What Are Precautions for Someone Traveling to the Middle East About the Risk of MERS?

Patient Presentation
Ten and twelve-year-old male siblings came to clinic before traveling from the United States to visit relatives in Jordan for 6 weeks. The children were healthy, had current routine vaccinations and had traveled to Jordan 5 years previously. They were visiting major cities and did not plan to visit rural locations or farms. The family was transferring planes in Europe during the visit. The mother was concerned because of the recent media coverage of MERS (Middle East Respiratory Syndrome) in the United States, and wanted to know what she should do about the trip. The pertinent physical examinations revealed healthy boys.

The diagnosis of healthy males was made. The pediatrician confirmed that the boys were fully vaccinated. In the room, he then used the Centers for Disease Control website to look at the specific travel recommendations for Jordan. The boys had previously had typhoid vaccine but because of the time lapse oral typhoid vaccine was prescribed. The risk of rabies was considered small so they did not receive that vaccine. For MERS, the physician discussed that the illness presented with common upper airway symptoms such as fever, cough and shortness of breath. The World Health Organization had increased its alert level and was issuing alerts for travelers to be more aware, and use standard precautions such as hand hygiene and covering coughs more consistently. The physician printed the information for the family and told them to monitor their health closely during and after the visit. If they had any concerns they should seek help in Jordan or call his office promptly after they returned. The physician also noted that although it was not exactly clear how the virus was spread there were clusters of patients who were health care workers. The mother said that none of the family they were staying with were health care providers, but were business and service workers. Nonetheless, the physician recommended using hand sanitizers, washing hands, and common sense at all times.

Middle East Respiratory Syndrome (MERS) is a respiratory illness cause by a coronavirus called MERS-CoV. It was first reported in Saudi Arabia in 2012. People with confirmed cases of MERS have developed severe respiratory illness that includes acute onset of cough, shortness of breath, and fever. Other symptoms include gastrointestinal symptoms such as diarrhea. Pneumonia is common, and patients may progress to respiratory failure. Other end organ failure has occurred, particularly kidney failure and septic shock. The death rate is up to ~30% currently. People with compromised immune systems are more at risk.

The exact transmission is not known but it has been shown to spread between people who are in close contact, from infected patients to health care personnel, and there some clustered cases in specific countries. There is no evidence of sustained spreading in community settings. All of the cases to date have been linked to countries in the Arabian Peninsula. The virus has been linked to bats and camels but it is unknown exactly how it is spread between or within species. MERS is different than the SARS virus that was identified in 2003 but both are caused by coronaviruses and have been linked to bats.

Health care providers should be alerted to patients who have traveled to the Arabian Peninsula and surrounding countries within 14 days of travel. People who transited within airports but did not enter the country are not considered at increased risk. Although more common causes of respiratory illness such as influenza are still more common, the risk of MERS should be considered. Vigilant appropriate precautions including consistent use of personal protective equipment should be instituted for health care providers.

A patient with an unexplained respiratory illness that meets the following criteria should be reported to the Centers for Disease Control:

A patient with “Fever (> or equal to38°C, 100.4°F) and pneumonia or acute respiratory distress syndrome (based on clinical or radiologic evidence)
History of travel from countries in or near the Arabian Peninsula[a] within 14 days before symptom onset
Close contact[b] with a symptomatic traveler who developed fever and acute respiratory illness (not necessarily pneumonia) within 14 days after traveling from countries in or near the Arabian Peninsula[a]
Is a member of a cluster of patients with severe acute respiratory illness (such as fever and pneumonia requiring hospitalization) of unknown etiology in which MERS-CoV is being evaluated, in consultation with state and local health departments

“[a]Countries in the Arabian Peninsula and neighboring countries: Bahrain, Iran, Iraq, Israel, Jordan, Kuwait, Lebanon, Palestinian territories, Oman, Qatar, Saudi Arabia, Syria, the United Arab Emirates (UAE), and Yemen.
[b]Close contact is defined as a) any person who provided care for the patient, including a health care worker or family member, or had similarly close physical contact; or b) any person who stayed at the same place (lived with or visited) as the patient while the patient was ill.

Learning Point
Public health officials recommend educating the traveling public to the increased risk of MERS and for them to consistently use general public health practices such as hand hygiene, covering coughs, disposing of tissues, and avoiding contact with ill individuals. Patients should monitor their health for acute onset of febrile respiratory illnesses for 14 days after traveling to the Arabian Peninsula.

Questions for Further Discussion
1. How is MERS different than H1N1 virus?
2. Name other zoonotic viruses?
3. Where can you find current pubic health traveler advisories?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Coronavirus Infections and International Health.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Centers for Disease Control. Middle East Respiratory Syndrome (MERS).
Available from the Internet at http://www.cdc.gov/CORONAVIRUS/MERS/INDEX.HTML (rev. 5/15/14, cited 5/16/14).

Centers for Disease Control. MERS in the Arabian Peninsula.
Available from the Internet at http://wwwnc.cdc.gov/travel/notices/alert/coronavirus-arabian-peninsula-uk (rev. 5/12/14, cited 5/16/14).

Centers for Disease Control. Middle East Respiratory Syndrome (MERS) Frequently Asked Questions.
Available from the Internet at http://www.cdc.gov/coronavirus/MERS/faq.html (rev. 5/12/14, cited 5/16/14).

World Health Organization. Frequently Asked Questions on Middle East Respiratory Syndrome Coronavirus (MERS-CoV)
Available from the Internet at http://www.who.int/csr/disease/coronavirus_infections/faq/en/ (rev. 5/9/14, cited 5/16/14).

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    6. Information technology to support patient care decisions and patient education is used.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.
    15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.

  • Professionalism
    20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.
    21. A commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices are demonstrated.
    22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.


    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital