Molecular insights on the coronavirus MERS-CoV interaction with the CD26 receptor

The Middle East respiratory syndrome (MERS) is a severe respiratory disease with high fatality rates, caused by the Middle East respiratory syndrome coronavirus (MERS-CoV). The virus initiates infection by binding to the CD26 receptor (also known as dipeptidyl peptidase 4 or DPP4) via its spike protein. Although the receptor-binding domain (RBD) of the viral spike protein and the complex between RBD and the extracellular domain of CD26 have been studied using X-ray crystallography, conflicting studies exist regarding the importance of certain amino acids outside the resolved RBD-CD26 complex interaction interface. To gain atomic-level knowledge of the RBD-CD26 complex, we employed computational simulations to study the complex's dynamic behavior as it evolves from its crystal structure to a conformation stable in solution. Our study revealed previously unidentified interaction regions and interacting amino acids within the complex, determined a novel comprehensive RBD-binding domain of CD26, and by that expanded the current understanding of its structure. Additionally, we examined the impact of a single amino acid substitution, E513A, on the complex's stability. We discovered that this substitution disrupts the complex through an allosteric domino-like mechanism that affects other residues. Since MERS-CoV is a zoonotic virus, we evaluated its potential risk of human infection via animals, and suggest a low likelihood for possible infection by cats or dogs. The molecular structural information gleaned from our insights into the RBD-CD26 complex pre-dissociative states may be proved useful not only from a mechanistic view but also in assessing inter-species transmission and in developing anti-MERS-CoV antiviral therapeutics.

Estimating the Epidemic Size of Superspreading Coronavirus Outbreaks in Real Time: Quantitative Study

BACKGROUND

Novel coronaviruses have emerged and caused major epidemics and pandemics in the past 2 decades, including SARS-CoV-1, MERS-CoV, and SARS-CoV-2, which led to the current COVID-19 pandemic. These coronaviruses are marked by their potential to produce disproportionally large transmission clusters from superspreading events (SSEs). As prompt action is crucial to contain and mitigate SSEs, real-time epidemic size estimation could characterize the transmission heterogeneity and inform timely implementation of control measures.

OBJECTIVE

This study aimed to estimate the epidemic size of SSEs to inform effective surveillance and rapid mitigation responses.

METHODS

We developed a statistical framework based on back-calculation to estimate the epidemic size of ongoing coronavirus SSEs. We first validated the framework in simulated scenarios with the epidemiological characteristics of SARS, MERS, and COVID-19 SSEs. As case studies, we retrospectively applied the framework to the Amoy Gardens SARS outbreak in Hong Kong in 2003, a series of nosocomial MERS outbreaks in South Korea in 2015, and 2 COVID-19 outbreaks originating from restaurants in Hong Kong in 2020.

RESULTS

The accuracy and precision of the estimation of epidemic size of SSEs improved with longer observation time; larger SSE size; and more accurate prior information about the epidemiological characteristics, such as the distribution of the incubation period and the distribution of the onset-to-confirmation delay. By retrospectively applying the framework, we found that the 95% credible interval of the estimates contained the true epidemic size after 37% of cases were reported in the Amoy Garden SARS SSE in Hong Kong, 41% to 62% of cases were observed in the 3 nosocomial MERS SSEs in South Korea, and 76% to 86% of cases were confirmed in the 2 COVID-19 SSEs in Hong Kong.

CONCLUSIONS

Our framework can be readily integrated into coronavirus surveillance systems to enhance situation awareness of ongoing SSEs.

Disease X: Beyond Fear, Toward Preparedness

In recent years, there has been a growing concern regarding the increasing incidence of infectious diseases with potential global transmission [1]. The World Health Organization (WHO) coined the phrase "Disease X" to denote a theoretical infectious disease that has not yet been detected but has the capacity to cause a global pandemic. Disease X denotes an unidentified pathogenic agent with the potential to instigate a forthcoming global outbreak [2]. Commencing with a convened gathering on the 18th of November 2022, the WHO has initiated a comprehensive assembly of more than 300 esteemed experts. The primary objective of this assembly is to meticulously examine the available information pertaining to over 25 virus families, bacteria, and a hypothetical pathogen referred to as "Disease X." The initial publication of the list occurred in 2017.

How heterogeneity in density dependence affects disease spread: when lifestyle matters

People's lifestyles play a major role in disease risk. Some employment sectors and transport modes involve fixed exposures regardless of community size, while in other settings exposure tracks with population density. MERS-CoV, a coronavirus discovered in Saudi Arabia in 2012 closely related to those causing SARS and COVID-19, appears to need extended contact time for transmission, making some segments of a community at greater risk than others. We model mathematically how heterogeneity in contact rate structure impacts disease spread, using as a case study a MERS outbreak in two Saudi Arabian communities. We divide the at-risk population into segments with exposure rates either independent of population density or density-dependent. Analysis shows disease spread is minimized for intermediate size populations with a limited proportion of individuals in the density-independent group. In the case study, the high proportion of density-independent exposure may explain the historical outbreak's extinction in the larger city.

IL-13 induced inflammation increases DPP4 abundance but does not enhance MERS-CoV replication in airway epithelia

BACKGROUND

Chronic pulmonary conditions such as asthma and COPD increase the risk of morbidity and mortality during infection with the Middle East respiratory syndrome coronavirus (MERS-CoV). We hypothesized that individuals with such comorbidities are more susceptible to MERS-CoV infection due to increased expression of its receptor, dipeptidyl peptidase 4 (DPP4).

METHODS

We modeled chronic airway disease by treating primary human airway epithelia with the Th2 cytokine IL-13, examining how this impacted DPP4 protein levels along with MERS-CoV entry and replication.

RESULTS

IL-13 exposure for 3 days led to increased DPP4 protein abundance, while a 21-day treatment increased DPP4 levels and caused goblet cell metaplasia. Surprisingly, despite this increase in receptor availability, MERS-CoV entry and replication were not significantly impacted by IL-13 treatment.

CONCLUSIONS

Our results suggest that increased DPP4 abundance is likely not the primary mechanism leading to increased MERS severity in the setting of Th2 inflammation. Transcriptional profiling analysis highlighted the complexity of IL-13 induced changes in airway epithelia, including altered expression of genes involved in innate immunity, antiviral responses, and maintenance of the extracellular mucus barrier. These data suggest that additional factors likely interact with DPP4 abundance to determine MERS-CoV infection outcomes.

Bibliometric Analysis of the Publications on Middle East Respiratory Syndrome Coronavirus Published Between 2012-2022

Objective

This study aimed to conduct a bibliometric analysis of the global scientific output related to the Middle East Respiratory Syndrome Coronavirus (MERS-CoV) between 2012 and 2022.

Materials and Methods

The Web of Science database was searched for articles on MERS-CoV published between 2012 and 2022 for bibliometric analysis. The parameters such as publication year, publication type, funding agencies, research institutions, journals, impact factors, language, and citation numbers of articles were analyzed.

Results

We included 1475 articles on MERS-CoV from 86 countries. The United States was the most published country on MERS-CoV, with 487 articles. The Saudi Ministry of Health (7.53%), King Saud bin Abdulaziz University for Health Sciences (6.92%), and The Egyptian Knowledge Bank (6.64%) were the most published institutions. The researchers who published the most on MERS-CoV were from Saudi Arabia. One thousand two hundred six funding agencies funded publications on MERS-CoV, most of which were funded by agencies from the United States.

Conclusion

MERS-CoV remains important because no treatment and no vaccine have been found since it was first detected, and accordingly, it continues to affect the world with new outbreaks and high mortality rates. In addition, experiences with MERS-CoV during the coronavirus disease 2019 (COVID-19) pandemic have guided new research on COVID-19, so scientific interest in MERS-CoV is still ongoing.

Coronavirus outbreaks and infection prevention in dentistry: a narrative review

OBJECTIVE

This narrative review aims to compile and analyse infection prevention and control (IPAC) practices followed by dental clinics during 3 coronavirus outbreaks: SARS (2002-2004), MERS (2012-2014), and COVID-19 (2019-); and to draw parallels from them for future epidemics.

