Middle East Respiratory Syndrome: Risk Assessment October 2015
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Middle East Respiratory Syndrome Risk assessment
October 2015
– Version control –
– Section – Date updated
– Full Document – October 2015 Citation: Ministry of Health. 2015. Middle East Respiratory Syndrome: Risk assessment. Wellington: Ministry of Health.
Published in October 2015 by the Ministry of Health PO Box 5013, Wellington 6145, New Zealand
ISBN 978-0-947491-31-3 (online) HP 6294
This document is available at health.govt.nz
This work is licensed under the Creative Commons Attribution 4.0 International licence. In essence, you are free to: share ie, copy and redistribute the material in any medium or format; adapt ie, remix, transform and build upon the material. You must give appropriate credit, provide a link to the licence and indicate if changes were made. Contents
List of Figures
Middle East Respiratory Syndrome: Risk assessment 3
Executive summary
Middle East respiratory syndrome (MERS) is a respiratory disease caused by a novel coronavirus, Middle East respiratory syndrome coronavirus (MERS-CoV).
Between September 2012, when MERS-CoV was first identified in Saudi Arabia, and 1 October 2015, 1593 laboratory-confirmed cases of MERS-CoV infection and at least 568 related deaths in over 25 countries have been reported to the World Health Organization. More than one third of cases have occurred since 1 January 2015.
No cases of MERS have been reported in New Zealand.
Growing evidence indicates that the dromedary camel is a host species for the virus and that camels play an important role as a source of human infection. However, while zoonotic transmission is likely to be the starting point for most clusters, human-to-human transmission is the dominant mode of transmission. No sustained human-to-human transmission in the community has yet been recorded.
Low-level transmission continues in countries on and neighbouring the Arabian Peninsula. Cases have been exported from that region to a range of other countries.
Nosocomial outbreaks have been reported in Saudi Arabia, the United Arab Emirates and South Korea. Note that in these nosocomial outbreaks, most cases of transmission occurred before proper infection prevention and control procedures were applied.
Overall, given the low prevalence of MERS, the risk of being exposed to the virus in an affected country is considered very low. The risk is slightly higher for health care workers in the most affected countries. The risk for the health care worker will depend on the health care setting, the kind of work they are involved in, and whether and how infection prevention and control measures are being applied.
This risk of MERS being imported to New Zealand is considered to be very low given that only a small number of people travel to New Zealand from severely affected areas and that New Zealand is relatively geographically isolated. The risk of MERS-CoV spreading within New Zealand is considered extremely low, once the virus has been recognised. However, as has been observed in other countries, imported cases and limited outbreaks are possible.
New Zealand has implemented a number of measures to reduce the risk of MERS being imported. Specifically, it: continues to monitor the international MERS situation made MERS a notifiable and quarantinable disease in September 2013 under the Health Act 1956 (Schedule 1) to facilitate the legal aspects of disease control and risk mitigation provides guidelines and advice for health professionals provides information to the general public provides advice to travellers to and from affected countries about risks, preventive strategies and signs/symptoms of illness provides health-related signage and information cards at international ports of entry and is educating border health protection officers about the illness has protocols and processes in place, such as the National Health Emergency Plan, the New Zealand Influenza Pandemic Action Plan, border response plans and local emergency response plans.
Overall the risk of MERS-CoV to public health in New Zealand remains very low; there is a low risk of imported cases, and an extremely low risk of spread in the event of an imported case. Early detection of MERS among travellers from affected countries remains essential. The recent outbreaks in health care settings in South Korea and Riyadh also highlight the continued risk of nosocomial transmission and the importance of making a timely diagnosis and implementing infection prevention and control measures.
A single case of MERS in New Zealand would result in an immediate and comprehensive response.
6 Middle East Respiratory Syndrome: Risk assessment Hazard identification
MERS-CoV
Middle East respiratory syndrome coronavirus (MERS-CoV) is a novel coronavirus that causes a viral respiratory disease, Middle East respiratory syndrome (MERS). Coronaviruses are a family of viruses that include the causative agents of many illnesses, from severe acute respiratory syndrome (SARS) to the common cold. Approximately 36 percent of reported patients infected with MERS-CoV have died, though this figure may not take into account those with subclinical infections. Growing evidence indicates that the dromedary camel is a host species for the MERS-CoV and that zoonotic transmission is the starting point for most clusters. However, human-to-human transmission is the most common mode of transmission. Infected camels frequently show no sign of illness. Coronaviruses can survive up to 48 hours in the environment; therefore it is important that the patient environment remains clean. Staff performing environmental cleaning should be appropriately trained and familiar with donning and removing personal protective equipment. As coronaviruses have a lipid envelope, a wide range of disinfectants and detergents is effective. MERS-CoV samples isolated from cases exported outside of the Middle East have not demonstrated significant genetic differences from the viruses detected in the Middle East.
