</fpage><lpage>1705</lpage><pub-id pub-id-type="pmid">28387845</pub-id></element-citation></ref><ref id="bib0210"><label>42</label><element-citation publication-type="journal" id="sbref0210"><person-group person-group-type="author"><name><surname>Al-Tawfiq</surname><given-names>J.A.</given-names></name><name><surname>Abdrabalnabi</surname><given-names>R.</given-names></name><name><surname>Taher</surname><given-names>A.</given-names></name><name><surname>Mathew</surname><given-names>S.</given-names></name><name><surname>Rahman</surname><given-names>K.A.</given-names></name></person-group><article-title>Infection control influence of Middle East respiratory syndrome coronavirus: a hospital-based analysis</article-title><source>Am J Infect Control</source><volume>0</volume><year>2018</year><fpage>1</fpage><lpage>4</lpage></element-citation></ref><ref id="bib0215"><label>43</label><element-citation publication-type="journal" id="sbref0215"><person-group person-group-type="author"><name><surname>Alfaraj</surname><given-names>S.H.</given-names></name><name><surname>Al Tawfiq</surname><given-names>J.A.</given-names></name><name><surname>Altuwaijri</surname><given-names>T.A.</given-names></name><name><surname>Alanazi</surname><given-names>M.</given-names></name><name><surname>Alzahrani</surname><given-names>N.</given-names></name><name><surname>Memish</surname><given-names>Z.A.</given-names></name></person-group><article-title>Middle East respiratory syndrome coronavirus transmission among health care workers: implication for infection control</article-title><source>Am J Infect Control</source><volume>46</volume><year>2018</year><fpage>165</fpage><lpage>168</lpage><pub-id pub-id-type="doi">10.1016/j.ajic.2017.08.010</pub-id><comment>[Available from:]</comment><pub-id pub-id-type="pmid">28958446</pub-id></element-citation></ref><ref id="bib0220"><label>44</label><element-citation publication-type="journal" id="sbref0220"><person-group person-group-type="author"><name><surname>Ki</surname><given-names>M.</given-names></name></person-group><article-title>MERS outbreak in Korea: hospital-to-hospital transmission</article-title><source>Epidemiol Health</source><volume>37</volume><year>2015</year><object-id pub-id-type="publisher-id">e2015033</object-id></element-citation></ref><ref id="bib0225"><label>45</label><mixed-citation publication-type="other" id="oref0225">Anwar E. Ahmed. Diagnostic delays in Middle East respiratory syndrome coronavirus patients and health systems. J Infect Public Health. [Available from: <ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by-nc-nd/4.0/" id="intr0075">http://creativecommons.org/licenses/by-nc-nd/4.0/</ext-link>].</mixed-citation></ref><ref id="bib0230"><label>46</label><element-citation publication-type="journal" id="sbref0230"><person-group person-group-type="author"><name><surname>Cowling</surname><given-names>B.</given-names></name><name><surname>Park</surname><given-names>M.</given-names></name><name><surname>Fang</surname><given-names>V.</given-names></name><name><surname>Wu</surname><given-names>P.</given-names></name><name><surname>Leung</surname><given-names>G.M.</given-names></name><name><surname>Wu</surname><given-names>J.T.</given-names></name></person-group><article-title>Preliminary epidemiological assessment of MERS-CoV outbreak in South Korea, May to June 2015</article-title><source>Euro Surveill.</source><volume>20</volume><year>2015</year><fpage>7</fpage><lpage>13</lpage><pub-id pub-id-type="pmid">26132767</pub-id></element-citation></ref><ref id="bib0235"><label>47</label><mixed-citation publication-type="other" id="oref0235">Middle East respiratory syndrome coronavirus (MERS-CoV), facts sheet. 23 January 2019. [Available from]: <ext-link ext-link-type="uri" xlink:href="https://www.who.int/news-room/fact-sheets/detail/middle-east-respiratory-syndrome-coronavirus-(mers-cov)" id="intr0080">https://www.who.int/news-room/fact-sheets/detail/middle-east-respiratory-syndrome-coronavirus-(mers-cov)</ext-link>.</mixed-citation></ref><ref id="bib0240"><label>48</label><mixed-citation publication-type="other" id="oref0240">Clinical management of severe acute respiratory infection when Middle East respiratory syndrome coronavirus (MERS-CoV) infection is suspected Interim guidance Updated January 2019 WHO/MERS/Clinical/15.1 Revision 1. [Available from]: <ext-link ext-link-type="uri" xlink:href="https://www.who.int/csr/disease/coronavirus_infections/case-management-ipc/en/" id="intr0085">https://www.who.int/csr/disease/coronavirus_infections/case-management-ipc/en/</ext-link>.</mixed-citation></ref></ref-list><ack id="ack0005"><title>Acknowledgments</title><p>We are in debt to Ahmed Al Saidi, Mohammed Al Hossani, Hanan Al Kindi, Seif Al Abri, Amena Al Jardania, Idris Al Obaidani, Hanan Al kindi, Ammal Al Maani, Badder Al Rawahi, Julanda Hamad Al Mawali, Adel Al Wahabi, Hammad Al Musharafi, South ASharqiyah Governorate, Ministry of Health (Mohamed Al Daowdi, Debbi Rawclaif, Farrouqu, Haleema Al Farsi, Othman AlRasbi, Fatma Naseeb, Yusra Yousuf, Alya Abdullah, Salhah Khalfan, Nabeel Al Araimi, Aysha Al Hashmi, Ahmed Al Seyabi, Mahmood Al Mughaighri, Thaniya Al Mamari), all Governorate epidemiologists focal points, KhanWasiq Mehmood, Mamun Malik, Allison Seeger and Magda Salim Al Wahebi for their vision and support.</p></ack></back></pmc></record>Pour manipuler ce document sous Unix (Dilib)
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