environment in MERS outbreak units. Clin Infect Transmissibility of Middle East a sequence similarity of 100%. Indeed, Dis 2016; 63:363–9. Respiratory Syndrome by the a recent study showed that the nucleo- 6. Seong MW, Kim SY, Corman VM, et al. Microevolu- Airborne Route tion of outbreak-associated Middle East respiratory tide substitution of MERS-CoV dur- syndrome coronavirus, South Korea, 2015. Emerg In- TO THE EDITOR—Hospital outbreak is one ing the Korean outbreak was very rare fect Dis 2016; 22:327–30. −6 of the deﬁning epidemiologic characteris- (3.78 × 10 per site per day), and no tics of Middle East respiratory syndrome Correspondence: M.-d. Oh, Department of Internal Medicine, nucleotide substitution was observed in Seoul National University College of Medicine, 101 Daehak- coronavirus (MERS-CoV) infection [1, the target region . In contrast, the 8 ro, Jongno-gu, Seoul 03080, South Korea (email@example.com). 2]. During the Korean MERS-CoV out- MERS-CoV isolates (NOs. 64, 65, 66, 68, Clinical Infectious Diseases 2016;63(8):1143 break in 2015, almost all case patients 69, 71, 72 and 75) from the same room © The Author 2016. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. were infected at hospitals, and the 5 larg- (hospital B, patient 3) had diverse similar- For permissions, e-mail firstname.lastname@example.org. DOI: est clusters of the hospital outbreaks ity in the target region. Therefore, both 10.1093/cid/ciw479 accounted for 83% of all cases [3–5]. the genotypic and the phenotypic charac- However, it remains to be determined teristics of the environmental isolates whether these outbreaks were due to con- are not in line with those of the clinical tact with infectious droplets or inhalation isolates. Further studies are needed to of infectious droplet nuclei. fully characterize the environmental In a recent article in Clinical Infectious isolates. Diseases,Kim etal reportedthat To assess the possibility of airborne viable MERS-CoV was isolated from 19 transmission, we also need to know the environmental samples, including 4 air amount of virus in the air samples. The au- samples. Two of the 3 patients were re- thors collected 1000 L of air for the virus ceiving mechanical ventilation when air culture study, a volume equivalent to samples were taken, but the other patient what a resting person inhales for >120 (patient 3) did not undergo any aerosol- minutes. However, we do not know the generating procedures. The isolation of amount of MERS-CoV in the samples. MERS-CoV from multiple air samples, Until we ﬁll all the knowledge gaps, we especially from the corridor air (hospital should remember that the mere presence B, patient 3), raises concern about possi- of MERS-CoV in the air is not directly ble airborne transmission of MERS-CoV. translated into airborne transmission. However, the characteristics of the en- Note vironmental isolates seem to differ from Potential conﬂict of interest. Author certiﬁes those of the clinical isolate. First, the im- no potential conﬂicts of interest. The author has munoﬂuorescence (IF) study showed few submitted the ICMJE Form for Disclosure of IF-positive cells in cultures of the air and Potential Conﬂicts of Interest. Conﬂicts that the editors consider relevant to the content of the surface samples but widespread IF-positive manuscript have been disclosed. cells in culture of the positive control virus (clinical isolate of MERS-CoV/Korea/ Myoung-don Oh Department of Internal Medicine, Seoul National University KNIH/002_05_2015) (Supplementary Fig- College of Medicine, South Korea ure 3B). Second, for the IF study, the cells inoculated with the environmental iso- References lates were harvested after 7 days in culture, 1. Assiri A, McGeer A, Perl TM, et al. Hospital outbreak of Middle East respiratory syndrome coronavirus. N whereas the cells inoculated with the clini- Engl J Med 2013; 369:407–16. cal isolate were harvested after 2 days in cul- 2. Oboho IK, Tomczyk SM, Al-Asmari AM, et al. 2014 MERS-CoV outbreak in Jeddah—a link to health care ture. These ﬁndings suggest that the facilities. N Engl J Med 2015; 372:846–54. environmental isolates have a limited ca- 3. Korea Centers for Disease Control and Prevention. Middle East respiratory syndrome coronavirus out- pacity for replication. break in the Republic of Korea, 2015. Osong Public Third, the sequence similarities of Health Res Perspect 2015; 6:269–78. the spike gene from the 19 environmen- 4. Oh MD, Choe PG, Oh HS, et al. Middle East respira- tory syndrome coronavirus superspreading event in- tal isolates ranged from 97% to 100% volving 81 persons, Korea 2015. J Korean Med Sci (Supplementary Figure 2). Considering 2015; 30:1701–5. 5. Kim SH, Chang SY, Sung M, et al. Extensive viable the small size of the target region (nucle- Middle East respiratory syndrome (MERS) corona- otides 22 300–22 682), one would expect virus contamination in air and surrounding CORRESPONDENCE � CID 2016:63 (15 October) � 1143
Clinical Infectious Diseases – Oxford University Press
Published: Oct 15, 2016
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