1. Health Security and Emergencies MERS Coronavirus (as of 3 Jun 2015) Ariuntuya, TO, ESR, WHO, Mongolia

2. Health Security and Emergencies Why are we concerned? MERS-CoV can cause severe disease and deaths in humans It can be transmitted from person to person – There have been outbreaks in healthcare facilities associated with inadequate infection control Critical information gaps (“unknown”) – Reservoir, source of infection, routes of transmission, etc. Ongoing largest cluster of MERS-CoV reported outside the Middle East – To date, there are 30 cases reported in the Republic of Korea and China following an imported case

3. Health Security and Emergencies Outline Basics about MERS Current Situation – Global – Regional Risk Assessment WHO Response 3

4. Health Security and Emergencies Basics about MERS 4

5. Health Security and Emergencies What causes MERS? MERS is caused by a CoronaVirus (CoV): – CoV’s look like a crown (corona in Latin) under the microscope – CoV’s can be found in humans and animals – A large family of viruses causing a broad range of symptoms from mild to severe disease 5 Coronavirus structure A decade after SARS: strategies for controlling emerging coronaviruses, Rachel L. Graham, Eric F. Donaldson & Ralph S. Baric, Nature Reviews Microbiology 11, 836–848 (2013)

6. Health Security and Emergencies Where does MERS-CoV come from? It is related to CoV in bats Previous epidemiologic investigations have identified dromedary camels likely source of zoonotic transmission 6 Potential zoonotic transmission of MERS-CoV Emergence of MERS-coronavirus, Raj et al., Current Opinion in Virology 2014(5):58-62

7. Health Security and Emergencies Where does MERS-CoV come from? It is related to MERS-CoV in bats Previous epidemiologic investigations have identified dromedary camels likely source of zoonotic transmission 7 Potential zoonotic transmission of MERS- CoV, Emergence of MERS-coronavirus, Raj et al., Current Opinion in Virology 2014(5):58-62

8. Health Security and Emergencies Possible transmission routes Primary cases: zoonotic – Direct or indirect exposures? – Camel exposures? (direct contact, droplet, raw camel milk) Secondary cases (ie, contact to primary cases) – Healthcare workers Younger, lower number of deaths, high proportion of asymptomatic/mild disease – Household, community Younger, lower number of deaths, high proportion of asymptomatic/mild disease – Patients (nosocomial transmission) Comorbidities, highest proportion of deaths 8

9. Health Security and Emergencies Incubation period: 2-14 days* Asymptomatic cases occur Initial symptoms include: fever, cough, chills, sore throat, muscle and joint pain(=influenza like illness), diarrhea, vomiting Possibly progressing to severe acute lower respiratory illness The complete clinical spectrum remains unknown 9 What are the symptoms? Source: WHO MERS-CoV Research Group, PLOS, 2013 Nov 12 * WHO Risk Assessment 24 April 2014

10. Health Security and Emergencies How is MERS treated? Anti-viral therapy: Unavailable Supportive care: – treatment of complications and infection prevention & control remain the most important components of clinical case management http://www.who.int/csr/disease/coronavirus_in fections/en/ 10

11. Health Security and Emergencies How is MERS prevented and controlled? Vaccine: Unavailable Infection Prevention and Control in health care settings: – Standard and droplet precaution – Airborne precautions needed when performing aerosol-generating procedures (intubation etc) 11

12. Health Security and Emergencies How is the virus detected? Molecular test – Yes, detection by PCR and sequencing Serology test – ELISA developed, validation ongoing Rapid diagnostic test available – Not yet 12

13. Health Security and Emergencies Knowledge gaps (1) Exact routes and modes of transmission – Primary cases (→ risk factors, e.g. zoonotic exposures) – Secondary cases (→ risk factors, e.g. health care workers) Viral shedding (→ Infectivity) – Length of shedding (start of shedding) – Viral load dynamic (also in asymptomatic persons) 13

14. Health Security and Emergencies Knowledge gaps (2) Clinical – Spectrum of clinical picture (→ case definition) – Best therapy for patients – Risk factors for poor outcome - comorbidities 14

