IOSR Journal of Pharmacy and Biological Sciences (IOSR-JPBS)

e-ISSN: 2278-3008, p-ISSN:2319-7676. Volume 8, Issue 5 (Nov. Dec. 2013), PP 74-81

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Middle East Respiratory Syndrome - Corona Virus (MERSCoV): A Deadly Killer

Harshit A. Jadav
L.J.Institute of Pharmacy, Ahmedabad

Abstract: Middle east respiratory syndrome-corona virus ,a new species of corona virus has emerge in the
middle east countries and has very high (almost 50%) fatality ratio. There is no any specific symptoms which
are seen in the MERS-CoV. The symptoms which are seen are similar to those of simple general respiratory
disease. There is no any treatment as well as no any vaccine available for the condition. Only one thing which
are in our hand is to prevent the disease. Transmission of the disease is mainly by person to person transmission
or by the virus affected bat or camels which are seen in the most of the cases. Disease is mostly seen in aged
people (age>65) which has week immune system and which are under ICU or Dialysis are more prone to the
disease. Phylogenetic analysis shows that the patients which have the disease they have directly or indirectly
contact shows that person to person transmission occur in the MERS-CoV. The pathogenesis of the disease is
still unknown. Clusters of cases in Saudi Arabia, Jordan, the UK, France, Tunisia, and Italy are being
investigated. The genome sequence of the virus has identified and real time reverse transcriptase polymerase
chain reaction(real time -RT-PCR) has important diagnostic tool for the identification of the disease. The WHO
and CDC are currently working on the specific transmission pattern and finding the new scope of treatment and
vaccine. There are specific prevention information for the patients, hospital staff, and visitors and the person
who travels in the middle east countries guided by WHO and CDC.
Key-words: MERS-CoV, beta-coronavirus, Middle East Respiratory Syndrome, novel coronavirus,
London1_novel CoV

I.

Introduction about Coronavirus:

Coronaviruses are species in the genera of virus belonging to the subfamily Coronavirinae in the
family Coronaviridae. Coronaviruses are enveloped viruses with a positive-sense RNA genome and with a
nucleocapsid of helical symmetry. The genomic size of coronaviruses ranges from approximately 26 to
32 kilobases, extraordinarily large for an RNA virus. With its characteristic surface, the virions appear as a
crown like image under the electron microscope and so the viruses are named after the Latin wordcorona,
meaning 'crown' or 'halo'.In people, coronaviruses can cause illnesses ranging in severity from the common cold
to Severe Acute Respiratory Syndrome (SARS). . In people, coronaviruses can cause illnesses ranging in
severity from the common cold to Severe Acute Respiratory Syndrome (SARS). First Human CoVs isolated in
the 2060s. The human coronaviruses mainly infect the upper respiratory and gastrointestinal tract. They often
result in upper respiratory tract infections (simple colds) in humans, causing mild illnesses usually of short
lasting nature with a rhinitis, cough, sore throat, as well as fever.
Six human CoVs (HCoVs) have been identified to date:
1. HCoV-220E
2. HCoV-OC43
3. HCoV-NL63
4. HCoV-HKU1
5. SARS-CoV
6. Middle East Respiratory Syndrome Coronavirus (MERS-CoV)
Different types of Corona Virus:
Alpha Co-V:
Human examples: HCoV-220E, HCoV-NL63
Pig, dog, and cat CoVs
Beta Co-V:
HCoV-OC43, HCoV-HKU1, HCoV-SARS
MHV, rat, pig and cow CoVs
MERS-CoV
Gamma Co-V:
Chicken and turkey CoVs
Delta Co-V:
Bird CoVs
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Middle East Respiratory Syndrome - Corona Virus (MERS-CoV): A Deadly Killer

Middle East Respiratory Syndrome Coronavirus (MERS-CoV):
Middle East Respiratory Syndrome (MERS) is a viral respiratory illness. MERS is caused by a corona
virus called Middle East Respiratory Syndrome Corona virus (MERS-CoV). MERS-CoV is a beta corona
virus. It was first reported in September 2012 in Saudi Arabia. MERS-CoV used to be called novel corona
virus. Corona viruses are a large family of viruses that cause illness in humans and animals
The novel corona virus, first detected in septmber2012.It was named by the Corona virus Study Group of the
International Committee on Taxonomy of Viruses in May 2013.Nine countries have now reported cases of
human infection with MERS-CoV. Death has occurred in about half of cases
Taxonomy of virus:
MERS-CoV is more closely related to the bat coronaviruses HKU4 and HKU5 (lineage 2C) than it is to
SARS-CoV sharing more than 90% sequence identity with their closest relationships, bat coronaviruses HKU4
and HKU5 and therefore considered to belong to the same species by the International Committee on Taxonomy
of Viruses (ICTV).
Other names:
novel coronavirus (nCoV)
London1_novel CoV 2012(34)
Human Coronavirus-Erasmus Medical Center (HCoV-EMC)
Virus
Order
Family
Subfamily
Genus
Species

