Middle East respiratory syndrome coronavirus (MERS-CoV) DR.S.MANSORI INFECTIOUS DISEASE SPECIALIST QAZVIN UNIVERCITY OF MEDICAL SCIENCE

INTRODUCTION Middle East Respiratory Syndrome (MERS) is viral respiratory illness first reported in Saudi Arabia in 2012. It is caused by a Coronavirus called MERS-CoV Most people who have been confirmed to have MERS-CoV infection developed severe acute respiratory illness.

MERS can affect anyone. MERS patients have ranged in age from younger than 1 to 94 years old. About 30% of people confirmed to have MERS-CoV infection have died. Most of the people who died had an underlying medical condition

The occurrence of new cases seems to The occurrence of new cases seems to follow a seasonal pattern, with increasing incidence from March‐April onwards. The number of cases sharply increased since mid‐March 2014

People Who May Be at Increased Risk for MERS Recent travelers from the arabian peninsula Close contacts of an ill traveler from the arabian peninsula Close contacts of a confirmed case of MERS Healthcare personnel not using recommended infection-control precautions

incubation period Time between when a person is exposed to MERS-COV and when they start to have symptoms is 2-14 days

CLINICAL MANIFESTATIONS MERS usually presents as a rapidly progressive pneumonia, Fever, cough, shortness of breath, and progressively severe acute respiratory disease are key symptoms in most cases the severity of illness associated with MERS-CoV infection ranges from mild to fulminant

Symptoms & Complications It is not always possible to identify patients with MERS-CoV early, because like other respiratory infections, the early symptoms of MERS-CoV are non-specific. Some infected people had mild symptoms (such as cold-like symptoms) or no symptoms at all; they recovered

Symptoms & Complications Most people confirmed to have MERS-COV infection have had severe acute respiratory illness with symptoms of: fever cough shortness of breath .

Nonrespiratory Manifestations (92%) had at least 1 extrapulmonary manifestation Acute kidney injury Hepatic Hematologic (lymphopenia 92% , Thrombocytopenia 58%, Gastrointestinal (Diarrhea, acute abdomen,...)

Symptoms & Complications People with pre-existing medical conditions may be more likely to become infected with MERS, or have a severe case

Pre-existing conditions Diabetes Cancer And chronic lung, heart, and kidney disease. Weakened immune systems Severe MERS-CoV disease has occurred primarily in older adults, particularly men, with comorbidities

Therefore, these people should avoid close contact with animals, particularly camels, when visiting farms, markets, or barn areas where the virus is known to be potentially circulating

more severe complications Pneumonia kidney failure pericarditis disseminated intravascular coagulation

“Patient under investigation” for novel coronavirus infection fever +cough AND pulmonary parenchymal disease AND history of travel to the Arabian Peninsula within 10 days before onset of illness AND not already explained by any other infection or aetiology

DIAGNOSIS the diagnosis of MERS-CoV relies heavily on clinical awareness combined with confirmatory testing for the presence of MERS-CoV by the polymerase chain reaction. No bedside test exists.

DIAGNOSIS nasopharyngeal swabs are less sensitive for detecting infection with MERS-CoV than specimens taken from the lower respiratory track. WHO now strongly recommends the collection of lower respiratory specimens such as sputum, endotracheal aspirate or bronchoalveolar lavage for diagnostic polymerase chain reaction (PCR) when possible

TREATMENT Treatment is primarily supportive and there are no convincing data that the use of potent antiviral agents, such as ribavirin and interferon, brings any benefit. The use of steroids in high doses should be avoided

TRANSMISSION MERS-COV has spread from ill people to others through close contact, such as caring for or living with an infected person. In healthcare settings, such as hospitals The rate of secondary transmission among household contacts of patients with MERS-CoV infection has been approximately 5%.(NEJM)

PREVENTIVE ACTIONS Wash your hands often with soap and water for 20 seconds, and help young children do the same. If soap and water are not available, use an alcohol-based hand sanitizer. Cover your nose and mouth with a tissue when you cough or sneeze, then throw the tissue in the trash. Avoid touching your eyes, nose and mouth with unwashed hands. Avoid personal contact, such as kissing, or sharing cups or eating utensils, with sick people. Clean and disinfect frequently touched surfaces such as toys and doorknobs.

PRECAUTIONS health-care workers should always apply standard precautions consistently with all patients, regardless of their diagnosis. Droplet precautions should be added to the standard precautions when providing care to patients with symptoms of acute respiratory infection

PRECAUTIONS airborne precautions should be applied when performing aerosol generating procedures. contact precautions and eye protection should be added when caring for probable or confirmed cases of MERS-CoV infection

PRECAUTIONS General hygiene measures, such as regular hand washing before and after touching animals and avoiding contact with sick animals, should be adhered to. Food hygiene practices should be observed. People should avoid drinking raw camel milk or eating meat that has not been properly cooked.

Prevention There is no vaccine to prevent mers-cov infection

ACUTE RESPIRATORY INFECTIONS (ARIS) Acute respiratory infections (ARIs) cause widespread diseases globally and are responsible for over 4 million deaths each year

THE INCIDENCE OF ARIS especially high among infants, children, and the elderly and is more pronounced in low- and middle-income countries

ARIs may affect either or both the upper or lower respiratory tract infections involving the lower respiratory tract may be especially severe

Severe pneumonia Adolescent or adult patient with fever or suspected infection, cough, respiratory rate > 30 breaths/min, severe respiratory distress, oxygen saturation (SpO2< 90%) on room air.

ETIOLOGY Although bacteria are significant pathogens, the most common etiologies of ARIs are viral and they are frequent causes of hospital admissions and nosocomial outbreaks.

ETIOLOGY The most common viruses associated with respiratory tract infections are: human adenovirus (ADNO), human coronavirus (CoV), human metapneumovirus (hMPV), human rhinovirus (HRV), influenza virus (influenza), parainfluenza virus (PIV), respiratory syncytial virus (RSV).

KEY STRATEGIES Administrative controls Source control (infection control committee, trained infection control professionals) and policies (e.g. guidelines). Provision of adequate staff and supplies, education of health-care workers, patients, and visitors Source control Health-care workers, patients and family members should cover mouth and nose when coughing and perform hand hygiene afterwards Environmental and engineering controls Keep distance of ≥1m between patients. Keep spaces well ventilated through natural (e.g. open windows) or mechanical ventilation. Clean soiled and/or frequently touched surfaces

Early recognition and management of acute respiratory infections Give supplemental oxygen therapy to patients with SARI Collect respiratory and other specimens for laboratory testing Give empiric antimicrobials to treat suspected pathogens, including community-acquired pathogens

Early recognition and management of acute respiratory infections 4.Use conservative fluid management in patients with SARI when there is no evidence of shock 5. Do not give high-dose systemic corticosteroids or other adjunctive therapies for viral pneumonitis outside the context of clinical trials

Early recognition and management of acute respiratory infections 6.Closely monitor patients with SARI for signs of clinical deterioration, such as severe respiratory distress/respiratory failure or tissue hypoperfusion/shock, and apply supportive care interventions