METHODS

Data were collected from 3 databases: Google Scholar, PubMed, and Embase using search terms "SARS," "MERS," "COVID-19," "infection control," "disinfection," and "sterilization".

RESULTS

Careful examination of 108 peer-reviewed articles on the 3 outbreaks revealed the following commonalities in the IPAC practices of dental clinics: use of sodium hypochlorite (surface disinfectant), ethanol and 1-propanol (hand hygiene), povidone-iodine (oral rinse), high-volume evacuation (HVE), rubber dam isolation, anti-retraction handpieces, and fogging.

DISCUSSION & CONCLUSION

Ethanol, 1-propanol, sodium hypochlorite, povidone-iodine, photocatalysis, and fogging have been shown to be effective against various coronaviruses. However, more studies are required to validate the effectiveness of anti-retraction handpieces, rubber dam isolation, HVE, and cold atmospheric plasma specifically in infection control of the current coronavirus strain, SARS-CoV-2.

Using a grey relational analysis in an improved Grunow-Finke assessment tool to detect unnatural epidemics

The Grunow-Finke epidemiological assessment tool (GFT) has several limitations in its ability to differentiate between natural and man-made epidemics. Our study aimed to improve the GFT and analyze historical epidemics to validate the model. Using a gray relational analysis (GRA), we improved the GFT by revising the existing standards and adding five new standards. We then removed the artificial weights and final decision threshold. Finally, by using typically unnatural epidemic events as references, we used the GRA to calculate the unnatural probability and obtain assessment results. Using the advanced tool, we conducted retrospective and case analyses to test its performance. In the validation set of 13 historical epidemics, unnatural and natural epidemics were divided into two categories near the unnatural probability of 45%, showing evident differences (p < 0.01) and an assessment accuracy close to 100%. The unnatural probabilities of the Ebola virus disease of 2013 and Middle East Respiratory Syndrome of 2012 were 30.6% and 36.1%, respectively. Our advanced epidemic assessment tool improved the accuracy of the original GFT from approximately 55% to approximately 100% and reduced the impact of human factors on these outcomes effectively.

MERS-CoV in sheep, goats, and cattle, United Arab Emirates, 2019: Virological and serological investigations reveal an accidental spillover from dromedaries

The recent COVID-19 pandemic has demonstrated again the global threat posed by emerging zoonotic coronaviruses. During the past two decades alone, humans have experienced the emergence of several coronaviruses, such as SARS-CoV in 2003, MERS-CoV in 2012, and SARS-CoV-2 in 2019. To date, MERS-CoV has been detected in 27 countries, with a case fatality ratio of approximately 34.5%. Similar to other coronaviruses, MERS-CoV presumably originated from bats; however, the main reservoir and primary source of human infections are dromedary camels. Other species within the Camelidae family, such as Bactrian camels, alpacas, and llamas, seem to be susceptible to the infection as well, although to a lesser extent. In contrast, susceptibility studies on sheep, goats, cattle, pigs, chickens, and horses obtained divergent results. In the present study, we tested nasal swabs and/or sera from 55 sheep, 45 goats, and 52 cattle, collected at the largest livestock market in the United Arab Emirates, where dromedaries are also traded, for the presence of MERS-CoV nucleic acid by RT-qPCR, and for specific antibodies by immunofluorescence assay. All sera were negative for MERS-CoV-reactive antibodies, but the nasal swab of one sheep (1.8%) repeatedly tested positive for MERS-CoV nucleic acid. Next generation sequencing (NGS) of the complete N gene of the sheep-derived MERS-CoV revealed >99% nucleotide identity to MERS-CoV sequences of five dromedaries in nearby pens and to three reference sequences. The NGS sequence of the sheep-derived MERS-CoV was confirmed by conventional RT-PCR of a part of the N gene and subsequent Sanger sequencing. All MERS-CoV sequences clustered within clade B, lineage 5. In conclusion, our study shows that noncamelid livestock, such as sheep, goats, and cattle do not play a major role in MERS-CoV epidemiology. The one sheep that tested positive most likely reflects an accidental viral spillover event from infected dromedaries in nearby pens.

Ecology of Middle East respiratory syndrome coronavirus, 2012-2020: A machine learning modelling analysis

The ongoing enzootic circulation of the Middle East respiratory syndrome coronavirus (MERS-CoV) in the Middle East and North Africa is increasingly raising the concern about the possibility of its recombination with other human-adapted coronaviruses, particularly the pandemic SARS-CoV-2. We aim to provide an updated picture about ecological niches of MERS-CoV and associated socio-environmental drivers. Based on 356 confirmed MERS cases with animal contact reported to the WHO and 63 records of animal infections collected from the literature as of 30 May 2020, we assessed ecological niches of MERS-CoV using an ensemble model integrating three machine learning algorithms. With a high predictive accuracy (area under receiver operating characteristic curve = 91.66% in test data), the ensemble model estimated that ecologically suitable areas span over the Middle East, South Asia and the whole North Africa, much wider than the range of reported locally infected MERS cases and test-positive animal samples. Ecological suitability for MERS-CoV was significantly associated with high levels of bareland coverage (relative contribution = 30.06%), population density (7.28%), average temperature (6.48%) and camel density (6.20%). Future surveillance and intervention programs should target the high-risk populations and regions informed by updated quantitative analyses.

Mental health impact of the Middle East respiratory syndrome, SARS, and COVID-19: A comparative systematic review and meta-analysis

BACKGROUND

Over the last few decades, 3 pathogenic pandemics have impacted the global population; severe acute respiratory syndrome coronavirus (SARS-CoV), Middle East respiratory syndrome coronavirus (MERS-CoV) and SARS-CoV-2. The global disease burden has attributed to millions of deaths and morbidities, with the majority being attributed to SARS-CoV-2. As such, the evaluation of the mental health (MH) impact across healthcare professionals (HCPs), patients and the general public would be an important facet to evaluate to better understand short, medium and long-term exposures.

AIM

To identify and report: (1) MH conditions commonly observed across all 3 pandemics; (2) Impact of MH outcomes across HCPs, patients and the general public associated with all 3 pandemics; and (3) The prevalence of the MH impact and clinical epidemiological significance.

METHODS

A systematic methodology was developed and published on PROSPERO (CRD42021228697). The databases PubMed, EMBASE, ScienceDirect and the Cochrane Central Register of Controlled Trials were used as part of the data extraction process, and publications from January 1, 1990 to August 1, 2021 were searched. MeSH terms and keywords used included Mood disorders, PTSD, Anxiety, Depression, Psychological stress, Psychosis, Bipolar, Mental Health, Unipolar, Self-harm, BAME, Psychiatry disorders and Psychological distress. The terms were expanded with a ‘snowballing’ method. Cox-regression and the Monte-Carlo simulation method was used in addition to I² and Egger’s tests to determine heterogeneity and publication bias.

RESULTS

In comparison to MERS and SARS-CoV, it is evident SAR-CoV-2 has an ongoing MH impact, with emphasis on depression, anxiety and post-traumatic stress disorder.

CONCLUSION

It was evident MH studies during MERS and SARS-CoV was limited in comparison to SARS-CoV-2, with much emphasis on reporting symptoms of depression, anxiety, stress and sleep disturbances. The lack of comprehensive studies conducted during previous pandemics have introduced limitations to the “know-how” for clinicians and researchers to better support patients and deliver care with limited healthcare resources.

Analysis of Infection Transmission Routes through Exhaled Breath and Cough Particle Dispersion in a General Hospital

Identifying infection transmission routes in hospitals may prevent the spread of respiratory viruses and mass infections. Most previous related research focused on the air movement of passive tracers, which typically represent breathing. In this study, particle evaporation and dispersions with various particle sizes were applied to evaluate particle movement because of breathing and coughing using computational fluid dynamics (CFD) simulations. Pyeongtaek St. Mary Hospital, where a Middle East respiratory syndrome (MERS) index patient infected several patients on the same floor, was used for a case study. We compared the dispersion characteristics of various particle sizes and validated results by comparing infection rates in different ward. Results indicated that droplets spread across the corridor and dispersed to wards that were more than 17 m apart from the index patient by natural ventilation. Droplets from exhaled breath under steady-state simulation showed a wider range of dispersion than cough droplets under transient simulation, but cough droplet dispersion was more consistent with the actual infection rate in each ward. Cough droplets sized under 75 µm evaporated to 26% of the initial size and started to disperse into the corridor within one minute; in nine minutes, droplets dispersed throughout every ward. This study may increase awareness on the dispersion characteristics of infectious particles.

The transmission dynamics of Middle East Respiratory Syndrome coronavirus

Background

In this study, we aimed to quantify the contribution of different transmission routes of the Middle East respiratory syndrome (MERS) and determine its transmissibility.

Methods

Based on the natural history and transmission features of MERS in different countries, a susceptible-exposed-symptomatic-asymptomatic-recovered/death (SEIARD) model and a multi-route dynamic model (MMDM). The SEIARD model and MMDM were adopted to simulate MERS in South Korea and Saudi Arabia, respectively. Data on reported MERS cases in the two countries were obtained from the World Health Organization. Thereafter, the next generation matrix method was employed to derive the equation for the basic reproduction number (R₀), and the model fitting procedure was adopted to calculate the R₀ values corresponding to these different countries.

Results

In South Korea, ‘Person-to-Person’ transmission was identified as the main mode of MERS transmission in healthcare settings, while in Saudi Arabia, in addition to ‘Person-to-Person’ transmission, ‘Host-to-Host’ and ‘Host-to-Person’ transmission also occurred under certain scenarios, with camels being the main host. Further, the fitting results showed that the SEIARD model and MMDM fitted the data well. The mean R₀ value was 8.59 (95% confidence interval [CI]: 0–28.02) for MERS in South Korea, and for MERS in Saudi Arabia, it was 1.15 and 1.02 (95% CI: 0.86–1.44) for the ‘Person-to-Person’ and ‘Camel-to-Camel’ transmission routes, respectively.

Conclusions

The SEIARD and MMDM model can be used to simulate the transmission of MERS in different countries. Additionally, in Saudi Arabia, the transmissibility of MERS was almost the same among hosts (camels) and humans.

Genetic diversity of bat coronaviruses and comparative genetic analysis of MERS-related coronaviruses in South Korea

Bats have been identified as a natural reservoir of several potentially zoonotic viruses, including Lyssavirus, Ebola virus, Marburg virus, Hendra virus, Nipah virus, as well as severe acute respiratory syndrome and Middle East respiratory syndrome coronavirus (CoV). Here, we performed a molecular epidemiological investigation of South Korean bat viruses. Genetic comparative analysis was performed on the spike glycoprotein gene of the detected MERS-related CoVs. Among 1640 samples (348 oral swabs, 1199 faecal samples, 83 urine samples and 10 bat carcass) collected across 24 South Korean provinces during 2017-2019, CoV was detected in 82 samples (75 faeces and seven oral swab samples) from 11 provinces. Surveillance over the 3 years during which samples were collected revealed significantly higher CoV detection rates between spring and autumn, and a high detection rate in Vespertillionidae and Rhinolophidae bats. Our phylogenetic analysis shows that Korean bat CoVs are genetically diverse regardless of their spatiotemporal distribution and their host species, and that the discovered bat CoVs belong to various subgenera within the Alpha- and Betacoronavirus genera. Twenty detected MERS-related CoVs belonging to the genus Betacoronavirus were similar to the Ia io bat CoV NL140422 and NL13845 strains. A comprehensive genetic analysis of two Korean bat MERS-related CoV spike receptor binding domain (RBDs) (176 and 267 strains) showed that the 18 critical residues that are involved in interactions with the human DPP4 receptor are most similar to the NL13845 strain, which is known to not bind with hDPP4. A deeper analysis of the interfacing residues in the Korean bat MERS-related CoVs RBD-hDPP4 complexes showed that the Korean bat CoVs has fewer polar contacts than the NL13845 strain. Although further study will be needed, these results suggest that Korean bat MERS-related CoVs are unlikely to bind with hDPP4. Nevertheless, these findings highlight the need for continuous monitoring to identifying the origin of new infectious diseases, specifically mutant CoV.

Coronavirus Disease (COVID-19) compared with Middle East Respiratory Syndrome (MERS): A Radiological Perspective

BACKGROUND

This study aims to describe the radiological findings in chest radiographs (CXRs) of patients with coronavirus disease (COVID-19) and the Middle East respiratory syndrome (MERS) and compare the radiological patterns of the two diseases.

METHOD

A retrospective cohort study was conducted in a tertiary care hospital in the Southern region of Saudi Arabia. The CXRs were evaluated for the presence and distribution of ground-glass opacities (GGO), consolidation, pleural effusions, pneumothorax, cavitation, and nodules.

RESULTS

A total of 120 CXRs from 15 MERS and six COVID-19 patients were assessed. In the first available CXR, GGO was present in 11 (73%) of the MERS patients (18% located in the middle zones and 67% located peripherally) and in 100% of COVID-19 patients (peripheral and middle zone involvement in all patients). In the first available CXRs, consolidation was present in 10 MERS patients (67%) and all six COVID-19 patients, while it was present in all patients of both groups when all the available CXRs were considered. Confluent consolidation was present in 47% of the MERS patients and 50% of COVID-19 patients. All the fatal cases had confluent consolidation and radiological signs of acute respiratory distress syndrome (ARDS). Pneumothorax was present in 13% of patients, with 100% mortality, and pleural effusion was present in 47% of patients, with 57% mortality. Lung nodules were present in one patient of each group.

CONCLUSION

COVID-19 patients showed earlier development of GGO and consolidation with greater involvement of the middle and peripheral lung zones. Confluent consolidation and ARDS-like radiological findings were associated with high mortality. Pneumothorax and pleural effusions were more frequent in MERS patients, with high associated mortality.

Longevity of Middle East Respiratory Syndrome Coronavirus Antibody Responses in Humans, Saudi Arabia

Understanding the immune response to Middle East respiratory syndrome coronavirus (MERS-CoV) is crucial for disease prevention and vaccine development. We studied the antibody responses in 48 human MERS-CoV infection survivors who had variable disease severity in Saudi Arabia. MERS-CoV-specific neutralizing antibodies were detected for 6 years postinfection.

Properties of Ethnomedicinal Plants and Their Bioactive Compounds: Possible Use for COVID-19 Prevention and Treatment

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has changed the global scenario. To date, there are no treatment or preventive options. The discovery of a new drug will take time. In addition, the new drug will have side effects, and the virus will gradually become resistant to it. Therefore, it is important to search for a drug with a natural origin.

OBJECTIVE

In this review, we analyzed and summarized various ethnomedicinal plants and their bioactive compounds as a source of antiviral agents for COVID-19 prevention and treatment.

METHODS

From the literature, we selected different natural compounds that can act as potential targets at low cost with broad-spectrum antiviral activity.

RESULTS

Of the 200 Chinese herbal extracts tested for their possible role against SARS-CoV, Lycoris radiata, Artemisia annua, Pyrrosia lingua, and Lindera aggregate showed anti-SARS-CoV effects with the median effective concentration = 2.4-88.2 μg/mL.

CONCLUSION

Ethnomedicinal herbs can be used as an alternative source of novel, promising antiviral agents that might directly or indirectly inhibit the COVID-19 progression.

Pandemic and hospital avoidance: Evidence from the 2015 Middle East respiratory syndrome outbreak in South Korea

Existing literature shows that people exhibit disease avoidance behaviors in response to contagious disease outbreaks. We examine hospital avoidance behaviors during the 2015 Middle East respiratory syndrome (MERS) outbreak in South Korea. The outbreak provides an excellent setting for the analysis because unlike the coronavirus disease-19 (COVID-19) situation, no mandatory lockdown was imposed during the outbreak, and the economic impact was also not large. Hence, reduced hospital visits are likely to reflect the public's intention to avoid hospitals to protect themselves from getting infected with MERS. Moreover, the outbreak did not spread to the entire country and vanished after a short period of time, allowing us to consider the affected regions as the treatment group and the other regions as the control group without much concern of confounding by other factors. The data come from a government agency, which assesses (national) health insurance claims made by hospitals, and hence cover all outpatient visits in the country. We find that people reduced outpatient visits by about 17% in response to the MERS outbreak, and the response was the most intense when new cases were reported most frequently.