Signs and symptoms
The incubation period for MERS is generally four to seven days, with a range of two to fourteen days. MERS symptoms commonly include coughing, shortness of breath, pneumonia and fever. Some cases also report muscle aches and gastrointestinal symptoms such as diarrhoea, nausea and vomiting. The pathogen has demonstrated a range of symptoms from asymptomatic infection to respiratory compromise and death. Symptoms tend to be more severe in the elderly, the immunocompromised and those with chronic illnesses. Severe illness can require intensive care support and mechanical ventilation. No specific treatment is currently available for MERS. Supportive treatment is offered based on the clinical condition of the case.
Transmission
MERS-CoV is a zoonotic pathogen. Though the route is not certain, evidence suggests the virus originated in bats and has been transferred to camels. The virus is now endemic in the camel populations of the Arabian Peninsula, as well as those in Egypt and Jordan. Humans seem to be exposed through contact with the fluids or meat of infected camels, alive or dead. The virus does not seem to pass easily from human to human without close contact. Health care provision without appropriate personal protective equipment is the most common method of human-to-human transmission.
Middle East Respiratory Syndrome: Risk assessment 7 Clusters of infections have most commonly occurred in health care settings. Infections in these settings generally occur in the period before the disease is diagnosed and sufficient infection control measures are put in place. Limited human-to-human household transmission of MERS-CoV has been reported. No transmission of MERS-CoV has been reported on transport, including air transport. Since 2102 the large majority of cases (over 80 percent) have occurred in Saudi Arabia, with most other cases occurring in neighbouring nations. The outbreak in South Korea was the only importation of the illness to a non-Middle Eastern state to evidence significant secondary transmission.
Prevention of MERS
No vaccine is currently available to protect against MERS-CoV infection. Vaccine trials have demonstrated efficacy in preventing illness in camels and monkeys. Visitors to farms, markets or other sites in affected countries where camels and other stock animals are present should practise good hygiene and wash their hands regularly. Similarly they should not consume undercooked camel products or unpasteurised milk. These measures are particularly important for those with chronic illnesses or those who are immunocompromised.
Middle East Respiratory Syndrome: Risk assessment 8 Current MERS-CoV outbreak
Epidemiology and geography of current outbreak
Between September 2012, when MERS was first reported, and 1 October 2015, 1593 laboratory- confirmed cases of MERS-CoV infection and at least 568 related deaths have been reported to the World Health Organization (WHO). Overall, 65 percent of cases where gender has been reported are male, and the median age is 50 years. Since 2012, over 25 countries have been affected (Figure 1). Algeria, Austria, China, Egypt, France, Germany, Greece, Iran, Italy, Kuwait, Lebanon, Malaysia, the Netherlands, Oman, the Philippines, Thailand, Tunisia, Turkey, the United Kingdom, the United States of America and Yemen have each had a small number of cases; Jordan, Qatar, the United Arab Emirates (UAE), South Korea and Saudi Arabia have each had more than 10 cases. More than two-thirds of diagnosed cases have been in Saudi Arabia.
