MERS-CoV M.Talebi-Taher,MD. IUMS

Cases and clusters: The index case was a patient in jaddah, who was hospitalized with pneumonia in June ARDS, acute kidney injury Died MERS-CoV was isolated from his sputum.

September 2012: A patient with acute kidney injury, ARDS I Qatar. He had recently traveled to Saudi Arabia. An additional case was reported from Qatar: severe pneumonia,kidney injury.

April 2012: Jordan 11 pneumonia cases( 8 HCWs) One patient: pneumonia and pericarditis Other: pneumonia and DIC

April 2013: 23 confirmed cases in Saudi Arabia. Person to person exposure( 9 cases in hemodialysis ward, four cases in ICU, 2 HCWs,…).

May 2014: 697 lab-confirmed cases of infection with MERS-CoV. 210 death

Possible sources: Camel:serves as intermediate hosts for MERS-CoV? 100% of camels in Oman had MERS-CoV- specific antibody. Sera from European sheep, goats,cattle, and other camelids had no specific antibodies.

Continue: Various wild and domestic animal species in the highest risk areas should be sampled for coronaviruses by serology, PCR, virus isolation,…in order to confirm the possible role of camels and to identify other potential reservoirs of MERS-CoV.

Human to human transmission: The case clusters in the UK, Tunisia, Italy, and in HCWs in Saudia Arabia and France strongly suggest that human to human transmission occurs. MERS-CoV does not yet have pandemic potential.

Case definitions: Limited data Fever, chills/rigors, headache, non- productive cough, dyspnea, and myalgia. Sore throat, coryza, sputum production, dizziness, nausea, and vomiting, diarrhea, and abdominal pain.

Case definitions: Atypical presentations: mild respiratory illness without fever and diarrheal illness preceding development of pneumonia.

Patient Under Investigation: PUI: A. Fever AND pneumonia or ARDS AND EITHER: HX. of travel within 14d Close contact with a symptomatic traveler within 14d A member of a cluster of patients with severe acute respiratory illness? MERS

PUI: OR B. Fever AND symptoms of respiratory illness AND being in a healthcare facility(as a patient, worker, or visitor) within 14 days before symptom onset.

Case definitions: Confirmed case: laboratory confirmation Probable case: a PUI with absent or inconclusive laboratory results for MERS- CoV infection who is a close contact of a laboratory-confirmed MERS-CoV case.

Close contact: Includes anyone who provided care for the patient, including a HCWs or family member or another individual who had other similarly close physical contact, and anyone who lived with or visited a case while the case was symptomatic.

Clinical manifestations: Incubation period: 5.2 days in S.Arabia 9-12 days: France 2-14 d WHO, CDC: MERS-CoV be considered in individuals with a syndrome of MERS who returned from travel to the Arabian countries within the past 14 days.

Clinical features: Most patients with MERS-CoV infection have been severely ill with pneumonia and ARDS, and some have had acute kidney injury. Many patients required mechanical ventilation. Gastrointestinal symptoms(anorexia, nausea, vomiting, abdominal pain, diarrhea).

Continue: Immunocompromised patients Comorbidities Study: in 47 patients with MERS 96 % had underlying comorbidities(DM, Hypertension, chronic cardiac disease, chronic kidney disease, prednisolone) Old age

HCWs: Over 25% of recent Saudi MERS patients were health worker. 402 MERS-CoV cases reported in Saudi Arabia over the past 2 months. 13 Jun :an iranian patient is a nurse assistant who had contact with Iran’s first MERS patient.

Stable transmission pattern: WHO: Sustained community transmission of MERS-CoV Household clusters has not increased.

Laboratory findings: Leukopenia Lymphopenia Thrombocytopenia LDH Virus can be detected with higher viral load and longer duration in the lower respiratory tract compared to URT(urine, feces, serum).