Neurologic Manifestations of COVID-19

Neurological manifestations of novel coronavirus disease (COVID-19) are reported to occur in as much as 37% of the affected patients. These manifestations range from headache and dizziness to altered mental status and consciousness, anosmia, ageusia, sensory disturbances, and stroke. The mechanisms by which the neurological symptoms arise are not yet determined but may either proceed as an indirect consequence of systemic hyperinflammation or result from the direct invasion of the virus to neural and glial cells. The neural invasion can explain both the retrograde pathway of encephalitis and the early manifestation of anosmia by invading the olfactory bulb. Moreover, in the case of attacking the brain stem, it may take part in the early apnea manifestation reported by patients. Additionally, neurotropism of the virus could be the cause of acute hemorrhagic encephalitis. Hyperinflammation can have acute and prolonged effects in the nervous system, such as acute demyelination and predisposition to multiple sclerosis. Moreover, the pro-inflammatory state contributes to hypercoagulation, which in turn could result in cerebrovascular injuries in COVID-19 patients. This chapter would discuss that the neurologic manifestations of the COVID-19 are to be looked at as a multifactorial entangled phenomenon.

Epidemiology and evolution of Middle East respiratory syndrome coronavirus, 2012-2020

BACKGROUND

The ongoing transmission of the Middle East respiratory syndrome coronavirus (MERS-CoV) in the Middle East and its expansion to other regions are raising concerns of a potential pandemic. An in-depth analysis about both population and molecular epidemiology of this pathogen is needed.

METHODS

MERS cases reported globally as of June 2020 were collected mainly from World Health Organization official reports, supplemented by other reliable sources. Determinants for case fatality and spatial diffusion of MERS were assessed with Logistic regressions and Cox proportional hazard models, respectively. Phylogenetic and phylogeographic analyses were performed to examine the evolution and migration history of MERS-CoV.

RESULTS

A total of 2562 confirmed MERS cases with 150 case clusters were reported with a case fatality rate of 32.7% (95% CI: 30.9‒34.6%). Saudi Arabia accounted for 83.6% of the cases. Age of ≥ 65 years old, underlying conditions and ≥ 5 days delay in diagnosis were independent risk factors for death. However, a history of animal contact was associated with a higher risk (adjusted OR = 2.97, 95% CI: 1.10-7.98) among female cases < 65 years but with a lower risk (adjusted OR = 0.31, 95% CI: 0.18-0.51) among male cases ≥ 65 years old. Diffusion of the disease was fastest from its origin in Saudi Arabia to the east, and was primarily driven by the transportation network. The most recent sub-clade C5.1 (since 2013) was associated with non-synonymous mutations and a higher mortality rate. Phylogeographic analyses pointed to Riyadh of Saudi Arabia and Abu Dhabi of the United Arab Emirates as the hubs for both local and international spread of MERS-CoV.

CONCLUSIONS

MERS-CoV remains primarily locally transmitted in the Middle East, with opportunistic exportation to other continents and a potential of causing transmission clusters of human cases. Animal contact is associated with a higher risk of death, but the association differs by age and sex. Transportation network is the leading driver for the spatial diffusion of the disease. These findings how this pathogen spread are helpful for targeting public health surveillance and interventions to control endemics and to prevent a potential pandemic.

The coronavirus disease 2019 vaccine in pregnancy: risks, benefits, and recommendations

The coronavirus disease 2019 has caused over 2 million deaths worldwide, with over 412,000 deaths reported in Unites States. To date, at least 57,786 pregnant women in the United States have been infected, and 71 pregnant women have died. Although pregnant women are at higher risk of severe coronavirus disease 2019-related illness, clinical trials for the available vaccines excluded pregnant and lactating women. The safety and efficacy of the vaccines for pregnant women, the fetus, and the newborn remain unknown. A review of maternal and neonatal coronavirus disease 2019 morbidity and mortality data along with perinatal vaccine safety considerations are presented to assist providers with shared decision-making regarding vaccine administration for this group, including the healthcare worker who is pregnant, lactating, or considering pregnancy. The coronavirus disease 2019 vaccine should be offered to pregnant women after discussing the lack of safety data, with preferential administration for those at highest risk of severe infection, until safety and efficacy of these novel vaccines are validated.

Determining the correlation between comorbidities and MERS-CoV mortality in Saudi Arabia

Objective

As of January 2020, there were 2,519 confirmed Middle East respiratory syndrome coronavirus (MERS-CoV) cases with 866 deaths across 27 countries. Most of these cases (2,121) were reported in Saudi Arabia. Since the initial identification of MERS, few studies have investigated the role of comorbidities that could potentially lead to mortality in cases of the infectious disease. This study aimed to examine the association between comorbidities and MERS mortality in Saudi Arabia.

Methods

This is a retrospective descriptive study. We retrieved the data published by the World Health Organization (WHO) between January 2017 and November 2019, and analysed the association between comorbidities and mortality.

Results

We found 572 MERS-CoV cases reported by WHO in Saudi Arabia during the defined period. Of these, 387 (68%) had a history of chronic illness. The overall mortality rate was found to be 25%. Diabetes mellitus was the most prevalent comorbidity—the mortality rate in the diabetics was 32% as opposed to 12% in the non-diabetics (p-value <0.01). Hypertension was second, with a mortality rate of 35%, as opposed to 15% in the non-hypertensive patients (p-value <0.001). The mortality rate in cases with cardiovascular disease was 39% as opposed to 21% in those without cardiovascular disease (p-value <0.05).

Conclusion

Our study shows that MERS-CoV had a significant case fatality rate in patients with comorbidities. Thus, it will be beneficial if future clinical trials for MERS-CoV examine the impact of improved societal infection control measures such as social distancing and masks, in the context of the coronavirus disease 2019 pandemic, on the prevalence and incidence of MERS and its clinical outcomes.

Towards a novel peptide vaccine for Middle East respiratory syndrome coronavirus and its possible use against pandemic COVID-19

Middle East respiratory syndrome coronavirus (MERS-CoV) is an emerging health concern due to its high mortality rate of 35%. At present, no vaccine is available to protect against MERS-CoV infections. Therefore, an in silico search for potential antigenic epitopes in the non-redundant proteome of MERS-CoV was performed herein. First, a subtractive proteome-based approach was employed to look for the surface exposed and host non-homologous proteins. Following, immunoinformatics analysis was performed to predict antigenic B and T cell epitopes that were used in the design of a multi-epitopes peptide. Molecular docking study was carried out to predict vaccine construct affinity of binding to Toll-like receptor 3 (TLR3) and understand its binding conformation to extract ideas about its processing by the host immune system. We identified membrane protein, envelope small membrane protein, non-structural protein ORF3, non-structural protein ORF5, and spike glycoprotein as potential candidates for subunit vaccine designing. The designed multi-epitope peptide then linked to β-defensin adjuvant is showing high antigenicity. Further, the sequence of the designed vaccine construct is optimized for maximum expression in the Escherichia coli expression system. A rich pattern of hydrogen and hydrophobic interactions of the construct was observed with the TLR3 allowing stable binding of the construct at the docked site as predicted by the molecular dynamics simulation and MM-PBSA binding energies. We expect that the panel of subunit vaccine candidates and the designed vaccine construct could be highly effective in immunizing populations from infections caused by MERS-CoV and could possible applied on the current pandemic COVID-19.

Kidney involvement in coronavirus-associated diseases (Review)

Since 2003, coronaviruses have caused multiple global pandemic diseases, including severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS) and coronavirus disease 2019 (COVID-19). Clinical and autopsy findings suggest that the occurrence of kidney injury during infection may negatively affect the clinical outcomes of infected patients. The authoritative model predicts that outbreaks of other novel coronavirus pneumonias will continue to threaten human health in the future. The aim of the present systematic review was to summarize the basic knowledge of coronavirus, coronavirus infection-associated kidney injury and the corresponding therapies, in order to provide new insights for clinicians to better understand the kidney involvement of coronavirus so that more effective therapeutic strategies can be employed against coronavirus infection in the future.