Middle East Respiratory Syndrome: Risk assessment 9 Figure 1: Confirmed cases of MERS-CoV, 2012–2015
Middle East Respiratory Syndrome: Risk assessment 10 Outbreak response
The WHO does not recommend applying any travel or trade restriction or entry screening related to MERS. As of 16 June 2015, the WHO has determined that the MERS outbreak has not met the conditions for a Public Health Emergency of International Concern (PHEIC). New Zealand’s actions are consistent with this advice. The Ministry of Health website (http://www.health.govt.nz/our-work/diseases-and-conditions/middle-east-respiratory- syndrome-coronavirus-mers-cov) and the Safe Travel website (https://www.safetravel.govt.nz/news/middle-east-respiratory-syndrome-coronavirus-mers- cov)both seek to raise awareness of MERS and its symptoms among those who travel to affected countries. The Ministry of Health has provided information to the general public, health sector and border officials to raise awareness and guide preparedness efforts for the health sector. With 1593 cases and 568 deaths up to 1 October 2015, and cases reported in several countries, it is clear that the pathogen is likely to spread sporadically in the future. The WHO is working with affected countries and partners globally to coordinate surveillance, research and prevention strategies. Training of health care staff and support for low-resource states are part of the international effort to stop the pathogen from spreading further. The WHO is also working with the Food and Agriculture Organization, the World Organisation for Animal Health, and similar bodies to identify and mitigate the risk factors related to contact with domesticated animals. The WHO will continue to assess the situation against the PHEIC criteria, imposing emergency conditions if the situation warrants.
Middle East Respiratory Syndrome: Risk assessment 11 Risk to New Zealand from MERS
This section assesses the likelihood of a case of MERS being imported into New Zealand and the likelihood of MERS-CoV spreading in New Zealand. This assessment takes into account the likelihood of exposure to the virus in a foreign country and the likelihood of an infected person arriving in New Zealand. The risk of MERS being imported into New Zealand is linked to the size and duration of the outbreak globally. As the MERS-CoV situation is rapidly changing, this assessment may change with it.
The likelihood of a traveller being exposed to MERS in affected countries
Saudi Arabia, Jordan, Kuwait, Oman, Qatar, the UAE and Yemen have all reported locally acquired cases of MERS. Therefore, in these countries there is increased risk of zoonotic exposure to an environmental source or exposure to a case in a health care setting. Nineteen other countries have also reported cases. As the situation continues to evolve, it is reasonable to expect further cases in other countries. The overall risk of infection for residents or visitors in affected countries is very low. Based on 2013 World Bank data, the affected countries listed above have a combined population of about 70 million, with approximately 1600 cases having been reported since 2012. The risk is greatest for those who consume or handle uncooked camel products, come into contact with camels or use health care facilities in affected countries. This risk of infection is not limited to hospitals that are currently providing care for MERS cases, given that cases may initially seek medical attention through any health care provider before diagnosis. The increase in the number of MERS cases over recent months, the existence of health care transmission and the existence of unknown zoonotic transmission chains make it more likely that residents and travellers in MERS-affected countries will be exposed to infected or ill people. The risk of infection will continue to increase as the number of cases increases.
Middle East Respiratory Syndrome: Risk assessment 12 The risk of infection following exposure
MERS-CoV, like other coronaviruses, is thought to spread from an infected person’s respiratory secretions. However, the exact mode of transmission between individuals and also from animals to people is not clearly understood. MERS-CoV does not appear to be highly contagious. There has been no known, sustained human-to-human transmission since the organism was identified. The role of subclinical infection in transmission of MERS-CoV is also poorly understood. Human-to-human transmission appears to require close contact with a case, with transmission being observed among household members, fellow patients and health care workers. The majority of cases have resulted from human-to-human transmission in health care settings. Unlike outbreaks such as SARS, where health care workers were at greatest risk of infection, MERS-CoV transmission in health care settings has been mostly to other patients at the facility. While the exact reasons for this pattern are unclear, it suggests that MERS-CoV is more likely to be transmitted when the exposed person has other health issues. In summary, while modes of transmission are not entirely clear at this time, the risk of infection following exposure appears to be greatest in settings where close contact occurs, in particular in health care settings. Those at greatest risk of infection following exposure in any setting appear to be those with other underlying health issues.
The risk of a person infected with MERS-CoV entering New Zealand
Given New Zealand’s geographical isolation, the likelihood of a person infected with MERS entering New Zealand is low. New Zealand is also not a major destination for travel from the most affected countries. There is a theoretical possibility that an infected person could become symptomatic during a flight to New Zealand. If a traveller on board an aeroplane becomes ill during the flight and is later diagnosed with MERS, the possibility of transmission to co-passengers and crew should be assessed. The level of risk will depend on how ill the passenger was during the flight and who was in contact with them. Note, however, that no cases of transmission between passengers on an aeroplane have been reported so far. Given the length of the incubation period, a person infected with MERS-CoV could theoretically travel to New Zealand before symptoms of the disease start. People travelling to New Zealand will be offered health information at the border. This measure is meant to increase the likelihood that a person would report to a health care facility when they developed symptoms and would be isolated to prevent further transmission. During the Hajj pilgrimage season each year, a number of New Zealand residents, believed to number in the low hundreds, travel to Saudi Arabia and other states in the region. Saudi Arabia makes strenuous efforts to control disease transmission during these times, but the large number of people gathering in the epicentre of the current outbreak necessarily poses a risk for spread of the MERS-CoV. New Zealand has addressed this risk by providing general health education at international airports, as well as yearly reminders and additional education to border control and health staff.
