Health professionals should be alert to the possibility of Middle East
respiratory syndrome (MERS) in unwell travellers returning from the
Middle East and obtain a full travel and exposure history. Apply
appropriate infection control measures as soon as you suspect MERS
and contact your local public health unit immediately
About MERS
MERS coronavirus (MERS-CoV) is a zoonotic virus that has repeatedly entered the human population via
infected dromedary camels in the Middle East. Person-to-person transmission is known to occur, particularly
in healthcare settings, and particular attention to infection control is required.
At the end of April 2024, the World Health Organization (WHO) global case count for MERS was 2613
laboratory-confirmed cases since the first cases were reported in April 2012. There have been 941
deaths (case-fatality ratio of 36%) though this may be an overestimate as mild cases may be missed by
existing surveillance systems. The latest situation updates can be found on the WHO website.
All cases have been linked with travel to or residence in Middle Eastern countries.
There is no evidence of ongoing community transmission in any country and only occasional instances of
household transmission.
What is MERS-CoV and how does it spread?
MERS-CoV is a zoonotic virus that has repeatedly entered the human population via direct or indirect
contact with infected dromedary camels in the Arabian Peninsula, although the mechanism of spread is
unclear. MERS-CoV is genetically distinct from other zoonotic coronaviruses, including the severe acute
respiratory syndrome coronavirus (SARS-CoV) and the severe acute respiratory syndrome coronavirus 2
(SARS-CoV-2) and appears to behave differently.
Many confirmed cases have occurred in healthcare-associated clusters, and there have been cases in
healthcare workers, mainly in hospital settings. Secondary infections have most frequently been associated
with healthcare settings but have also occurred amongst family and workplace contacts.
The virus does not seem to transmit easily, unless there is close contact, such as occurs when providing
unprotected care to a patient. The conditions or procedures that lead to transmission in hospital are not well
known. From observational studies, transmission in health-care settings is believed to have occurred before
adequate infection prevention and control procedures were applied and cases were isolated. A joint mission
to the Republic of Korea (where in 2015, the only large outbreak outside of the Middle East occurred)
assessed that factors contributing to the outbreak were a lack of awareness about MERS, sub-optimal
infection control, overcrowding in emergency departments, multi-bedrooms, the practice of doctor-shopping or seeking care at multiple hospitals and the practice of having many visitors including family members
staying in the room as carers.
MERS has so far not been demonstrated to transmit from asymptomatic cases to their contacts.
Health professionals are encouraged to follow the recommended infection prevention measures as soon as
MERS is suspected so as to minimise the risk of transmission.
Symptoms
Sporadic infections have typically presented with, or later developed, severe acute lower respiratory disease,
with radiological, clinical or histopathological evidence of pneumonia and pneumonitis. Symptoms have
included fever, cough, shortness of breath, and breathing difficulties. Sporadic cases have predominantly
been adult males with underlying medical conditions that may have predisposed them to infection, or may
have increased the severity of the disease, including diabetes, kidney disease, hypertension, asthma and
lung diseases, cancer and cardiovascular disease. Health professionals should be aware of the possibility of
atypical presentations including fever, diarrhoea, muscle pain, nausea and vomiting.
Secondary infections acquired through person-to-person spread have occurred in people of all ages, may
frequently have mild influenza-like symptoms or be asymptomatic.
Approximately 36% of patients with MERS have died, but this may be an overestimate of the true mortality
rate, as mild cases of MERS may be missed by existing surveillance systems. Until more is known about the
disease, the case fatality rates are counted only amongst laboratory-confirmed cases
Pre-travel advice, travel restrictions, periods of peak travel
The WHO does not currently recommend any restrictions to travel due to MERS.
Umrah and Hajj including vaccination recommendations
Health professionals should be aware that many Muslims from Australia travel to Saudi Arabia to undertake
the Umrah throughout the year but particularly during the period at the end of Ramadan and for the Hajj,
currently around June/July.
The Saudi Arabian Ministry of Health has specific vaccination requirements for Umrah and Hajj pilgrims. In
addition to these requirements, the Australian Government Department of Health and Aged Care
recommends all travellers are up to date with vaccinations, including routine vaccinations (such as tetanus,
diphtheria, pertussis, measles, mumps, rubella, influenza and polio vaccinations), and vaccines required for
occupational risk, lifestyle risks or underlying medical conditions.
There is no vaccine available for MERS.
Pre-travel advice
All people travelling to the Middle East should take general precautions when visiting farms and markets
where camels might be present. Travellers should wash their hands often, including before eating, and after
touching animals and adhere to food safety and hygiene measures. Hand sanitiser may be used when soap
and water is not available. Close contact with people or animals that are unwell should be avoided. In
addition to the usual food and water precautions, travellers should avoid consuming raw or unpasteurised
camel products, including milk, urine and meat.
People with underlying illnesses (such as diabetes, renal failure, chronic lung disease, and the
immunocompromised) are considered at high risk of severe disease from MERS and should consult their
health care provider before travelling to discuss the risks. In addition to the advice for all travellers, this group
of people should avoid all contact with dromedary camels.
See www.health.gov.au/MERS for an information card for travellers.
Anyone travelling to affected areas to work or volunteer in a healthcare setting should seek advice and
ensure they are fully informed about infection control procedures and recommendations.
Who should be tested for MERS
The likelihood of a case of pneumonia or pneumonitis in Australia being due to MERS is very low, and health
professionals should investigate as usual, but be aware of the possibility of MERS in patients with a
compatible exposure history.
Testing and initial infection control and public health actions for MERS should be
undertaken for persons with:
Fever AND pneumonia or pneumonitis or acute respiratory distress syndrome (ARDS) AND
• history of travel from or residence in affected countries in the Middle East1 within 14 days before
symptom onset, OR
• contact (within the incubation period of 14 days) with a symptomatic traveller who developed fever
and acute respiratory illness of unknown aetiology within 14 days after travelling from affected
countries in the Middle East, OR
• contact (within the incubation period of 14 days) with a symptomatic traveller who developed fever
and acute respiratory illness of unknown aetiology within 14 days after travelling from a region with
a known MERS outbreak at that time
OR
• Fever AND symptoms of respiratory illness (e.g. cough, shortness of breath) AND
• being in a healthcare facility (as a patient, worker, or visitor) in a country or territory in which recent
healthcare-associated cases of MERS have been identified3 within 14 days before symptom onset,
OR
• being in contact with camels or raw camel products within affected countries in the Middle East
within 14 days before symptom onset.
OR
• Fever OR acute symptoms compatible with MERS AND onset within 14 days after contact with a
probable or confirmed MERS case while the case was ill.
OR
• Testing and initial infection control and public health actions for MERS should also be considered,
in consultation with the public health unit, where there is a cluster of patients with severe acute
respiratory illness of unknown aetiology following routine microbiological investigation, particularly
where the cluster includes health care workers.
Further information
See our information on how to manage a suspected MERS case in a general practice setting.