Correlation between bioactive lipids and novel coronavirus: constructive role of biolipids in curbing infectivity by enveloped viruses, centralizing on EPA and DHA

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) belongs to the family coronaviridae. It is spherical and possesses proteins called spikes, which can clamp onto the human cells. Once in close interaction with the human cells, these viruses undergo structural change and can fuse with the cell membrane. The virus enters the host and starts the process of translation and transcription in the cells and uncoated genome, respectively. Due to the rapid transmittable nature of the virus, extant actions should be taken. The fatty acids administrated orally, or intravenously, could help us gear things up in providing resistance and preventing infection. Hence, the multiplication of the virus could be hindered by arachidonic acid, eicosapentaenoic acid (EPA), and docosahexaenoic acid (DHA). In that context, the current review highlights the role of these unsaturated fatty acids and their derivatives such as lipoxins and resolvins in the inactivation of the enveloped coronavirus disease 2019 (COVID-19).

Critically ill patients with diabetes and Middle East respiratory syndrome: a multi-center observational study

BACKGROUND

Diabetes is a risk factor for infection with coronaviruses. This study describes the demographic, clinical data, and outcomes of critically ill patients with diabetes and Middle East Respiratory Syndrome (MERS).

METHODS

This retrospective cohort study was conducted at 14 hospitals in Saudi Arabia (September 2012-January 2018). We compared the demographic characteristics, underlying medical conditions, presenting symptoms and signs, management and clinical course, and outcomes of critically ill patients with MERS who had diabetes compared to those with no diabetes. Multivariable logistic regression analysis was performed to determine if diabetes was an independent predictor of 90-day mortality.

RESULTS

Of the 350 critically ill patients with MERS, 171 (48.9%) had diabetes. Patients with diabetes were more likely to be older, and have comorbid conditions, compared to patients with no diabetes. They were more likely to present with respiratory failure requiring intubation, vasopressors, and corticosteroids. The median time to clearance of MERS-CoV RNA was similar (23 days (Q1, Q3: 17, 36) in patients with diabetes and 21.0 days (Q1, Q3: 10, 33) in patients with no diabetes). Mortality at 90 days was higher in patients with diabetes (78.9% versus 54.7%, p < 0.0001). Multivariable regression analysis showed that diabetes was an independent risk factor for 90-day mortality (odds ratio, 2.09; 95% confidence interval, 1.18-3.72).

CONCLUSIONS

Half of the critically ill patients with MERS have diabetes; which is associated with more severe disease. Diabetes is an independent predictor of mortality among critically patients with MERS.

Life after recovery from SARS, influenza, and Middle East respiratory syndrome: An insight into possible long-term consequences of COVID-19

Viral infectious diseases have become an increased public health issue in the past 20 years. The outbreaks of severe acute respiratory syndrome coronavirus (SARS-CoV-1) in 2002, influenza H1N1 in 2009, Middle East respiratory syndrome-CoV in 2012, and the current new coronavirus SARS-CoV-2 have shown that viral infectious diseases are a major concern in the 21^st century. As the world lives under the pandemic of a new coronavirus (COVID-19), knowing the clinical characteristics from those past diseases and their long-term outcomes is important to understand the current coronavirus pandemic and its complications and consequences better and plan for possible future outbreaks. Several long-term complications have been described with these respiratory viral diseases, such as decreased pulmonary function, pulmonary fibrosis, chronic fatigue syndrome, avascular necrosis of bone, polyneuropathy, encephalitis, posttraumatic stress disorder, depression, and anxiety. This article summarizes several studies describing chronic complications and long-term outcomes of patients recovered from these viral syndromes.

Phylogenetic Analysis of MERS-CoV in a Camel Abattoir, Saudi Arabia, 2016-2018

We detected Middle East respiratory syndrome coronavirus (MERS-CoV) RNA in 305/1,131 (27%) camels tested at an abattoir in Al Hasa, Eastern Province, Saudi Arabia, during January 2016–March 2018. We characterized 48 full-length MERS-CoV genomes and noted the viruses clustered in MERS-CoV lineage 5 clade B.

Small Particle Aerosol Exposure of African Green Monkeys to MERS-CoV as a Model for Highly Pathogenic Coronavirus Infection

Emerging coronaviruses are a global public health threat because of the potential for person-to-person transmission and high mortality rates. Middle East respiratory syndrome coronavirus (MERS-CoV) emerged in 2012, causing lethal respiratory disease in »35% of cases. Primate models of coronavirus disease are needed to support development of therapeutics, but few models exist that recapitulate severe disease. For initial development of a MERS-CoV primate model, 12 African green monkeys were exposed to 103, 104, or 105 PFU target doses of aerosolized MERS-CoV. We observed a dose-dependent increase of respiratory disease signs, although all 12 monkeys survived for the 28-day duration of the study. This study describes dose-dependent effects of MERS-CoV infection of primates and uses a route of infection with potential relevance to MERS-CoV transmission. Aerosol exposure of African green monkeys might provide a platform approach for the development of primate models of novel coronavirus diseases.

Coronavirus infection and kidney disease: a review of current and emerging evidence

In November 2009, an outbreak of a new strain of coronavirus (later named severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) was first noticed in the city of Wuhan in China, rapidly spreading to assume pandemic proportions within a short period of time. The disease was subsequently designated as coronavirus disease-19 (COVID-19). The death toll has continued to rise with grave health and socio-economic implications for individuals, families and nations globally. Although the respiratory tract is primarily involved in this disease, kidney affectation is increasingly reported and has been shown to worsen the prognosis of the disease. Current evidence shows that kidney disease is not uncommon in patients with coronavirus infection especially in those with COVID-19 and may arise from a constellation of factors such as hypotension, sepsis, rhabdomyolysis, multi-organ failure, use of nephrotoxic medications as well as direct infection in some cases. Factors associated with acute kidney injury in coronavirus infected patients may include elderly age, male sex, presence of co-morbidities as well as pre-existing chronic kidney disease and end stage renal disease. Although, there is presently no effective treatment for COVID-19, there is room for conservative management, extracorporeal therapy and renal replacement therapy. The aim of this review was to integrate current and emerging evidences on renal disease resulting from COVID-19 and the previous epidemics of coronavirus infections including the Middle East Respiratory Syndrome (MERS) and the Severe Acute Respiratory Syndrome (SARS) caused by other strains of the virus.

Novel respiratory infectious diseases in Korea

Respiratory infections are very common and highly contagious. Respiratory infectious diseases affect not only the person infected but also the family members and the society. As medical sciences advance, several diseases have been conquered; however, the impact of novel infectious diseases on the society is enormous. As the clinical presentation of respiratory infections is similar regardless of the pathogen, the causative agent is not distinguishable by symptoms alone. Moreover, it is difficult to develop a cure because of the various viral mutations. Various respiratory infectious diseases ranging from influenza, which threaten the health of mankind globally, to the coronavirus disease 2019, which resulted in a pandemic, exist. Contrary to human expectations that development in health care and improvement in hygiene will conquer infectious diseases, humankind’s health and social systems are threatened by novel infectious diseases. Owing to the development of transport and trading activity, the rate of spread of new infectious diseases is increasing. As respiratory infections can threaten the members of the global community at any time, investigations on preventing the transmission of these diseases as well as development of effective antivirals and vaccines are of utmost importance and require a worldwide effort.

Middle East Respiratory Syndrome Coronavirus Transmission

Middle East respiratory syndrome coronavirus (MERS-CoV) infection causes a spectrum of respiratory illness, from asymptomatic to mild to fatal. MERS-CoV is transmitted sporadically from dromedary camels to humans and occasionally through human-to-human contact. Current epidemiologic evidence supports a major role in transmission for direct contact with live camels or humans with symptomatic MERS, but little evidence suggests the possibility of transmission from camel products or asymptomatic MERS cases. Because a proportion of case-patients do not report direct contact with camels or with persons who have symptomatic MERS, further research is needed to conclusively determine additional mechanisms of transmission, to inform public health practice, and to refine current precautionary recommendations.