Middle East Respiratory Syndrome: Risk assessment 13 The Ministry of Foreign Affairs and Trade is currently aware of about 1400 New Zealand residents visiting, living in and/or working in the Middle East countries that have a high MERS-CoV incidence. This number is based on individuals who have registered with the Safe Travel website, which they do voluntarily, and is therefore not likely to reflect the total number of New Zealand residents in these countries. It is not known how many of these individuals have either serious ongoing medical conditions or close, frequent contact with camels, the two greatest risk factors for MERS-CoV infection. While the risk to New Zealanders in these countries is difficult to quantify, countries such as the Philippines and India, which have many more expatriates in high-incidence countries in the Middle East, have not had significant MERS outbreaks. Their experience suggests the risk of transmission by expatriates or tourists returning home is low.
The risk of MERS spreading in New Zealand
MERS has spread in the most affected countries as a result of repeated exposures to infected camels and, in the case of the outbreak in South Korea, local traditions regarding seeking health care. The risk of MERS spreading within New Zealand is considered extremely low, once MERS has been recognised. New Zealand maintains a comprehensive surveillance programme for diseases of concern, such as MERS, and national reference laboratories to facilitate testing and identification of organisms. The probability of sustained chains of MERS-CoV transmission occurring in New Zealand is extremely low due to the capacity within New Zealand to recognise, identify and isolate suspected cases, undertake laboratory testing, isolate and treat MERS patients and conduct contact tracing. However, if a case infected with MERS-CoV presents in New Zealand, secondary transmission to caregivers in the family and in health care facilities cannot be excluded, particularly at an early stage when unprotected contacts are occurring.
Middle East Respiratory Syndrome: Risk assessment 14 Risk management
The following risk management options focus on protecting travellers to affected countries and minimising the risk of MERS being imported to and spreading in New Zealand.
Reducing exposure to MERS-CoV in an affected country
The simplest option to reduce exposure to MERS-CoV in the affected countries is to advise travellers to avoid contact with camels and health care facilities as much as possible. People with severe chronic illnesses or those who are immunocompromised should take extra precautions during travel to affected countries. The Ministry of Health is working with the Ministry of Foreign Affairs and Trade to keep the Safe Travel website up to date with advice and information to travellers to the affected countries (www.safetravel.govt.nz). The overall risk of exposure for residents and travellers through exposure in the community is considered low if they take the following recommended precautions. 1. Avoid sites housing camels, and health care settings that have been affected by a MERS- CoV outbreak. a. Avoid direct contact with people who are ill with MERS or unknown illnesses. b. Maintain strict standards of hygiene. 2. Avoid close contact with or handling of camels. a. Avoid live camels or undercooked camel products, as both can spread the virus. b. Fully cooked or pasteurised camel products should be safe for consumption.
Reducing the risk of a person infected with MERS-CoV entering New Zealand
No MERS cases have been reported in New Zealand to date. Given New Zealand is geographically isolated and has a relatively small volume of travel to and from the Arabian Peninsula, the likelihood of a MERS case entering New Zealand is very low. The Ministry of Health and local Public Health Unit staff have provided signage to international airports with advice for travellers who are unwell at arrival or who become unwell after arrival. Health advice cards in a range of languages are available at international airports. Border health protection officers of district health boards have received information regarding MERS and advice for travellers who become unwell after visiting an affected country.
