The document provides guidelines for dealing with cases of Middle East respiratory syndrome coronavirus (MERS-CoV). It discusses what MERS-CoV infections may look like clinically, including symptoms like fever, cough and shortness of breath. It provides criteria for who should be tested for MERS-CoV, such as those with severe acute respiratory illness who have traveled to the Middle East. It also outlines appropriate infection control measures, like droplet and contact precautions, to prevent transmission in healthcare settings. Currently there is no antiviral treatment available for MERS-CoV.

1. Middle East respiratory
syndrome coronavirus
(MERS-CoV)
Extract from the presentation by
Dr Benedict Sim
Infectious disease physician
Hosp Sg Buloh
4 July 2013
1

2. Outline
• What will MERS-CoV look like?
• Who has MERS-CoV?
• Who to test?
• How do test?
• When and where to admit?
• What infection control needed?
• How to treat ?
2

3. What will MERS-CoV look
like?
3

4. Pt characteristics (as of 7.6.13)
Male to female ratio 2.6 : 1.0
Median age 56 years (range: 2–94 years)
All aged >24 years, except 2 children(2 & 14
yrs)
Deaths:
Case fatality rate = 31/55 = 56%
4~14d after onset, 2~10d after hospitalization4

5. Mortality
55%
5

6. N Engl J Med 2013;368:2487-94.
6

7. Important findings
Limited person-to-person
transmission
Settings: Hospital,
Household
Most family members and
HCWs closely exposed did
not develop disease
No evidence at present of
sustained person-to-person
transmission
Coinfection with influenza &
parainfluenza - ? Roles in
transmissibility and/or the
severity of the illness.
Transmissibility pattern ?
SARS
Reported case of milder
nCoV illness – spectrum of
clinical disease maybe
wider
7

8. This article was published on June 19, 2013, at NEJM.org
8

9. 23 confirmed cases in Eastern
Saudi Arabia
• fever
• cough
• shortness of breath
• gastrointestinal symptoms
• diarrhoea
• vomiting
• abnormal CXR
20/23 (87%)
20/23 (87%)
11/23 (48%)
8/23 (35%)
5/23 (22%)
4/23 (17%)
20/23
9

10. Clinical symptoms
• Most - pneumonia. Some - GI symptoms, diarrhoea
• 1 immuno-compromised patient - fever and diarrhoea;
pneumonia only on CXR
• Half have died.
• Complications
– respiratory failure
– ARDS with multi-organ failure
– renal failure requiring dialysis
– consumptive coagulopathy
– pericarditis
10

11. Incubation period
• Where exposure is known or strongly
suspected - generally < 1/52
• In at least one case, 9 to 12 days
• In a minority of cases, may exceed one
week but is less than 2 weeks
11

12. Route of transmission
Undetermined
Droplet and direct contact probably
Large droplet transmission is suspected as
the most likely route.
B Guery et al. Clinical features and viral diagnosis of two cases of infection with Middle
East Respiratory Syndrome coronavirus: a report of nosocomial transmission. Lancet
(2013).
12

13. What we know
• infections can occur
across the age range –
most in older people with
comorbids
• very high fatality rate
• Sporadic cases in
communities
• limited person to person
transmission – families &
healthcare settings
• Some travel-related
cases, but no big
outbreaks
What we do not know
• How people in
communities get
infected?
• what is the main
exposure?
• what are the main risk
factors?
• what is the animal
reservoir?
13

14. Who has got MERS-CoV?
14

15. 15

16. WHO Interim case definition 3.7.13
Confirmed case
• A person with laboratory confirmation of
MERS-CoV infection.
– molecular diagnostics including either +ve
PCR on at least two specific genomic targets
or a single +ve target with sequencing on a
second.
Probable case
16

17. WHO Interim case definition 3.7.13
Probable case
Febrile ARI Clinical, radiological/ HPE
evidence (C/R/HPE) of pulm
parenchymal ds (PPD)
eg. pneumonia or ARDS
Testing for MERS-
CoV
Contact history
unavailable /
negative on a single
inadequate specimen
Direct epid-link
with a confirmed
MERS-CoV case
Inconclusive MERS-
CoV (+ve screening
test w/out
confirmation)
A resident of or
traveler to Middle
East 14/7 before
onset of illness
Of any severity
Inconclusive MERS-
CoV (+ve screening
test w/out
confirmation)
Direct epid-link
with a confirmed
MERS-CoV case
17

18. 1 Inadequate sp
• NP swab without lower resp sp,
• sp with improper handling,
• judged to be poor quality by lab,
• taken too late.
2 A direct epid link may include:
• Close physical contact
• Working together in close proximity or sharing the
same classroom environment
• Traveling together in any kind of conveyance
• Living in the same household
• 14/7 period before or after the onset of illness in the
case under consideration.
3 Inconclusive tests may include:
• A positive screening test without further confirmation
eg positive on a single PCR target
• A serological assay positive. 18