Convalescent Plasma Therapy for COVID-19: State of the Art

Convalescent plasma (CP) therapy has been used since the early 1900s to treat emerging infectious diseases; its efficacy was later associated with the evidence that polyclonal neutralizing antibodies can reduce the duration of viremia. Recent large outbreaks of viral diseases for which effective antivirals or vaccines are still lacking has renewed the interest in CP as a life-saving treatment. The ongoing COVID-19 pandemic has led to the scaling up of CP therapy to unprecedented levels. Compared with historical usage, pathogen reduction technologies have now added an extra layer of safety to the use of CP, and new manufacturing approaches are being explored. This review summarizes historical settings of application, with a focus on betacoronaviruses, and surveys current approaches for donor selection and CP collection, pooling technologies, pathogen inactivation systems, and banking of CP. We additionally list the ongoing registered clinical trials for CP throughout the world and discuss the trial results published thus far.

The effect of coronavirus infection (SARS-CoV-2, MERS-CoV, and SARS-CoV) during pregnancy and the possibility of vertical maternal-fetal transmission: a systematic review and meta-analysis

BACKGROUND

Coronavirus is challenging the global health care system from time to time. The pregnant state, with alterations in hormone levels and decreased lung volumes due to a gravid uterus and slightly immunocompromised state may predispose patients to a more rapidly deteriorating clinical course and can get a greater risk of harm for both the mother and fetus. Therefore, this systematic review was aimed to assess the effect of coronavirus infection (SARS-CoV-2, MERS-CoV, and SARS-CoV) during pregnancy and its possibility of vertical maternal-fetal transmission.

METHODS

A systematic search was conducted on PubMed, Web of Science, Embase, Google Scholar and the Cochrane Library until the end of April. All authors independently extracted all necessary data using excel spreadsheet form. Only published articles with fully accessible data on pregnant women infected with SARS-CoV, MARS-CoV, and SARS-CoV-2 were included. Data on clinical manifestations, maternal and perinatal outcomes were extracted and analyzed.

RESULT

Out of 879 articles reviewed, 39 studies involving 1316 pregnant women were included. The most common clinical features were fever, cough, and myalgia with prevalence ranging from 30 to 97%, while lymphocytopenia and C-reactive protein were the most common abnormal laboratory findings (55-100%). Pneumonia was the most diagnosed clinical symptom of COVID-19 and non-COVID-19 infection with prevalence ranged from 71 to 89%. Bilateral pneumonia (57.9%) and ground-glass opacity (65.8%) were the most common CT imaging reported. The most common treatment options used were hydroxychloroquine (79.7%), ribavirin (65.2%), and oxygen therapy (78.8%). Regarding maternal outcome, the rate of preterm birth < 37 weeks of gestation was 14.3%, preeclampsia (5.9%), miscarriage (14.5%, preterm premature rupture of membranes (9.2%) and fetal growth restriction (2.8%). From the total coronavirus infected pregnant women, 56.9% delivered by cesarean, 31.3% admitted to ICU, while 2.7% were died. Among the perinatal outcomes, fetal distress rated (26.5%), neonatal asphyxia rated (1.4%). Only, 1.2% of neonates had apgar score < 7 at 5 min. Neonate admitted to ICU was rated 11.3%, while the rate of perinatal death was 2.2%. In the current review, none of the studies reported transmission of CoV from the mother to the fetus in utero during the study period.

CONCLUSION

Coronavirus infection is more likely to affect pregnant women. Respiratory infectious diseases have demonstrated an increased risk of adverse maternal obstetrical complications than the general population due to physiological changes occurred during pregnancy. None of the studies reported transmission of CoV from the mother to the fetus in utero, which may be due to a very low expression of angiotensin-converting enzyme-2 in early maternal-fetal interface cells.

Prevalence of Cardiovascular Comorbidities in Coronavirus Disease 2019, Severe Acute Respiratory Syndrome, and Middle East Respiratory Syndrome: Pooled Analysis of Published Data

Background Coronavirus disease 2019 (COVID-19) is spreading widely around the world. We conducted this meta-analysis to explore the prevalence of cardiovascular comorbidities in COVID-19, severe acute respiratory syndrome (SARS), and Middle East respiratory syndrome (MERS) cases. Methods and Results Relevant reports updated to April 17, 2020, were searched from PubMed, Embase, Web of Science, and the Cochrane Library with no restriction on language. A random-effects model was used in this meta-analysis to obtain pooled proportions of cardiovascular comorbidities in COVID-19, SARS, and MERS. A total of 22 studies (12 for COVID-19, 4 for SARS, and 6 for MERS) were included in this analysis, and the average age of patients with COVID-19, SARS, and MERS was 46.41±1.79, 39.16±2.25, and 52.51±4.64 years, respectively. Proportions of cardiovascular comorbidities in coronavirus diseases were as follows: COVID-19: proportion of hypertension was 17.1% (95% CI, 13.2%-20.9%), proportion of cardiac disease was 4.5% (95% CI, 3.6%-5.5%) and proportion of diabetes mellitus was 8.5% (95% CI, 5.5%-11.4%); SARS: proportion of hypertension was 4.5% (95% CI, 2.0%-7.0%), proportion of cardiac disease was 2.1% (95% CI, 0.6%-3.7%) and proportion of diabetes mellitus was 3.7% (95% CI, 1.0%-6.4%); MERS: proportion of hypertension was 30.3% (95% CI, 18.3%-42.2%), proportion of cardiac disease was 20.9% (95% CI, 10.7%-31.1%), and proportion of diabetes mellitus was 45.4% (95% CI, 27.3%-63.5%). Conclusions The prevalence of cardiovascular comorbidities varies among different coronavirus-associated diseases. With the development of time, proportions of cardiovascular comorbidities in COVID-19 need further attention.

Mechanism of higher risk for COVID-19 in diabetes: a mask to lift

PURPOSE

This essay aims to propose suggestions on what we can learn from previous investigations to conduct further studies on the potential mechanisms underlying the effect of diabetes mellitus on COVID-19.

METHODS

We reviewed some literature on diabetes and other types of coronavirus infection such as Middle East respiratory syndrome (MERS) and severe acute respiratory syndrome (SARS) and made some summaries and comparisons.

RESULTS

Diabetes affect the occurrence and progression of COVID-19.

CONCLUSIONS

In-depth and comprehensive exploration of the mechanism of diabetes affecting COVID-19 should be carried out.

Computational analysis of SARS-CoV-2, SARS-CoV, and MERS-CoV genome using MEGA

The novel coronavirus pandemic that has originated from China and spread throughout the world in three months. Genome of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) predecessor, severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus (MERS-CoV) play an important role in understanding the concept of genetic variation. In this paper, the genomic data accessed from National Center for Biotechnology Information (NCBI) through Molecular Evolutionary Genetic Analysis (MEGA) for statistical analysis. Firstly, the Bayesian information criterion (BIC) and Akaike information criterion (AICc) are used to evaluate the best substitution pattern. Secondly, the maximum likelihood method used to estimate of transition/transversions (R) through Kimura-2, Tamura-3, Hasegawa-Kishino-Yano, and Tamura-Nei nucleotide substitutions model. Thirdly and finally nucleotide frequencies computed based on genomic data of NCBI. The results indicate that general times reversible model has the lowest BIC and AICc score 347,394 and 347,287, respectively. The transition/transversions bias for nucleotide substitutions models varies from 0.56 to 0.59 in MEGA output. The average nitrogenous bases frequency of U, C, A, and G are 31.74, 19.48, 28.04, and 20.74, respectively in percentages. Overall the genomic data analysis of SARS-CoV-2, SARS-CoV, and MERS-CoV highlights the close genetic relationship.

Ribavirin and Interferon Therapy for Critically Ill Patients With Middle East Respiratory Syndrome: A Multicenter Observational Study

BACKGROUND

The objective of this study was to evaluate the effect of ribavirin and recombinant interferon (RBV/rIFN) therapy on the outcomes of critically ill patients with Middle East respiratory syndrome (MERS), accounting for time-varying confounders.