Middle East Respiratory Syndrome: Risk assessment 15 Reducing the risk of MERS spreading in New Zealand
To decrease the risk of MERS spreading in New Zealand, it is important to minimise the time between the onset of symptoms and the recognition of a suspect case in the health care system. Infection prevention and control are crucial to prevent MERS from spreading in health care settings. Health care staff receive regular training updates on infection prevention and disease risks. Infection prevention and control measures available in New Zealand and other measures such as contact tracing and information for health professionals would greatly limit the risk of further transmission once a MERS case was identified. Active monitoring of all close contacts, including in particular staff who have been involved in the care of MERS patients, would facilitate early detection, isolation and treatment of secondary cases among health care workers. The Ministry of Health has issued advice to health professionals that specifically considers managing suspected outbreaks in health care settings. New Zealand has established protocols and processes in place, such as the National Health Emergency Plan, the New Zealand Influenza Pandemic Action Plan (NZIPAP), border response plans and local emergency response plans. The NZIPAP was developed around a respiratory disease and will likely be applicable to a MERS-CoV outbreak. A technical advisory group on infectious disease is being set up to provide the Ministry of Health with additional expert advice on diseases such as MERS-CoV, as required.
Middle East Respiratory Syndrome: Risk assessment 16 Risk assessments from other jurisdictions
Australia (12 June 2015) MERS-CoV is a serious disease that was first identified in September 2012 that results in death in some people. Most deaths have occurred in people with underlying illnesses that may make them more likely to get respiratory infections. Other Coronaviruses that are like MERS-CoV cause the common cold and SARS. All people who have had MERS-CoV have had a history of living in or travel to the Middle East (mostly Saudi Arabia), contact with travellers returning from these areas, or can be linked to an imported case. There have been no people with MERSCoV in Australia. Doctors and hospitals in Australia are ready to look after a person with MERSCoV. Procedures to stop MERS-CoV spreading would include: Asking a sick person to wear a mask over their mouth and be in a room by themselves. Laboratory and healthcare workers seeing patients or handling specimens would follow special safety guidelines. Health departments would be told that there is a person with MERS-CoV. Health departments would follow up people who had been in close contact with that person so they can be given information and be tested if necessary.1
Canada (1 October 2015)
The public health risk posed by MERS-CoV to Canada is considered low based on available information at this time. The risk may change as new information arises. MERS-CoV is considered a zoonotic virus that can lead to secondary infections among people. Many community-acquired infections are thought to be associated with direct or indirect contact with infected dromedary camels or camel-related products. Some of the infections have occurred in clusters of close contacts or in health care settings. This provides good evidence of human-to-human transmission. However, no community wide transmission has been observed. While human-to-human transmission has been observed in households in affected countries, most human cases reported to date have resulted from human-to- human transmission in health care settings. Additional cases of MERS-CoV infection are expected to be reported from the Middle East. Additionally, it is likely that cases will continue to be exported to other countries by tourists, travellers, guest, workers or pilgrims who might acquire infection following exposure to an animal or human source.2
1 Department of Health, Australia. 2015. Fact sheet for consumers/patients. URL: www.health.gov.au/internet/main/publishing.nsf/Content/ohp-mers-cov-factsheet-cp.htm (accessed 26 August 2015). 2 Public Health Agency of Canada. 2015. Summary of assessment of public health risk to Canada associated with Middle East respiratory syndrome coronavirus (MERS-CoV). URL: www.phac-aspc.gc.ca/eri- ire/coronavirus/risk_assessment-evaluation_risque-eng.php (accessed 6 October 2015).
Middle East Respiratory Syndrome: Risk assessment 17 United States of America (25 June 2015) The MERS situation in the US represents a very low risk to the general public in this country. Only two patients in the US have ever tested positive for MERS-CoV infection – both in May 2014 – while more than 500 have tested negative. CDC continues to closely monitor the situation.
In May 2014, CDC confirmed two unlinked imported cases of MERS in the United States – one to Indiana, the other to Florida. Both cases were among healthcare providers who lived and worked in Saudi Arabia. Both travelled to the US from Saudi Arabia, where they are believed to have been infected. Both were hospitalised in the US and later discharged after fully recovering.