ssRNA, positive single strand RNA virus

Nidovirales
Coronaviridae
Coronavirinae
Betacoronavirus
Human coronavirus HKU1
Rousettus bat coronavirus HKU9
Murine coronavirus
Severe acute respiratory syndrome-related coronavirus (SARS-CoV)
Middle East respiratory syndrome- MERS-CoV

Structural features of novel MERS-CoV:

(Electron microscope image of MIddle East Respiratory Syndrome virus particles, colorized in yellow.
(Credit: NIAID))

Here the virus of MERS-CoV contains mainly spike like structures mainly consists of glycoproyein for mainly
receptor binding and antigenic activity. It also contains neucleocapsid phosphoprotein for RNA-binding,
Membrane glycoprotein for triple membrane spanning, and positive strand RNA (+)ssRNA. The glycoprotein
spike serves as the shape of crown for the virus so called as corona virus.
Histroy of MERS-CoV:
Dr. Zaki isolated and identified a previously unknown coronavirus from the lungs of a 60-year-old
Saudi Arabian man with pneumonia and acute renal failure. [2][3] He used a broad-spectrum "pan-coronavirus"
RT-PCR method and got a positive result. The UK Health Protection Agency (HPA) confirmed the diagnosis of
severe respiratory illness associated with a new type of coronavirus in a second patient, a 49-year-old Qatari
man who had recently been flown into the UK. He died from an acute, serious respiratory illness in a London
hospital.[4][5]. In September 2012 Ron Fouchier speculated that the virus might have originated in bats. [6]. In
September 2012, the United Kingdom's Health Protection Agency (HPA) named it the London1_novel CoV
2012 and produced the virus' preliminary phylogenetic tree, the genetic sequence of the virus [12] based on the
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Middle East Respiratory Syndrome - Corona Virus (MERS-CoV): A Deadly Killer

virus's RNA obtained from the Qatari case. [5][7] On 25 September 2012, the World Health Organization(WHO)
announced that it is "engaged in further characterizing the novel coronavirus" and that it has "immediately
alerted all its Member States about the virus and has been leading the coordination and providing guidance to
health authorities and technical health agencies."[8]In May 2013, the Coronavirus Study Group of
the International Committee on Taxonomy of Viruses adopted the official designation, the Middle East
Respiratory Syndrome Coronavirus (MERS-CoV),[1] which was adopted by the World Health Organization to
"provide uniformity and facilitate communication about the disease." [9]. Fouchier and his team of researchers
successfully sequenced the whole genome of the new coronavirus naming the viral strain Human CoronavirusErasmus Medical Center (hCoV-EMC) after their research center. They published its genomic sequence in
the GenBank(accession code: JX869059) in the fall of 2012.[5]
Natural reservoir:
In September 2012, Ron Fouchier speculated that the virus might have an animal origin originating
in bats.[10],[11] Sequencing and subsequent analysis indicated that the novel coronavirus shared high sequence
homology with both bat[5]. On July 21, 2013, the World Organisation for Animal Health (OIE) announced that
"currently there is no strong evidence to suggest that camels are a source of infection for human cases of
MERS." [13] Several victims have been known to have had contact with camels, including visibly ill camels,
however.[14] On 9 August, 2013 a report in the Lancet showed that 50 of 50 (100%) blood
serum from Omani camels and 11 of 105 (14%) from Spanish camels had protein-specific antibodies against
MERS-CoV spike. Countries like Saudi Arabia and the United Arab Emirates produce and consume large
amounts of camel meat and there's a possibility that African or Australian bats harbor the virus which then
camels carried to the Middle East.[11]
Emergens of MERS-CoV:

Clinical definations and reporting criteria:

[https://ceno.chp.gov.hk/casedef/casedef.pdf] [20]
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Middle East Respiratory Syndrome - Corona Virus (MERS-CoV): A Deadly Killer

