Unfortunately, the answer is “YES”. Although the Severe Acute Respiratory Syndrome (SARS) outbreak was controlled within a year, Middle East Respiratory Syndrome Coronavirus (MERS-Cov) which is a recently diagnosed virus related to SARS-CoV, remains occurring and posing a great threat to human health in the Middle East and globally.¹

MERS-CoV belongs to the genus Coronavirus, within the family Coronaviridae which comprises enveloped single-stranded RNA viruses known for causing various infections in mammalian and avian hosts.²

Coronaviruses (CoVs) were known to cause mild upper respiratory tract infections, until SARS-CoV emerged in 2002 and confronted the global health community to try containing a new epidemic that spread rapidly from its origins in southern China until reaching many countries.³ Ten years later, in September 2012, a Saudi physician reported the isolation of a new coronavirus from a patient in Jeddah, Saudi Arabia presenting with acute pneumonia and subsequent renal failure with a fatal outcome.⁴ Within a few days, the same virus was detected in a Qatari patient who has been transferred to London, United Kingdom to receive intensive care.^5-6 The emergence of the new disease was retrospectively traced to a preceding event; an outbreak of lower respiratory illnesses at a hospital in Jordan in April 2012 where two persons died, both of whom were retrospectively confirmed to have been infected with the new CoV.⁷ A large outbreak of MERS-CoV has occurred in 2015 in South Korea, after a single patient exposure in an emergency room at the Samsung Medical Center, a tertiary-care hospital in Seoul.⁸ On 23 January 2016, 1,626 laboratory confirmed cases, and 586 related deaths were reported by the World Health Organization (WHO). Such cases have been reported from 26 countries, but the initial zoonotic transmission from dromedary camels to humans has so far been reported only within the Arabic Peninsula.⁹

The natural reservoir of MERS-CoV is still unknown, however, bats may represent one possible reservoir. Dromedary camels have been shown as mainly responsible for animal to human transmission. The virus has been isolated from dromedary camels in the Arabian Peninsula and across North, East, West, and Central Africa; seropositive camels were detected in Egypt, Kenya, Nigeria, Tunisia, and Ethiopia.^{10 – 12} However, the virus is not present in either dromedary camels in Kazakhstan, or in Bactrian camels in Mongolia or other countries as Japan.^{13 – 15}
Upon admission to hospitals, MERS patients present with fever, cough, expectoration, and shortness of breath.^{16 – 17} In addition, ground glass opacities and consolidation in the lungs are usually reported in chest radiographs or computed tomography scans.¹⁸ Nevertheless, these symptoms and findings overlap with those of other lower respiratory tract infections, and are not pathognomonic for MERS-CoV; a situation that calls for the need to develop highly specific laboratory-based diagnostic assays.¹⁹

Real-time Polymerase Chain reaction (PCRRT-PCR) based assays, despite their high specificity and sensitivity, still have limitations since MERS-CoV can only be detected upon being actively shed by the host. Afterwards, serology-based assays were developed to distinguish those individuals who have been previously exposed to MERS-CoV. Other alternative assays were developed, but they were not reliable because of different limitations.¹⁹ Finally, a detection method for MERS-CoV that can be used towards rapid and accurate diagnosis was published in May 2018 by Huang et al.²⁰ In order to detect the N gene of MERS-CoV, they developed a nucleic acid visualization technique that incorporates the reverse transcription loop-mediated isothermal amplification technique and a vertical flow visualization strip (RT-LAMP-VF). Successfully, this technique did not exhibit cross-reactivities with various CoVs including SARS-related (SARSr)-CoV, HKU4, HKU1, OC43 and 229E; which demonstrates high specificity. Moreover, this assay’s rapidity and lack of need for special instrumentation point to its ease of conduction within different laboratory settings.²⁰

Treatment of MERS-CoV is mainly supportive, which is not highly effective given the high case-fatality rate.²¹ High flow oxygen therapy, noninvasive ventilation, and high frequency oscillatory ventilation may be used with caution in MERS-CoV patients due to their capacity of generating aerosols, and the lack of effectiveness in Acute Respiratory Distress Syndrome (ARDS), which commonly complicates MERS-CoV infection.²² Conservative fluid management is recommended in MERS patients with acute renal injuries and hypoxaemia in the absence of shock.^23-24
Regarding anti-viral therapy, Interferon -α 2b (IFN-α 2b) combined with ribavirin was effective in reducing MERS-CoV replication in vitro. Accordingly, Falzarano et al.²⁵ have tried it in vivo through initiating this treatment 8 hours after inoculation of rhesus macaques- the only known model organism for MERS-CoV infection. Promisingly, the treated animals did not suffer breathing abnormalities. Furthermore, they showed no or very mild radiographic evidence of pneumonia, lower levels of systemic (serum) and local (lung) proinflammatory markers, and less severe histopathological changes in the lungs. These results suggest that the combination of IFN-α 2b and ribavirin can be considered for the management of MERS-CoV cases.

There is no licensed vaccine for MERS-CoV, and therefore many laboratories are focusing on developing an effective vaccine against it.²⁶ For the purpose of preventing, or if necessary managing, MERS-CoV infections during a mass gathering, WHO recommends that public health authorities may consider enhanced surveillance, command and control arrangements that link actions across agencies, travel health planning, clinical management of confirmed MERS-CoV cases, infection prevention and control, and risk communication.²⁷

We are still trying to dig deeper to develop a better understanding of MERS-CoV, being challenged with a wide gap in our knowledge of the modes of zoonotic transmissions, clinical management, and prevention. There is a worldwide urgent need for larger epidemiological and outcome studies.

As recently announced by the European Centre for Disease Prevention and Control, an agency of the European Union, “A new case of Middle East respiratory syndrome coronavirus (MERS-CoV) has been confirmed by Public Health England (PHE) on the 23 August”.²⁸

The health of people everywhere must be a growing concern for all of us. Diseases do not respect boundaries; there have been large outbreaks of Mosquito-borne diseases in India and South East Asia, and the geographical spread is increasing. Human Immunodeficiency Virus (HIV) has spread all over the world. The West Nile Virus (WNV) was first identified in the Mediterranean area, in Egypt, but now it is widely established. A person with tuberculosis can infect up to 10-15 people over the course of a year. Not to mention that alarm bells are ringing over the risk of a worldwide epidemic (or pandemic) of influenza. And here we are talking about MERS-CoV which was first isolated in the Arabic Peninsula and remains a global threat that has the potential to cause large outbreaks.