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DOD Lab Identified First Cases of Middle East Coronavirus

A Defense Department-funded lab in Egypt detected the earliest-known cases of Middle East Respiratory Syndrome virus,
A Defense Department-funded lab in Egypt detected the earliest-known cases of Middle East Respiratory Syndrome virus, a new coronavirus strain that is infecting people on the Arabian Peninsula, an expert from DOD's global disease surveillance system said.

The lab shared samples so the Centers for Disease Control and Prevention could develop tests for the virus, said Public Health Service Capt. Michael J. Cooper, head of respiratory disease for the Global Emerging Infections Surveillance and Response System, called GEIS, which is part of the Armed Forces Health Surveillance Center.
GEIS is a funding agency that supports military laboratories in the United States and in Egypt, Germany, Kenya, Peru, Thailand and Singapore -- all of which serve as hubs for infectious disease surveillance and as regional hubs for addressing global public health issues -- and it funds respiratory disease surveillance projects at 400 sites in more than 30 countries.

As of May 9, the World Health Organization, or WHO, reports 536 laboratory-confirmed cases of MERS-CoV since April 2012,including 145 deaths.
Some people infected with MERS-CoV develop severe acute respiratory illness with symptoms of fever, cough and shortness of breath, and about 30 percent of known cases die, according to the CDC. Some people exposed to the virus get only a mild respiratory illness, the CDC reported.

A CDC fact sheet says MERS-CoV has spread between people in close contact and from infected patients to health care workers. Clusters of cases in several countries are being investigated, as is the source of the new strain, the CDC says.

MERS-CoV has been found in camels in Qatar, Egypt and Saudi Arabia, and in a bat in Saudi Arabia. Camels in other countries have tested positive for MERS-CoV antibodies, meaning they have been infected with MERS-CoV or a closely related virus. But CDC says it needs more information to identify the potential roles of camels, bats or other animals in MERS-CoV transmission.
On May 2, CDC reported the first confirmed U.S. case of MERS-CoV in a health care worker traveling from Saudi Arabia to London to the United States. The patient was hospitalized in Indiana and at the time was in stable condition, CDC officials said.


During a recent interview with American Forces Press Service, Cooper said, "[GEIS's] first objective is force health protection" for U.S. troops, "but we are also involved with global public health issues."
He added, "We also do surveillance on diseases that aren't necessarily militarily relevant but are relevant to global public health because sick people can board aircraft and carry infectious diseases anywhere in the world within 24 hours."


One of GEIS's funded laboratories is the Naval Medical Research Unit-3, or NAMRU-3, the largest DOD overseas lab, formally established in Cairo in 1946.
Scientists there conduct research on a range of diseases and perform infectious disease surveillance to support military personnel deployed to Africa, the Middle East and Southwest Asia.

NAMRU-3 also works closely with the Egyptian Ministry of Health and Population, the U.S. National Institutes of Health, WHO and CDC, and is a WHO regional Collaborating Center for HIV and Emerging Infectious Diseases.
Cooper said GEIS funds the Jordan National Influenza Center, called the NIC, and that NAMRU-3 and members of the Jordan Ministry of Health and the NIC work together often.

The story of MERS-CoV, although the first case reported to WHO was from Saudi Arabia in September 2012, really began in Jordan earlier that year, Cooper explained.
"In April 2012 there was an outbreak of severe acute respiratory illness in a Jordanian hospital -- we call them SARI cases -- and the folks at the Ministry of Health in Jordan asked NAMRU-3 to help with the outbreak investigation," he said.

Eleven people were hospitalized, he said. Eight of them were health care workers. NAMRU-3 team members arrived and took samples from the patients, but back at the lab in Cairo they could find no pathogen at that time, he said. MERS-CoV hadn't yet been discovered, so no specific test for it existed.

On April 24, the NAMRU-3 team told the Jordan Ministry of Health that all samples tested negative for known coronaviruses and other respiratory viruses. The samples were saved at NAMRU-3.
"Flash forward to September 2012, London, England," Cooper said.
On Sept. 11 that year, a 49-year-old Qatari man with a history of travel to Saudi Arabia was flown by air ambulance from Qatar to a London intensive-care unit. He suffered from acute respiratory infection and kidney failure.

