While infection preventionists get caught up in day-to-day concerns of a multifaceted job, there is always the threat of an emerging infection one plane ride away from virtually anywhere on the globe.

In less than 20 years, this century as already seen a Severe Acute Respiratory Syndrome (SARS) outbreak that moved quickly from China to Canada and inflicted both patients and healthcare workers with fatal infections. There is a similar virus lurking in the Middle East, much in the same way that we now see Ebola again in Africa after thousands died in the 2014-2015 epidemic.

The SARS coronavirus has not been seen again since it emerged in 2002, but another coronavirus - a cousin, if you will - is percolating, trying to make that next evolutionary step that could facilitate ease of transmission between humans.

Middle East Respiratory Syndrome (MERS) coronavirus threatened emergence in the United States in May 2014, when two healthcare workers became symptomatic after returning from working in Saudi Arabian hospitals.

The emerging infection was identified and stopped, but it is a little shocking to note that healthcare workers in Saudi Arabia and the surrounding region are still acquiring MERS - sometimes fatally.

A recently published analysis1 of reported MERS cases between December 2016 and January 2019 revealed that 26% of 403 cases in the region were in healthcare workers. The case fatality rate was a disturbing 16% among healthcare workers - compared with 34% among patients. Only 1.9% of the healthcare workers infected had comorbidities compared to 71% in other MERS cases over the period.

“Healthcare workers constitute a high-risk group owing to continued exposure at healthcare settings,” the authors warn. “It is important to screen exposed healthcare workers prior to allowing them to resume medical duties and multiple samples may be needed. In addition, there is a need for continued vigilance and identification of suspected cases.”

The review period included a large outbreak in Saudi Arabia in 2017 involving three hospitals, with healthcare workers acquiring the virus from admitted patients.

“All healthcare facilities should adopt strategies for early detection and isolation of patients suspected to have MERS infection,” the authors reported.

Most healthcare workers who acquire MERS have mild or asymptomatic infections. However, there have been cases of asymptomatic workers transmitting MERS to their colleagues.

In addition to Saudi Arabia, MERS cases were reported from Lebanon, Malaysia, Oman, Qatar, and United Arab Emirates. Though most likely of bat origin, the coronavirus has established an animal reservoir in camels in the region. Camel exposures, primarily consuming camel milk, were reported in 64% of community MERS cases.

The first MERS cases emerged in 2012 and the link to dromedary camels is now well-established. The beast is deeply entrenched the Saudi culture, which has thus far resisted the kind of large cull of animal reservoirs done for emerging infections like SARS and H5N1 avian flu.


  1. Al-Tawfiq JA, Memish ZA. Middle East respiratory syndrome coronavirus in the last two years: Health care workers still at risk. Am J Infect Control 2019;47:1167-1170.