UPDATED RAPID RISK ASSESSMENT Severe respiratory disease associated with Middle East Respiratory Syndrome

• The number of new cases per month in Saudi Arabia increased ten-fold since April 2013 and more asymptomatic and mild secondary cases have been detected through contact tracing. • Ten asymptomatic cases have been reported since 8 June, eight by Saudi Arabia and two by the United Arab Emirates (UAE). Six of these asymptomatic cases have been health care workers. All the new cases reported since the previous update have been reported by Saudi Arabia and UAE. • The skewed age and sex distribution with a higher incidence in older men has become less accentuated since the last update as more mild and asymptomatic cases are detected through contact tracing. • The Ministry of Health Saudi Arabia updated its Health Regulations for travellers to Saudi Arabia for Umrah and Hajj pilgrimage regarding MERS-CoV: ‘...recommends that elderly (above 65 years of age) and those with chronic diseases (e.g. heart disease, kidney disease, respiratory disease, diabetes) and pilgrims with immune deficiency (congenital and acquired), malignancy and terminal illnesses, pregnant women and children (under 12) coming for Hajj and Umrah this year, to postpone the performance of the Hajj and Umrah for their own safety.’ [1]. • WHO published Revised interim case definition for reporting to WHO – Middle East respiratory syndrome coronavirus (MERS-CoV) on 3 July 2013. • An Emergency Committee concerning Middle East Respiratory Syndrome Coronavirus (MERS-CoV) was set up by WHO in accordance with the International Health Regulations. The Committee held its second meeting on 17 July. It concluded that ‘...the conditions for a Public Health Emergency of International Concern have not at present been met.’ • Modelling results of MERS-CoV transmission have been published in The Lancet. They indicate that the virus currently has a low potential pandemic spread [2].