15. Health Security and Emergencies Global situation update 15

16. Health Security and Emergencies Global update (as of 31 May 2015) Globally reported to WHO – 1174 laboratory confirmed cases – 431 deaths (crude CFR 36.7%) The reported number of cases has decreased sharply since large nosocomial outbreaks occurred in KSA and UAE (April-May 2014) > 85% cases are from KSA 25 countries have been affected, including China, the Republic of Korea, Malaysia and the Philippines Median age= 48 years (range=9mo-99 years; n=964); 63.5% male as of 5 Feb 2015 16

17. Health Security and Emergencies 17

18. Health Security and Emergencies Regional update 18

19. Health Security and Emergencies MERS-CoV in the Region Since 20 May 2015, 30 MERS cases have been reported by the Republic of Korea (n=29 and China (n=1) as of 3 Jun 2015 All cases are linked to one chain of transmission from an imported case that became ill in the Republic of Korea following travel to the Middle East This is the first cluster of MERS cases in the Western Pacific Region This is the first time MERS cases have been reported in the Republic of Korea and China. Previously, Malaysia and the Philippines were the only Member States in the Region to have reported laboratory confirmed cases of MERS-CoV (one case each). 19

20. Health Security and Emergencies Epicurve of MERS cases reported in the Republic of Korea and China * 20 Index case isolated *4 confirmed cases without clear date of onset Isolation of index case Median age=55.5 years (range=28-79 ) 63% of cases (19/30) are male

21. Health Security and Emergencies Timeline of exposures in healthcare settings 21 24 linked to Hospital B 2 linked to Hospital F 1 linked to Clinic A 1 linked to Clinic C 2 linked to Hospital E

22. Health Security and Emergencies Transmission chain of MERS cluster 22

23. Health Security and Emergencies The index case Travelled to Bahrain, the Kingdom of Saudi Arabia, Qatar and the United Arab Emirates between 18 April to 3 May Returned to Republic of Korea on 4 May There has been no reported history of exposure to known risk factors such as contact with camels or MERS patients Source of infection is still under investigation Notified to WHO on 20 May 2015 Presented to 4 healthcare facilities prior to suspicion of MERS 23

24. Health Security and Emergencies The case reported in China Contact to index case Became symptomatic 19 May 2015 Travelled to Guangdong, China via Hong Kong SAR on 26 May 2015 Travel occurred despite advice by authorities of home- monitoring Isolated on 27 May 2015 in China Tested positive and notified to WHO on 29 May 2015 24

25. Health Security and Emergencies Country Response Republic of Korea – As of 29 May, 1364 contacts have been identified 1261 under self-monitoring 103 under self-monitoring – Contact tracing and extensive epidemiological investigation is ongoing China – Mainland China: As of 3 June, 78 close contacts have been identified and 69 have been located and are being monitored at home or in a hotel. To date, all cases are asymptomatic. Actively strengthening hospital infection control measures and strengthening surveillance. – Hong Kong SAR: As of 31 May, 42 contacts are under monitoring including 19 close contacts are under quarantine in a quarantine centre and remain asymptomatic and 23 other contacts are under medical surveillance and remain asymptomatic. 25

26. Health Security and Emergencies Risk Assessment 26

27. Health Security and Emergencies Risk of further cases in our Region The occurrence of such a large outbreak outside the Middle East is a new development, as is exportation of the disease to a third country. Further cases are expected among initial contacts – First case visited four healthcare facilities before MERS-CoV was suspected (before the index case was isolated) The ongoing cluster is similar to health setting outbreaks in other countries. Adequate IPC measures have ended transmission in previous outbreaks. – Human-to-human transmission has occurred in close family contacts, patients (or their visitors) who shared a room/ward with the index case, and to healthcare workers caring for the patient. Sustainable transmission is unlikely – To date, appears to be one generation of spread Viral sequencing from external laboratories is pending Countries have to revise their risk assessment accordingly based on their own country context 27