Diagnosis:
confirmatory real-time RT-PCR assays exist for rapid identification of MERS-CoV from patientderived samples (suchThroat-swab (Eurotubo, Deltalab), sputum, tracheal-aspirate, or bronchoalveolar-lavage),
upE (targets elements upstream of the E gene) and 1A (targets the ORF1a gene)[15].
In addition, hemi-nested sequencing amplicons targeting RdRp (present in all corona viruses) and N
gene (specific to MERS-CoV) fragments can be generated for confirmation via sequencing. Reports of potential
polymorphisms in the N gene between isolates highlight the necessity for sequence-based characterization.
Protocols for biologically safe immune fluorescence assays (IFA) have also been developed.
[(A)Bilateral enhanced pulmonary hilar vascular shadows (more prominent on the left) and accentuated
bronchovascular lung markings. Multiple patchy opacities in middle and lower lung fields, On admission (B)
Opacities more confluent and dense, 2 days later] [Zaki et al. N Engl J Med 2012 367:1814-20]
Progression of disease:
The disease is started with initially simple respiratory problem with simple fever, chills, muscle ache
and shortness of breath. Then it leads to severe pneumonia within 2 to 3 days. Then after some period of time it
will convert in to the SARS (severe acute respiratory syndrome) or ARDS (acute respiratory distress syndrome).
Then death is occurred in almost half of the cases.[1]
MERS-CoV cases and death:
Countries
France
Italy
Jordan
Qatar
Saudi Arabia
Tunisia
United kingdom (UK)
United Arab Emirates (UAE)
Total

Cases (death)
2 (1)
1 (0)
2 (2)
6 (3)
115 (49)
3 (1)
3 (2)
6 (2)
139 (60)

Symptoms of middle east respiratory syndrome(MERS-CoV):

Fever, chills, muscle ache, & shortness of breath are seen in most of the patients with coronavirus.
Some patients also had gastrointestinal symptoms which leads to sometimes diarrhea and vomiting and nausea
.kidney impairment is seen in about half of the cases[1]. MERS-CoV is known to infect cell lines of the intestinal
tract. MERS-CoV hasno any specific symptoms , it generally shows all the symptoms which are occurred in the
pneumonia and other respiratory disease. So its difficult to understand the disease with respect to the symptoms.
Phylogenetic analysis of middle east respiratory syndrome:

[de Groot et al. J Virol. May, 2013;]

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Middle East Respiratory Syndrome - Corona Virus (MERS-CoV): A Deadly Killer

Testing algorithm for the middle east respiratory syndrome:

Time line for UK Cluster of MERS-CoV:

[HPA UK Novel Coronavirus Investigation Team; Eurosurv 2013; 18(11)]
Evidence of person-to-person transmission was to be found out in this study. Coinfection with
influenza (index case) and parainfluenza type 2 (both secondary cases) are repoterd. No sustained chains of
transmission are measured. And Incubation periodwas found out to be 1-9 days.[17]
Transmission:
We still do not know the answer to this question. It is unlikely that transmission of the MERs-CoV to
people occurs through direct exposure to an infected camel, as very few of the cases have reported a camel
exposure.MERS-CoV has been shown to spread between people who are in close contact. [1] Transmission from
infected patients to healthcare personnel has also been observed. Clusters of cases in Saudi Arabia, Jordan, the
UK, France, Tunisia, and Italy are being investigated.

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Middle East Respiratory Syndrome - Corona Virus (MERS-CoV): A Deadly Killer

Infection control measures:[20]
Specimens Collection
Exercise standard, contact, droplet and airborne precautions for patients under isolation.
Transport of patients
Patient should wear a surgical mask and attendants should practice standard, contact, droplet and
airborne precautions.
Linen and Laundry
Pack on site and avoid shaking and Send to laundry as soon as possible.
Waste Management
All wastes arising from the patient care should be considered as clinical waste using the red bags.
Staff removing wastes should wear appropriate PPEs.
Administration Support
Management should ensure adequate resources, issue formal instructions for visitors and patients, and
postappropriate signage.
A special prevention for persons who travels in Arabian and neighbouring country:
CDC does not recommend that travelers change their plans because of MERS. However, the Saudi Arabia
Ministry of Health has made special recommendations for travelers to Hajj and Umrah. [20] Because of the risk of
MERS, Saudi Arabia recommends that the following groups should postpone their plans for Hajj and Umrah
this year:
People over 65 years old
Children under 12 years old
Pregnant women
People with chronic diseases (such as heart disease, kidney disease, diabetes, or respiratory disease)
People with weakened immune systems
People with cancer or terminal illnesses
CDC encourages people traveling to Saudi Arabia to perform Hajj or Umrah to consider this advice. People who
are concerned about MERS should discuss their travel plans with their doctor.
Treatment & Vaccine:
There are no specific treatments recommended for illnesses caused by MERS-CoV. Medical care is supportive
and to help relieve symptoms. Only symptomatic treatment is given to the patients according to its severity.[18]
There is no any vaccine available for this particular disease. CDC currently working and discussing with
partners the possibility of developing one.
Prevention for individual:
There are specific precaution which are acquired for the prevention and protection of the Disease. [16][18][20]
Avoid to going into the hospital where the chances of getting infection is very high.
Wash your hands often with soap and water for 20 seconds, and help young children do the same. If
soap and water are not available, use an alcohol-based hand sanitizer.
Cover your nose and mouth with a tissue when you cough or sneeze then throw the tissue in the trash.
Avoid touching your eyes, nose, and mouth with unwashed hands.
Avoid close contact, such as kissing, sharing cups, or sharing eating utensils, with sick people.
Clean and disinfect frequently touched surfaces, such as toys and doorknobs.Wash your hands before
and after visiting someone in a care home (many hospitals provide antibacterial gel in wards).
Prevention for hospital staff:
Hospital staff that comes into contact with patients should maintain very high standards of hygiene and
take extra care when treating patients with pneumonia and MERS-CoV.
Staff should thoroughly wash and dry their hands before and after caring for a patient, before and after
touching any potentially contaminated patients
Patients with a known or suspected MERS-CoV infection should be isolated.
The hospital environment, including floors, toilets and beds, should be kept as clean and dry as
possible.

