Middle East respiratory syndrome (MERS) is a viral respiratory disease caused by a coronavirus (MERS‐CoV) which was first isolated in Saudi Arabia in 2012.¹ Since then, 1,365 confirmed cases of MERS-CoV, including almost 490 associated deaths (case fatality rate - 36%) have been reported in 26 different nations across Middle East (9), Europe (8), Africa (3), Asia (5), and United States of America.¹ However, the maximum number of cases (>85%) has been isolated from Saudi Arabia alone.¹ Although a major proportion of these cases have been attributed to human-to-human transmission (close contact, non-adherence to standard infection prevention guidelines while providing care to an infected patient, especially among healthcare staff and family members), nevertheless, the possibility of non-human to human transmission through camels (reservoir host) cannot be ruled out.^1,2

The most recent outbreak of MERS-CoV has been reported in the Republic of Korea, and is being considered as the largest disease outbreak outside Middle East, accounting for a total of 186 MERS-CoV cases, including 36 deaths to date.³ The primary case, a 68 year-old male, was confirmed with MERS-CoV infection on 20^th May 2015. He had acquired the infection during a trip to Middle East (Bahrain, Saudi Arabia, Qatar).⁴ This patient entered Korea on May 4 and then approached two clinics and one hospital in the next 14 days before being admitted in a hospital in Seoul on May 18.⁴ Subsequently, by June 9, almost 40 secondary cases (3 health staff plus 37 other patients/relatives) were diagnosed in the three health facilities which the primary case had visited before being diagnosed with the infection.^4,5 Thereafter, multiple tertiary cases were isolated in the same hospital and various other hospitals (overall 14 health facilities), which were visited by the secondary cases for seeking treatment. In fact, one of the secondary cases exposed to the primary/index case visited China via Hong Kong and is now under isolation.^3,5 To date, except for the index case, all the other cases of MERS-CoV in Korea are associated with health establishments.³ Further, it is anticipated that as earlier observed in Middle East, many more tertiary cases are expected to develop.^3-5

The current outbreak of MERS-CoV infection in Korea emphasizes that this is a major public health threat which has the potential to reach epidemic proportions despite the absence of any evidence of virus mutation.^3,6 However, the most serious concerns remain the poor standards of infection control measures in the hospitals among the healthcare workers, and the ineffective disinfection procedures as the virus was isolated from specimens obtained from bathrooms/ doorknobs.⁴ In addition, issues like risk of evolution of more virulent forms of the virus in the future, loopholes in the knowledge on epidemiology of the infection, absence of effective prophylaxis or therapeutic tools, high risk of mortality among healthcare staff, pilgrimage of millions of people to Middle-East during Ramadan, and inadequacy in the global surveillance mechanism to detect emerging/ re-emerging communicable diseases, have raised serious concerns about the disease.^3,4,6

As almost all patients with MERS-CoV present with non-specific respiratory complaints, the implementation of sound infection prevention and control measures (including standard precautions by healthcare workers for all patients irrespective of their diagnosis) is critical to prevent the possible spread of MERS-CoV in healthcare facilities.^1,7On a national scale, the countries should strengthen their surveillance mechanisms to comprehensively monitor cases of severe acute respiratory infections, ensure isolation of cases as well as contacts, notify any probable/ confirmed cases of MERS-CoV to the World Health Organization (WHO), implement routine measures at airports/ ship harbors to take care of ill travelers, and create awareness among travelers about the symptoms of the disease and desired preventive measures.^1,3,7 Health professionals should be educated and trained regarding infection prevention and control so that the potential risk of transmission of the virus from an infected patient to other patients, healthcare workers, and visitors can be significantly reduced.^2,5However, from the travel perspective, as there is no confirmatory evidence to suggest sustained human-to-human transmission in the community, no restriction in travel or trade is recommended as of now.³ Nevertheless, it is advisable to inform travelers about the extent of risk in the nation in which travel is planned, and to instruct them to adhere to basic precautions and seek medical attention if they develop symptoms either during travel or within two weeks of completion of travel.^3,6

Furthermore, there is need for implementation of other measures like discouraging the practice of consumption of raw or undercooked animal products; creating awareness among the general population (especially those visiting places where camels/ other animals are present) to practice general hygiene measures before and after touching animals; strategic use of different tools of mass media to address the misconceptions/ fear in the community; and motivating high-risk group people (i.e., patients with chronic illness or immunosuppression) to avoid contact with camels or consume meat/ milk of camels.^2,6,7 In addition, it is essential that the countries in which no cases have been detected yet maintain a high level of vigilance, especially among the travelers returning from MERS-CoV affected nations.^4,7However, at the same time, WHO is working in coordination with various experts to understand the virus and its attributes better, and to formulate priorities for outbreak response/ management of diagnosed patients.^3,7

To conclude, MERS-CoV is a global public health concern and essentially requires strengthening of the existing infection prevention and control measures to reduce the magnitude of the disease.

1. World Health Organization. Middle East respiratory syndrome coronavirus (MERS-CoV): Fact sheet N°401;
2015. Accessed on: July 11, 2015. Available at: http://who.int/mediacentre/factsheets/mers-cov/en/
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Ctries 2015; 9:543-6. [CrossRef] MERS-CoV outbreak in Korea – Shrivastava et al.• Correspondence
www.jccp.ro • Journal of Contemporary Clinical Practice 2(1) • March 2016 • page 33
3. World Health Organization. Middle East respiratory syndrome coronavirus (MERS-CoV) – Republic of Korea;
2015. Accessed on: July 11, 2015. Available at: http://who.int/csr/don/10-july-2015-mers-korea/en/
4. Lee J. Better understanding on MERS corona virus outbreak in Korea. J Korean Med Sci 2015;30:835-6. [CrossRef]
5. Cowling BJ, Park M, Fang VJ, Wu P, Leung GM, Wu JT. Preliminary epidemiological assessment of MERS-CoV
outbreak in South Korea, May to June 2015. Euro Surveill 2015;20:7-13. [CrossRef]
6. Petersen E, Hui DS, Perlman S, Zumla A. Middle East Respiratory Syndrome - advancing the public health and
research agenda on MERS - lessons from the South Korea outbreak. Int J Infect Dis 2015;36:54-5. [CrossRef]
7. World Health Organization. Frequently asked questions on Middle East respiratory syndrome coronavirus
(MERS‐CoV); 2015. Accessed on: July 12, 2015. Available at:
http://who.int/csr/disease/coronavirus_infections/faq/en/