title: Travel-related MERS-CoV cases: an assessment of exposures and risk factors in a group of Dutch travellers returning from the Kingdom of Saudi Arabia, May 2014.
abstract: BACKGROUND
  In May 2014, Middle East respiratory syndrome coronavirus (MERS-CoV) infection, with closely related viral genomes, was diagnosed in two Dutch residents, returning from a pilgrimage to Medina and Mecca, Kingdom of Saudi Arabia (KSA). These patients travelled with a group of 29 other Dutch travellers. We conducted an epidemiological assessment of the travel group to identify likely source(s) of infection and presence of potential risk factors.
  
  
  METHODS
  All travellers, including the two cases, completed a questionnaire focussing on potential human, animal and food exposures to MERS-CoV. The questionnaire was modified from the WHO MERS-CoV questionnaire, taking into account the specific route and activities of the travel group.
  
  
  RESULTS
  Twelve non-cases drank unpasteurized camel milk and had contact with camels. Most travellers, including one of the two patients (Case 1), visited local markets, where six of them consumed fruits. Two travellers, including Case 1, were exposed to coughing patients when visiting a hospital in Medina. Four travellers, including Case 1, visited two hospitals in Mecca. All travellers had been in contact with Case 1 while he was sick, with initially non-respiratory complaints. The cases were found to be older than the other travellers and both had co-morbidities.
  
  
  CONCLUSIONS
  This epidemiological study revealed the complexity of MERS-CoV outbreak investigations with multiple potential exposures to MERS-CoV reported such as healthcare visits, camel exposure, and exposure to untreated food products. Exposure to MERS-CoV during a hospital visit is considered a likely source of infection for Case 1 but not for Case 2. For Case 2, the most likely source could not be determined. Exposure to MERS-CoV via direct contact with animals or dairy products seems unlikely for the two Dutch cases. Furthermore, exposure to a common but still unidentified source cannot be ruled out. More comprehensive research into sources of infection in the Arabian Peninsula is needed to strengthen and specify the prevention of MERS-CoV infections.
authors.affiliation: National Institute for Public Health and the Environment, Centre for Infectious Disease Control, Bilthoven, The Netherlands ; European Programme for Intervention Epidemiology Training (EPIET), European Centre for Disease Prevention and Control, (ECDC), Stockholm, Sweden ; Public Health Service region of Utrecht, Zeist, The Netherlands ; National Institute for Public Health and the Environment, Epidemiology and Surveillance Unit, Antonie van Leeuwenhoeklaan 9, Bilthoven, MA 3721, The Netherlands.
authors.forename: Ewout B
authors.initials: EB
authors.lastname: Fanoy
authors.affiliation: National Institute for Public Health and the Environment, Centre for Infectious Disease Control, Bilthoven, The Netherlands ; Julius Center, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Marianne Ab
authors.initials: MA
authors.lastname: van der Sande
authors.affiliation: National Institute for Public Health and the Environment, Centre for Infectious Disease Control, Bilthoven, The Netherlands.
authors.forename: Marleen
authors.initials: M
authors.lastname: Kraaij-Dirkzwager
authors.affiliation: Public Health Service Haaglanden, Den Haag, The Netherlands.
authors.forename: Kees
authors.initials: K
authors.lastname: Dirksen
authors.affiliation: National Institute for Public Health and the Environment, Centre for Infectious Disease Control, Bilthoven, The Netherlands.
authors.forename: Marcel
authors.initials: M
authors.lastname: Jonges
authors.affiliation: National Institute for Public Health and the Environment, Centre for Infectious Disease Control, Bilthoven, The Netherlands.
authors.forename: Wim
authors.initials: W
authors.lastname: van der Hoek
authors.affiliation: Erasmus Medical Center, Rotterdam, The Netherlands.
authors.forename: Marion Pg
authors.initials: MP
authors.lastname: Koopmans
authors.affiliation: Public Health Service IJsselland, Zwolle, The Netherlands.
authors.forename: Douwe
authors.initials: D
authors.lastname: van der Werf
authors.affiliation: Public Health Service Amsterdam, Amsterdam, The Netherlands.
authors.forename: Gerard
authors.initials: G
authors.lastname: Sonder
authors.affiliation: Public Health Service Flevoland, Lelystad, The Netherlands.
authors.forename: Charlie
authors.initials: C
authors.lastname: van der Weijden
authors.affiliation: Public Health Service Hart voor Brabant's, Hertogenbosch, The Netherlands.
authors.forename: Jet
authors.initials: J
authors.lastname: van der Heuvel
authors.affiliation: Medical Centre Haaglanden, The Hague, The Netherlands.
authors.forename: Luc
authors.initials: L
authors.lastname: Gelinck
authors.affiliation: Isalaklinieken, Zwolle, The Netherlands.
authors.forename: Jolande W
authors.initials: JW
authors.lastname: Bouwhuis
authors.affiliation: National Institute for Public Health and the Environment, Centre for Infectious Disease Control, Bilthoven, The Netherlands.
authors.forename: Arianne B
authors.initials: AB
authors.lastname: van Gageldonk-Lafeber
keywords: Epidemiology; Exposure; MERS; MERS-CoV; Middle East respiratory syndrome coronavirus; Risk factors