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Middle East Respiratory Syndrome - Corona Virus (MERS-CoV): A Deadly Killer

Prevention for visitor to the patients:
Visitors can reduce the chance of spreading MRSA to other people by not sitting on the patient's bed
and by cleaning their hands before and after entering the ward.
They should use hand wipes or hand gel before touching the person they are visiting.
Patients who travels to the Arabian countries:
Taking these everyday actions can help prevent the spread of germs and protect against colds, flu, and other
illnesses:[18]
Wash your hands often with soap and water. If soap and water are not available, use an alcohol-based
hand sanitizer
Avoid touching your eyes, nose, and mouth. Germs spread this way.
Avoid close contact with sick people.
Be sure you are up-to-date with all of your shots, and if possible, see your healthcare provider at least
46 weeks before travel to get any additional shots.
If you are sick:
o Cover your mouth with a tissue when you cough or sneeze, and throw the tissue in the trash.
o Avoid contact with other people to keep from infecting them.
Clinical information about the MERS-CoV:
Health care providers should be alert to patients who develop severe acute lower respiratory illness
(e.g., requiring hospitalization) within 14 days after traveling from countries in the Arabian or neighbouring
countries, excluding those who transited at airports without entering the countries.[20][20]
Consider other more common causes of respiratory illness, such as influenza.
Immediately report patients with unexplained respiratory illness and who meet CDCs criteria for
patient under investigation (PUI) to CDC through the state or local health department. A PUI is a
person with o an acute respiratory infection, which may include fever (38C, 100.4F) and cough;
o suspicion of pulmonary parenchyma disease (e.g., pneumonia or acute respiratory distress
syndrome based on clinical or radiologic evidence of consolidation);
o history of travel from countries in the Arabian Peninsula* or neighbouring countries* within 14
days;
o not already explained by any other infection or etiology, including all clinically indicated tests for
community-acquired pneumonia according to local management guidelines.
Collect specimens for MERS-CoV testing from all PUIs.
Recent findings of virus antibodies in camels:
The recent study by Reusken and colleagues (link to the article) suggests that MERS-CoV or a virus
very similar to the MERS-CoV has been recently circulating among camels. [10] The most critical question
remains to be answered, that is, the type of human exposures that result in infection. Most human cases do not
have a history of direct contact with camels; if camels or other animals are the source, the route of transmission
to humans may be indirect. Although related viruses infect bats, molecular clock analyses have been unable to
identify direct ancestors of MERS-CoV.[12] Anecdotal exposure histories suggest that patients had been in
contact with dromedary camels or goats.
Question unsolved???
1) Pathophysiology of the MERS-CoV is still unknown.
2) Treatment and vaccine development of the disease is the primary requirement.
3) What are actual mode of transmission of the disease.?
4) Where the actual origin of the MERS-CoV.?
5) What are the actual causes of the disease?
These are some question which are still unanswered for the community. WHO and CDC are currently
working on these topic to finding out the solution of the MER-CoV. Yet there is no any further
information is available for the disease, we can only prevent the disease not cure. So finally MERSCoV is deadly kiler now a days.

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Middle East Respiratory Syndrome - Corona Virus (MERS-CoV): A Deadly Killer

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