METHODS

This is a retrospective cohort study of critically ill patients with laboratory-confirmed MERS from 14 hospitals in Saudi Arabia diagnosed between September 2012 and January 2018. We evaluated the association of RBV/rIFN with 90-day mortality and MERS coronavirus (MERS-CoV) RNA clearance using marginal structural modeling to account for baseline and time-varying confounders.

RESULTS

Of 349 MERS patients, 144 (41.3%) patients received RBV/rIFN (RBV and/or rIFN-α2a, rIFN-α2b, or rIFN-β1a; none received rIFN-β1b). RBV/rIFN was initiated at a median of 2 days (Q1, Q3: 1, 3 days) from intensive care unit admission. Crude 90-day mortality was higher in patients with RBV/rIFN compared to no RBV/rIFN (106/144 [73.6%] vs 126/205 [61.5%]; P = .02]. After adjusting for baseline and time-varying confounders using a marginal structural model, RBV/rIFN was not associated with changes in 90-day mortality (adjusted odds ratio, 1.03 [95% confidence interval {CI}, .73-1.44]; P = .87) or with more rapid MERS-CoV RNA clearance (adjusted hazard ratio, 0.65 [95% CI, .30-1.44]; P = .29).

CONCLUSIONS

In this observational study, RBV/rIFN (RBV and/or rIFN-α2a, rIFN-α2b, or rIFN-β1a) therapy was commonly used in critically ill MERS patients but was not associated with reduction in 90-day mortality or in faster MERS-CoV RNA clearance.

Patient follow-up after discharge after COVID-19 pneumonia: Considerations for infectious control

Coronavirus disease 2019 (COVID-19) represents a significant global medical issue, with a growing number of cumulative confirmed cases. However, a large number of patients with COVID-19 have overcome the disease, meeting hospital discharge criteria, and are gradually returning to work and social life. Nonetheless, COVID-19 may cause further downstream issues in these patients, such as due to possible reactivation of the virus, long-term pulmonary defects, and posttraumatic stress disorder. In this study, we, therefore, queried relevant literature concerning severe acute respiratory syndrome, Middle East respiratory syndrome, and COVID-19 for reference to come to a consensus on follow-up strategies. We found that strategies, such as the implementation of polymerase chain reaction testing, imaging surveillance, and psychological assessments, starting at the time of discharge, were necessary for long-term follow-up. If close care is given to every aspect of coronavirus management, we expect that the pandemic outbreak will soon be overcome.

A Cell-Based Reporter Assay for Screening Inhibitors of MERS Coronavirus RNA-Dependent RNA Polymerase Activity

Severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS), and coronavirus disease 2019 (COVID-19) are emerging zoonotic diseases caused by coronavirus (CoV) infections. The viral RNA-dependent RNA polymerase (RdRp) has been suggested as a valuable target for antiviral therapeutics because the sequence homology of CoV RdRp is highly conserved. We established a cell-based reporter assay for MERS-CoV RdRp activity to test viral polymerase inhibitors. The cell-based reporter system was composed of the bicistronic reporter construct and the MERS-CoV nsp12 plasmid construct. Among the tested nine viral polymerase inhibitors, ribavirin, sofosbuvir, favipiravir, lamivudine, zidovudine, valacyclovir, vidarabine, dasabuvir, and remdesivir, only remdesivir exhibited a dose-dependent inhibition. Meanwhile, the Z-factor and Z'-factor of this assay for screening inhibitors of MERS-CoV RdRp activity were 0.778 and 0.782, respectively. Ribavirin and favipiravir did not inhibit the MERS-CoV RdRp activity, and non-nucleoside HCV RdRp inhibitor, dasabuvir, partially inhibited MERS-CoV RdRp activity. Taken together, the cell-based reporter assay for MERS-CoV RdRp activity confirmed remdesivir as a direct inhibitor of MERS-CoV RdRp in cells. A cell-based MERS-CoV RdRp activity reporter assay is reliable and accurate for screening MERS-CoV RdRp-specific inhibitors. It may provide a valuable platform for developing antiviral drugs for emerging CoV infections.

Overview: The history and pediatric perspectives of severe acute respiratory syndromes: Novel or just like SARS

Many respiratory viral infections such as influenza and measles result in severe acute respiratory symptoms and epidemics. In the spring of 2003, an epidemic of coronavirus pneumonia spread from Guangzhou to Hong Kong and subsequently to the rest of the world. The WHO coined the acronym SARS (severe acute respiratory syndrome) and subsequently the causative virus as SARS-CoV. In the summer of 2012, epidemic of pneumonia occurred again in Saudi Arabia which was subsequently found to be caused by another novel coronavirus. WHO coined the term MERS (Middle East respiratory syndrome) to denote the Middle East origin of the novel virus (MERS-CoV). In the winter of 2019, another outbreak of pneumonia occurred in Wuhan, China which rapidly spread globally. Yet another novel coronavirus was identified as the culprit and has been named SARS-CoV-2 due to its similarities with SARS-CoV, and the disease as coronavirus disease-2019. This overview aims to compare and contrast the similarities and differences of these three major episodes of coronavirus outbreak, and conclude that they are essentially the same viral respiratory syndromes caused by similar strains of coronavirus with different names. Coronaviruses have caused major epidemics and outbreaks worldwide in the last two decades. From an epidemiological perspective, they are remarkably similar in the mode of spread by droplets. Special focus is placed on the pediatric aspects, which carry less morbidity and mortality in all three entities.

Effect of coronavirus infection on the human heart: A scoping review

BACKGROUND

The global coronavirus disease 2019 pandemic has highlighted the importance of understanding the cardiovascular implications of coronavirus infections, with more severe disease in those with cardiovascular co-morbidities, and resulting cardiac manifestations such as myocardial injury, arrhythmias, and heart failure.

DESIGN

A systematic review of the current knowledge on the effects of coronavirus infection on the cardiovascular system in humans was performed and results were summarized.

METHODS

Databases such as MEDLINE, EMBASE, CENTRAL, Scopus, Web of Science, ClinicalTrials.gov, Chinese Knowledge Resource Integrated Database and Chinese Clinical Trial Registry were searched on 20 March 2020.

RESULTS

In total, 135 studies were included, involving severe acute respiratory syndrome, Middle East respiratory syndrome, coronavirus disease 2019 and other coronaviruses. Most were case reports, case series and cohort studies of poor to fair quality. In post-mortem examinations of subjects who died from infection, around half had virus identified in heart tissues in severe acute respiratory syndrome, but none in Middle East respiratory syndrome and coronavirus disease 2019. Cardiac manifestations reported include tachycardia, bradycardia, arrhythmias, and myocardial injury, secondary to both systemic infection and treatment. Cardiac injury and arrhythmias are more prevalent in coronavirus disease 2019, and elevated cardiac markers are associated with intensive care unit admission and death. In severe acute respiratory syndrome, Middle East respiratory syndrome, and coronavirus disease 2019, comorbidities such as hypertension, diabetes mellitus, and heart disease are associated with intensive care unit admission, mechanical ventilation, and mortality. There were cases of misdiagnosis due to overlapping presentations of cardiovascular diseases and coronavirus infections, leading to hospital spread and delayed management of life-threatening conditions.

CONCLUSION

This review highlighted the ways in which coronaviruses affect cardiovascular function and interacts with pre-existing cardiovascular diseases.

Pharmacologic Treatments and Supportive Care for Middle East Respiratory Syndrome

Available animal and cell line models have suggested that specific therapeutics might be effective in treating Middle East respiratory syndrome (MERS). We conducted a systematic review of evidence for treatment with pharmacologic and supportive therapies. We developed a protocol and searched 5 databases for studies describing treatment of MERS and deaths in MERS patients. Risk of bias (RoB) was assessed by using ROBINS-I tool. We retrieved 3,660 unique citations; 20 observational studies met eligibility, and we studied 13 therapies. Most studies were at serious or critical RoB; no studies were at low RoB. One study, at moderate RoB, showed reduced mortality rates in severe MERS patients with extracorporeal membrane oxygenation; no other studies showed a significant lifesaving benefit to any treatment. The existing literature on treatments for MERS is observational and at moderate to critical RoB. Clinical trials are needed to guide treatment decisions.