Eleven days later, on Sept. 22, the U.K. Health Protection Agency reported to WHO that it had compared information from the U.K. Qatari patient with that of a virus sequenced earlier in the year by Erasmus University Medical Centre in the Netherlands. This earlier sample, from lung tissue of a 60-year-old Saudi man who had died in June, was a 99.5 percent match with the new coronavirus strain from the Qatari man, according to a Sept. 23 WHO Global Alert and Response document.

Now, WHO had two confirmed cases of the new strain.
The news "caused a lot of concern," Cooper said, "because the last time the world saw an emerging coronavirus strain was 2002-2003, and it was severe acute respiratory syndrome -- SARS -- which caused about 8,000 cases and 780 deaths" in more than 24 countries.

In 2012, Cooper said, this got GEIS's attention.
"In October we decided to ask our partners at four different locations to do retrospective surveillance for all their samples that were associated with respiratory illness," he said.
The partners were NAMRU-3 in Cairo, Landstuhl Regional Medical Center in Germany, U.S. Army Research Unit-Kenya in Africa and the U.S. Air Force School of Aerospace Medicine at Wright Patterson Air Force Base in Ohio.
"Then NAMRU-3, remembering the outbreak in Jordan in April," Cooper said, retested the Jordan samples from April. By November 2012 the NAMRU-3 team provided lab results that confirmed two of the original 11 cases as infections by the novel coronavirus.

"Now the NAMRU-3 team understood that what they had back in April 2012 was the earliest known outbreak of this emerging infection," Cooper explained.
"Until then," he said, "the vast majority of cases had come out of Saudi Arabia. If we had never found the earliest cases, Jordan wouldn't even be in the mix. And you'd like to know the earliest cases to get an idea of where [the new strain] is coming from."
NAMRU-3 then shared samples from the earliest MERS-CoV cases with CDC, Cooper said, "so an assay, or test, could be developed, which is very important. Now you've got a positive control [for the novel MERS-CoV strain] because you have the actual sample."

According to its fact sheet, with such samples CDC develops molecular diagnostics that let scientists accurately identify MERS cases, and it develops assays to detect MERS-CoV antibodies. These lab tests help scientists tell whether a person is or has been infected with MERS-CoV.
CDC also provides MERS-CoV test kits to state health departments so they can test for patients under investigation for MERS-CoV infection.

CDC evaluates genetic sequences as they become available as well, and at NAMRU-3 scientists today grow the new coronavirus strain, sequence it and continue to work with it.
"They've gotten additional samples to confirm because they serve as a WHO reference laboratory for that region," Cooper said, "and they've recently discovered a travel case from the Saudi Arabian peninsula to Egypt."
NAMRU-3 also trains physicians and scientists from ministries of health in countries such as the United Arab Emirates, Saudi Arabia, Jordan and Yemen, and in West African countries, he said, adding that the GEIS-funded training involves teaching attendees how to use the MERS-CoV assays and discussing important facts about the new coronavirus.
Cooper defines infectious disease surveillance as "basically collecting data in a systematic way so that disease levels can be monitored. Hopefully this information gives you an idea of the distribution of a given disease and hopefully helps to understand what populations are affected."
Doing surveillance, he said, usually involves "testing people who are ill and in some cases testing people who are not ill but who may have been exposed to the virus."

All DOD major infectious disease labs have surveillance capabilities for MERS-CoV, Cooper added, and all DOD major medical centers around the world have MERS-CoV diagnostic capabilities.
GEIS does surveillance for a range of diseases, he said, including H7N9 influenza emerging in China, enteric infections like those caused by contaminated food or water, parasitic infections like malaria, other respiratory infections like multidrug-resistant tuberculosis, and sexually transmitted infections.

Cooper said respiratory diseases are the ones that typically go pandemic because of the way they spread.
"The most recent examples are SARS and the pandemic of 2009, which was H1N1 influenza," he said. "They spread easily from person to person and they don't kill their hosts too soon or maybe at all."
About MERS-CoV, Cooper said, "We were well ahead of the curve on this one and we have a very strong network of respiratory disease surveillance."
He added, "We'll also say this, though. We're dealing with a virus and viruses can change and quite frankly frequently do change. So you have to monitor the situation and you have to be careful. Surveillance is key in this situation. You have to know what's going on."
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