28. Health Security and Emergencies WHO Response 28

29. Health Security and Emergencies 29 WHO’s response to MERS-CoV Globally, guided by: – International Health Regulations or IHR (2005) – WHO Emergency Response Framework In WPR through: – Implementation of the Asia Pacific Strategy for Emerging Diseases or APSED(2010)

30. Health Security and Emergencies WHO Response for this event (1) Leadership and coordination – MERS event is ERF grade 2 – Establishment of a WPRO Event Management Team (EMT) – Dedicated resources for leadership and coordination; epidemiology and information; technical expertise; risk communication; and core services Epidemiology and Information – Risk assessment ongoing and will be posted online. – EIS and DON posting – Working and communicating closely with health officials in the Republic of Korea and China 30

31. Health Security and Emergencies WHO Response for this event (2) Technical expertise – Providing technical support, as needed in areas of epidemiology, laboratory and risk communications Risk communication – Talking points will be distributed daily Core services – Activated EOC – Mobilization of staff from other units/division in WPRO for additional support to EMT 31

32. Health Security and Emergencies Event Management Team for MERS-CoV in the Region

33. Health Security and Emergencies Preparedness in the Region Why a framework for action? Translates APSED 2010 Focus Areas and IHR core capacities into operational planning Provides a checklist of what needs to be in place to respond effectively MERS-CoV infection in the Region highlights the importance of APSED/IHR implementation as part of emergency preparedness planning 33 Checklist  Keeping up-to-date  Leadership and coordination  Preparing to respond  Surveillance, risk assessment and response  Laboratory functions  IPC  Risk communications  Public health emergency preparedness  Monitoring &Evaluation Checklist  Keeping up-to-date  Leadership and coordination  Preparing to respond  Surveillance, risk assessment and response  Laboratory functions  IPC  Risk communications  Public health emergency preparedness  Monitoring &Evaluation

34. Health Security and Emergencies WHO Recommendations to Member States Enhance their surveillance for severe acute respiratory infections (SARI) Review any unusual patterns of SARI or pneumonia cases. Notify or verify any probable or confirmed case of infection with MERS‐CoV with WHO. Raise awareness of MERS – Alert practitioners and facilities to the possibility of MERS‐CoV infection in returning travellers from the Middle East – Provide information to travellers 34

35. Health Security and Emergencies WHO Recommendations to Member States Enhance their surveillance for severe acute respiratory infections (SARI) Review any unusual patterns of SARI or pneumonia cases. Notify or verify any probable or confirmed case of infection with MERS‐CoV with WHO. Raise awareness of MERS – Alert practitioners and facilities to the possibility of MERS‐CoV infection in returning travellers from the Middle East – Provide information to travellers 35

36. Health Security and Emergencies Advice to general public People at higher risk – Health care workers, travellers to the ME exposed to animals or human cases Travellers to the Middle East – Take precautions when visiting farms or other places with camels, particularly if you have underlying diseases – Avoid contact with sick animals / camels – Practice good hand hygiene – Practice food hygiene: Avoid drinking raw milk or eating potentially contaminated food Travellers from the Middle East – See the doctor and report travel history if you have acute respiratory symptoms after returning from the Middle East 36

37. Health Security and Emergencies WHO recommendations for travellers WHO does not recommend travel restrictions or closure of borders in response to MERS-CoV Screening of passengers at POEs (arrivals or departures) is not recommended All countries should advise people in high risk groups (medical risk factors, elderly, pregnant women, parents of young children) to: ̶seek travel medicine advice before travelling, especially to mass gatherings (e.g. pilgrimage) ̶avoid contact with live birds/other animals

38. Health Security and Emergencies WPRO and MERS-CoV 38 Website: http://www.wpro.who.int/outbreaks_emergencies/wpro_coronavirus/en/

39. Health Security and Emergencies Conclusions  It is certain that health security threats and emergencies will continue to occur…  We must Prepare for a rapid response to outbreaks  We need greater investment during peaceful time

40. Health Security and Emergencies Thank you ! FAQs: http://www.who.int/csr/disease/coronavirus_infections/faq/en/