Obstetric Management of COVID-19 in Pregnant Women

The 2019 novel coronavirus disease (COVID-19), which is caused by the novel beta coronavirus, SARS-CoV-2, is currently prevalent all over the world, causing thousands of deaths with relatively high virulence. Like two other notable beta coronaviruses, severe acute respiratory syndrome coronavirus-1 (SARS-CoV-1) and Middle East respiratory syndrome coronavirus (MERS-CoV), SARS-CoV-2 can lead to severe contagious respiratory disease. Due to impaired cellular immunity and physiological changes, pregnant women are susceptible to respiratory disease and are more likely to develop severe pneumonia. Given the prevalence of COVID-19, it is speculated that some pregnant women have already been infected. However, limited data are available for the clinical course and management of COVID-19 in pregnancy. Therefore, we conducted this review to identify strategies for the obstetric management of COVID-19. We compared the clinical course and outcomes of COVID-19, SARS, and MERS in pregnancy and discussed several drugs for the treatment of COVID-19 in pregnancy.

Developing a questionnaire to assess Iranian nurses' knowledge of and attitude to Middle East respiratory syndrome

Background

With the emergence of Middle East respiratory syndrome (MERS), health care preparedness has received increasing attention, which requires valid tools to assess the knowledge and attitude of health workers, such as nurses, with regard to this disease.

Aims

This study aimed to develop and evaluate a knowledge and attitudes questionnaire on MERS coronavirus for Iranian nurses.

Methods

A questionnaire was developed based on international and national guidelines and a literature review. Ten nurses were recruited to assess face validity and 11 experts reviewed the instrument to determine the content validity ratio and index. Exploratory factor analysis was then done with a random sample of 155 nurses in Tabriz city, Islamic Republic of Iran.

Results

Following determination of face and content validity, 78 items (61 knowledge and 17 attitude) were retained in the final version of the questionnaire. The knowledge scale had an average content validity index of 0.80 and the attitude scale a value of 0.91. In the exploratory factor analysis, five dimensions with eigenvalues > 1 and loading level ≥ 0.4 were extracted for the knowledge scale (46 items) and two for the attitude scale (16 items). The Kuder-Richardson 21 coefficient and intraclass correlation coefficient for the knowledge scale were 0.94 and 0.91 respectively. In the attitude scale, the Cronbach alpha coefficient and intraclass correlation coefficients were 0.82 and 0.89 respectively.

Conclusions

The scale developed in this study is reliable and stable and a suitable instrument for evaluating the knowledge and attitude of nurses about MERS-CoV.

Serologic Detection of Middle East Respiratory Syndrome Coronavirus Functional Antibodies

We developed and validated 2 species-independent protein-based assays to detect Middle East respiratory syndrome coronavirus functional antibodies that can block virus receptor-binding or sialic acid-attachment. Antibody levels measured in both assays correlated strongly with virus-neutralizing antibody titers, proving their use for serologic confirmatory diagnosis of Middle East respiratory syndrome.

Posttraumatic stress disorder and depression of survivors 12 months after the outbreak of Middle East respiratory syndrome in South Korea

Background

The 2015 outbreak of Middle East Respiratory Syndrome (MERS) in the Republic of Korea is a recent and representative occurrence of nationwide outbreaks of Emerging Infectious Diseases (EIDs). In addition to physical symptoms, posttraumatic stress disorder (PTSD) and depression are common following outbreaks of EID.

Methods

The present study investigated the long-term mental health outcomes and related risk factors in survivors of MERS. A prospective nationwide cohort study was conducted 12 months after the MERS outbreak at multi-centers throughout Korea. PTSD and depression as the main mental health outcomes were assessed with the Impact of Event Scale-Revised Korean version (IES-R-K) and the Patient Health Questionnaire-9 (PHQ-9) respectively.

Results

42.9% of survivors reported PTSD (IES-R-K ≥ 25) and 27.0% reported depression (PHQ-9 ≥ 10) at 12 months post-MERS. A multivariate analysis revealed that anxiety (adjusted odds ratio [aOR], 5.76; 95%CI, 1.29–25.58; P = 0.021), and a greater recognition of stigma (aOR, 11.09, 95%CI, 2.28–53.90; P = 0.003) during the MERS-affected period were independent predictors of PTSD at 12 months after the MERS outbreak. Having a family member who died from MERS predicted the development of depression (aOR, 12.08, 95%CI, 1.47–99.19; P = 0.020).

Conclusion

This finding implies that psychosocial factors, particularly during the outbreak phase, influenced the mental health of patients over a long-term period. Mental health support among the infected subjects and efforts to reduce stigma may improve recovery from psychological distress in an EID outbreak.

Coronavirus Disease 2019 (COVID-19) and pregnancy: what obstetricians need to know

Coronavirus disease 2019 is an emerging disease with a rapid increase in cases and deaths since its first identification in Wuhan, China, in December 2019. Limited data are available about coronavirus disease 2019 during pregnancy; however, information on illnesses associated with other highly pathogenic coronaviruses (ie, severe acute respiratory syndrome and the Middle East respiratory syndrome) might provide insights into coronavirus disease 2019's effects during pregnancy. Coronaviruses cause illness ranging in severity from the common cold to severe respiratory illness and death. Currently the primary epidemiologic risk factors for coronavirus disease 2019 include travel from mainland China (especially Hubei Province) or close contact with infected individuals within 14 days of symptom onset. Data suggest an incubation period of ∼5 days (range, 2-14 days). Average age of hospitalized patients has been 49-56 years, with a third to half with an underlying illness. Children have been rarely reported. Men were more frequent among hospitalized cases (54-73%). Frequent manifestations include fever, cough, myalgia, headache, and diarrhea. Abnormal testing includes abnormalities on chest radiographic imaging, lymphopenia, leukopenia, and thrombocytopenia. Initial reports suggest that acute respiratory distress syndrome develops in 17-29% of hospitalized patients. Overall case fatality rate appears to be ∼1%; however, early data may overestimate this rate. In 2 reports describing 18 pregnancies with coronavirus disease 2019, all were infected in the third trimester, and clinical findings were similar to those in nonpregnant adults. Fetal distress and preterm delivery were seen in some cases. All but 2 pregnancies were cesarean deliveries and no evidence of in utero transmission was seen. Data on severe acute respiratory syndrome and Middle East respiratory syndrome in pregnancy are sparse. For severe acute respiratory syndrome, the largest series of 12 pregnancies had a case-fatality rate of 25%. Complications included acute respiratory distress syndrome in 4, disseminated intravascular coagulopathy in 3, renal failure in 3, secondary bacterial pneumonia in 2, and sepsis in 2 patients. Mechanical ventilation was 3 times more likely among pregnant compared with nonpregnant women. Among 7 first-trimester infections, 4 ended in spontaneous abortion. Four of 5 women with severe acute respiratory syndrome after 24 weeks' gestation delivered preterm. For Middle East respiratory syndrome, there were 13 case reports in pregnant women, of which 2 were asymptomatic, identified as part of a contact investigation; 3 patients (23%) died. Two pregnancies ended in fetal demise and 2 were born preterm. No evidence of in utero transmission was seen in severe acute respiratory syndrome or Middle East respiratory syndrome. Currently no coronavirus-specific treatments have been approved by the US Food and Drug Administration. Because coronavirus disease 2019 might increase the risk for pregnancy complications, management should optimally be in a health care facility with close maternal and fetal monitoring. Principles of management of coronavirus disease 2019 in pregnancy include early isolation, aggressive infection control procedures, oxygen therapy, avoidance of fluid overload, consideration of empiric antibiotics (secondary to bacterial infection risk), laboratory testing for the virus and coinfection, fetal and uterine contraction monitoring, early mechanical ventilation for progressive respiratory failure, individualized delivery planning, and a team-based approach with multispecialty consultations. Information on coronavirus disease 2019 is increasing rapidly. Clinicians should continue to follow the Centers for Disease Control and Prevention website to stay up to date with the latest information (https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html).