Imaging findings: Increased bronchoalveolar marking Airspace opacities Patchy infiltrates Interstitial changes Patchy to confluent airspace consolidation Nodular, reticular opacities Reticulonodular shadowing Pleural effusion

Diagnosis: Preferred tests and specimen types: rRT-PCR testing of lower respiratory specimens appears to be more sensitive for detection of MERS-CoV than testing of upper respiratory tract specimens.

Continue: Multiple specimens be collected from different sites and at different times to increase the likelihood of detecting MERS- CoV. Serology: acute phase, ≥3weeks

WHO,CDC: Lower respiratory tract specimens such as sputum, endotracheal aspirate, or BAL should be obtained from all cases of severe dis. And from milder cases when possible. Nasopharyngeal and oropharyngeal swab specimen. Serology, rRT-PCR from blood, urine, stool?

Whom to test: A person with an acute respiratory infection, which may include history of fever and cough and evidence of pulmonary parenchymal disease(pneumonia, ARDS) based upon clinical or radiographic evidence of consolidation, who requires admission to hospital.

And any of the following: 1)The disease is in a cluster that occurs within a 14-day period, without regard to place of residence or history of travel. Cluster: workplace, household,…

Continue: 2)the disease occurs in a HCW who has been working in an environment where patients with severe acute respiratory infections are being cared.

Continue: 3)the person has HX. Of travel to the Middle East within 14 days before onset of illness.

Continue: 4)unusual clinical course, especially sudden deterioration despite appropriate treatment.

Continue: 5)a person with acute respiratory illness of any severity who, within 14 days before onset of illness, was in close physical contact with a confirmed or probable case of MERS-CoV infection while that patient was ill.

Treatment: No antiviral agents are recommended for the treatment of MERS-CoV infection. Ribavirin, interferon alpha-2b?

Prevention: There is no licensed vaccine for MERS- CoV. Infection control:standard, contact, and airborne precautions for the management of hospitalized patients.

May : High rate of morbidity and mortality. Evidence of limited human to human transmission Poorly characterized clinical signs and symptoms Unknown modes of transmission of MERS-CoV. Lack of vaccine or chemoprophylaxis.

Continue: Patient placement: airborne infection isolation room(AIIR). The patient should not be placed in any room where room exhaust is recirculated without high-efficiency particulated air(HEPA)filtration.

Continue: In AIIR room facemask may be removed. Outside of the AIIR, patient should wear a facemask to contain secretions. Limit transport of patient. Minimize the number of personnel

Aerosol generating procedure: Bronchoscopy, sputum induction, intubation and extubation, CPR, open suctioning of airways. Conduct the procedures in a private room and ideally in an AIIR when feasible. Rooms doors should be kept closed except when entering or leaving the room.

Continue: Entry and exit should be minimized during and shortly after the procedure. PPE(gloves, gown, goggles, N95 mask). PPE should be removed and either -discard -reused: cleaned and disinfected

Hand hygiene: Hand hygiene should be performed after removal of PPE. Before and after all patient contact, infectious material. Water and soap Alcohol based hand rubs.

Environmental infection control: Follow standard procedures, per hospital policy, and manufactures’ instruction, for cleaning and or disinfection of: Environmental surfaces and equipment. Textiles and laundry Food utensils and dishware.

Duration of infection control precautions : ? Symptoms resolved

Monitoring and management of potentially exposed personnel: HCWs: close contact 14 days HCW who developed respiratory symptoms or fever after an unprotected exposure: -stop working -comply with work exclusion until they are deemed no longer infectious to others.

Continue: Asyptomatic HCW who had unprotected exposure: 1)exclusion from work for 14 days. 2) or wear a facemask for 14 days

Visitors: Limit visitors

Treatment: There is no specific antiviral treatment recommended for MERS-CoV infection. Rest, Fluid, pain relievers, O2 therapy.

Travel recommendations: >65yr <12yr Pregnant women Immuncompromised patients Chronic disease(heart dis., kidney dis., respiratory dis., diabetes) Patients with a terminal illness