19. Inconclusive testing: 3.7.13
1. Should undergo additional virologic and
serologic testing.
2. Strongly advised that lower resp sp such as
sputum, ET aspirate, or BAL be used.
3. If no S&S of LRTI and lower track sp not
available or clinically indicated, both NP and
OP swab sp should be collected.
4. If NP swab is negative in a pt strongly
suspected to have MERS-CoV infection,
retest using a lower resp sp or a repeat NP
sp with additional OP sp and paired acute
and convalescent sera. 19

20. Who to test?
MOH 14.6.13
20

21. Patient Under Investigation (PUI)
• SARI, (include history of fever and cough) and
indications of PPD (e.g., pneumonia or ARDS),
based on clinical or radiological evidence of
consolidation, (possibility of atypical
presentations in immunocompromised) AND
• Travel to the Middle East 14/7 before AND
• Not explained by other aetiology
SARI = severe acute respiratory illness
PPD = pulmonary parenchymal disease
21

22. Contacts
• ARI of any severity,
– 14 days before onset of illness
– close physical contact with a confirmed or
probable case of MERS-CoV infection
• HCW
– working where pt with SARI cared for, (esp
ICU)
– without regard to history of travel (WRTHOT)
– Not explained by other aetiology
ARI = Acute respiratory illness 22

23. Who to test?
WHO 27.6.13
23

24. Who should be investigated?-
summarized
• SARI + PPD + either
– In a cluster (within 14/7)
– HCW exposed to pt with severe LRTI
– Traveled to middle east - 14/7
– unexpected clinical course unexplained by current
aetiology
• ARI of any severity
– close contact with confirmed/probable MERS-CoV
within 14/7
• Middle East, any ventilated pt
SARI = severe acute respiratory illness
PPD = pulmonary parenchymal disease 24

25. SARI + PPD + either
• cluster (>1 persons in a specific setting -classroom, workplace, household,
extended family, hospital, other residential institution, military barracks or
recreational camp) that occurs within 14-days, WRTHOT
unless another aetiology identified (UAAI).
• HCW working with severe ARI patients (particularly
ICU) WRTHOT UAAI
• travel to the Middle East within 14 days before onset
of illness, UAAI.
• unusual or unexpected clinical course, especially
sudden deterioration despite appropriate treatment,
WRTHOT , even if another aetiology has been identified, if
it does not fully explain the presentation or clinical course
of the patient.
WRTHOT = without regard to history of travel 25

26. How to test?
26

27. WHO 27 June 2013 update
• Stronger recommendations for lower
respiratory specimens, rather than NP
swabs, to be used to diagnose MERS-CoV
infection.
27

28. WHO 27.6.13
• NP swabs are not as sensitive as lower
respiratory specimens – BAL, tracheal
aspirate, sputum
• If patients do not have LRTI or specimens not
possible, both NP and OP should be collected
28

29. When to admit?
Where to admit?
29

30. Respiratory impairment: any of the following
Tachypnoea, respiratory rate > 24/min
Inability to complete sentence in one breath
Use of accessory muscles of respiration, supraclavicular
recession
Oxygen saturation < 92% on pulse oximetry
Decreased effort tolerance since onset of ILI
Respiratory exhaustion
Chest pains
Evidence of clinical dehydration or clinical shock
Systolic BP < 90mmHg and/or diastolic BP < 60mmHg
Capillary refill time > 2 seconds, reduced skin turgor
Altered Conscious level (esp. in extremes of age)
New confusion, striking agitation or seizures
Other clinical concerns:
Rapidly progressive (esp. high fever > 3 days) or serious atypical
illness
Severe & persistent vomiting 30

31. 31

32. 32

33. 33

34. 34

35. 35

36. What infection control
needed?
36

37. 37

38. Administrative controls
• Most important
• From door to door
• Infrastructures and equipment
• Education of HCWs
• Prevent overcrowding in waiting areas
• Placement of hospitalized patients
• Occupational health; seeking medical care
• Monitoring of compliance.
• Rapid identification of patients.
Triaging !
38

39. Environmental and engineering
controls
• Adequate ventilation
• Regular environmental cleaning
• Spatial separation of at least 1 m
39

40. PPE
• Rational and consistent use of PPE and
appropriate hand hygiene.
In this document, the term "medical mask" refers to disposable surgical or
procedure masks.
40

41. 41

42. Isolation precautions
Standard precautions
+
Droplet precautions
+
Contact precautions
Airborne for aerosol generating proceedures
42

43. 43

44. 44

45. 45

46. How to treat ?
46

47. No antiviral available !
47

48. 48

49. Early recognition and management
• Recognize SARI
• Initiate infection control measures
• Give supplemental O2 therapy
• Collect respiratory and other sp for lab testing
• Empiric antimicrobials for suspected pathogens
• Conservative fluids when no shock
• No high-dose steroids or other adjunctive
therapies outside the context of clinical trials
• Watch for clinical deterioration, eg severe resp
distress/resp failure; tissue hypoperfusion/shock49

50. 50

51. Thank you
51