CDC and other public health partners continue to closely monitor the MERS situation. We recognise the potential for MERS-CoV to spread further and cause more cases in the United States and globally. In preparation for this, we have: improved the way we collect data about MERS cases increased lab testing capacity in states to detect cases developed guidance and tools for health departments to conduct public health investigations when MERS cases are suspected or confirmed provided recommendations for healthcare infection control and other measures to prevent disease spread provided guidance for flight crews, Emergency Medical Service (EMS) units at airports, and US Customs and Border Protection (CPB) officers about reporting ill travellers to CDC disseminated up-to-date information to the general public, international travellers, and public health partners used Advanced Molecular Detection (AMD) methods to sequence the complete virus genome on specimens from the two US MERS cases to help evaluate and further describe the characteristics of MERS-CoV. (See Decoding MERS Coronavirus: AMD Provides Quick Answers.)3
United Kingdom (9 September 2015) There is a risk of imported cases to the UK, and health professionals should remain vigilant. Early identification and implementation of infection control measures for suspected cases is crucial. South Korea will remain as a country within the UK case definition for MERS-CoV until WHO declare the outbreak as over. This is likely to be 28 days (ie, two times the maximum incubation period of 14 days) after the last case has tested negative twice.
The risk of infection with MERS-CoV to UK residents in the UK remains very low.
The risk of infection with MERS-CoV to UK residents travelling to the Middle East is.
The probability of MERS-CoV in those who come to the UK from, or return from, the Middle East, and meet the case definition for a ‘case under investigation’ is low, but requires testing for MERS- CoV infection.
The probability that a cluster of cases of severe acute respiratory infection of unexplained aetiology requiring intensive care admission is due to MERS-CoV remains very low, but warrants
3 Centers for Disease Control and Prevention (CDC). 2015. MERS in the US URL: www.cdc.gov/coronavirus/mers/us.html (accessed 26 August 2015).
Middle East Respiratory Syndrome: Risk assessment 18 investigation and testing. A history of travel to the Middle East or South Korea would increase the likelihood of MERS-CoV.
The majority of outbreaks of MERS-CoV in the Middle East and South Korea have been linked to healthcare settings. The WHO has concluded that gaps in infection control measures have most likely contributed to these outbreaks and has recommended reinforcing the importance of strict adherence to recommended infection control measures in healthcare facilities.
Therefore, when UK infection control procedures have been followed correctly and promptly, the probability that a case of acute respiratory infection in a healthcare worker caring for a case of MERS-CoV is due to MERS-CoV is very low.
The risk will be higher in healthcare workers exposed to MERS-CoV who have not adhered to UK infection control procedures or not used adequate personal protective equipment.
The risk of MERS-CoV infection in a healthcare worker based in an ICU who meets the case definition for a ‘case under investigation’ (by virtue of caring for patients with severe acute respiratory infection regardless of travel history or PPE use) is very low, but warrants testing.
The risk to contacts of confirmed cases of MERS-CoV infection is low but contacts should be followed up in the 14 days following exposure and any new febrile or respiratory illness investigated urgently.4
European Union (27 August 2015) The majority of the MERS cases continue to be reported from the Middle East, and specifically from Saudi Arabia. Given the substantial number of people travelling between the Middle East and EU countries, sporadic imported cases to Europe can be expected. In addition to the Hajj, large numbers of people travel to and from the Middle East throughout the year.
The role of hospitals as amplifiers of MERS-CoV infection is now well known, making the strict and timely application of comprehensive infection prevention and control measures all the more imperative.
Sporadic, imported cases can be expected in EU/EEA Member States, and are associated with a risk of nosocomial spread. This highlights the need for awareness among healthcare workers, early detection through functioning testing algorithms, preparedness planning and stringent infection control precautions.5
4 Public Health England. 2015. Risk assessment of Middle East respiratory system coronavirus (MERS-CoV). URL: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/461192/MERS- COV_RA_sep_2015_final.pdf (accessed 6 October 2015). 5 European Centers for Disease Prevention and Control (ECDC). 2015. Severe respiratory disease associated with Middle East respiratory syndrome coronavirus. URL: http://ecdc.europa.eu/en/publications/Publications/MERS- CoV-rapid-risk-assessment-August-2015.pdf (accessed 6 October 2015).
Middle East Respiratory Syndrome: Risk assessment 19 Summary
The risk of MERS-CoV to public health in New Zealand is low; there is a low risk of imported cases, and an extremely low risk of spread in the event of an imported case. It remains essential to detect MERS-CoV infection early among travellers from affected countries. The recent outbreaks in health care settings in South Korea and Riyadh also highlight the continued risk of nosocomial transmission and the importance of timely diagnosis and implementation of infection prevention and control measures. A single case of MERS-CoV in New Zealand would result in an immediate and comprehensive response.
This risk assessment may change as the situation continues to evolve.
Middle East Respiratory Syndrome: Risk assessment 20