MERS COV

1
Middle East Respiratory Syndrome Corona Virus
(MERS CoV)

• Dr Sanjay Kumar Gupta MD,DHM
• Infection Prevention and Control Department
• AGH

2
Content

• Introduction
• Case definition
• Algorithm for managing patients
• General IPC precautions
• Visual triage and patients placement
• Diagnostic samples
• Management
• Take home message

3
Introduction

• Middle-East Respiratory Syndrome (MERS) was first
  reported from the Kingdom of Saudi Arabia
  September 2012 caused by the novel
  betacoronavirus MERS-CoV (1). Since then more
  than 1686 cases were reported from KSA and 1028
  cases recovered, 703 cases died with substantial
  mortality of about 40. 7 Cases on treatment. (as
  of 1st Nov. 2017).

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Case definition and surveillance guidance

• A. Suspected case (patients who should be tested
  for MERS-CoV)1,2
• Adults (gt 14 years)
• I. Acute respiratory illness with clinical
  and/or radiological evidence of pulmonary
  parenchymal disease (pneumonia or Acute
  Respiratory Distress Syndrome) 3.
• II. A hospitalized patient with healthcare
  associated pneumonia based on clinical and
  radiological evidence.
• III. Upper or lower respiratory illness within 2
  weeks after exposure to a confirmed or probable
  case of MERS-CoV infection4,5.
• IV. Unexplained acute febrile (38C) illness,
  AND body aches, headache, diarrhea, or
  nausea/vomiting, with or without respiratory
  symptoms, AND leucopenia (WBClt3.5x109/L) and
  thrombocytopenia (plateletslt150x109/L) 6.
• V. Unexplained febrile illness with recent (14
  days) exposure to camels or camel products1.

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New Case Definition

• Age Clinical Presentation
  Epidemiologic Link
• Adults
• I. Severe pneumonia (severity score 3 points)
• (Appendix A) or ARDS (based on clinical or
  radiological evidence)
• Not required
• Adults2
• II. Unexplained deterioration3 of a chronic
  condition of patients with congestive heart
  failure or chronic kidney disease on hemodialysis
  
• 
  Not required
  
• Children and adults
• III. Acute febrile illness (T 380 C)
  with/without respiratory symptoms OR

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Cont.

• IV. Gastrointestinal symptoms (diarrhea or
  vomiting), AND leukopenia (WBC3.5x109 /L) or
  thrombocytopenia (platelets lt 150x109/L)
• Mnemonic Sudan fee Gamal Corona
• Sudan Severe Pneumonia and deterioration
• fee - Fever
• Gamal GIT symptoms
• Corona - CBC

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(Epidemiology link)

• Within 14 days before symptom onset
• 1. Exposure 4 to a confirmed case of MERS-CoV
  infection OR
• 2. Visit to a healthcare facility where MERS-CoV
  patients(s) has recently (within 2 weeks) been
  identified/treated OR
• 3. Contact with dromedary camels5 or consumption
  of camel products (e.g. raw meat, unpasteurized
  milk, urine)

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Severity Scores for Community-Acquired Pneumonia
(CURB 65)

• Clinical Factor
  Points
• Confusion
  1
• Blood urea nitrogen gt 19 mg per dL 1
• Respiratory rate 30 breaths per minute 1
• Systolic blood pressure lt 90 mm Hg OR
• Diastolic blood pressure 60 mm Hg 1
• Age 65 years
  1
• Total points
• CURB-65 Confusion, Urea nitrogen, Respiratory
  rate, Blood pressure, 65 years of age and older.

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Cont

• Paediatrics ( 14 years)
• I. Meets the above case definitions and has at
  least one of the following
• a. History of exposure to a confirmed or
  suspected MERS in the 14 days prior to onset of
  symptoms
• b. History of contact with camels or camel
  products in the 14 days prior to onset of
  symptoms
• II. Unexplained severe pneumonia

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Confirmed case

• A confirmed case is a suspected case with
  laboratory confirmation of MERS-CoV infection.

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Algorithm for managing patients with suspected
MERS-CoV

• Suspected MERS CoV (Case definition I-IV)
• Isolations precaution plus MERS CoV RT PCR test
• Mild2
  Moderate to severe 1
• 
  Admission
• 
  
• 
  
  RT PCR
  RT PCR
• RT PCR Positive RT PCR Negative
• Home isolation
  
  High probability 3 Low
  probability
• Discharge home
  
  
  
• 
  
  Retest RT PCR
  Not MERS CoV
• 
  
  try to obtain lower respiratory
• Retest RT PCR after 7days then every 3 days
  
  sample DC isolation
• DC isolation if asymptomatic and RT PCR negative
  5
• 
  
  Positive Negative 6

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Cont

• RT PCR positive
• No Improvement
  Improvement Retesting RT PCR
  Discharge to home
  not required isolation
  
  
  Retest after 7
  days then every 3 days
• 
  DC isolation if asymptomatic
  RT PCR negative5
• 
  

1.As determined by the treating team (one or more
of bilateral lung infiltrate, hypoxemia, systemic
toxicity, co morbidity) 2. Any that is not under
1. May discharge to home pending the lab result
and report back if worsen? Patient's residence
location obtained. 3. Strong exposure risk
factors and /or un-explained by other
diagnosis. 4. If home situation not suitable,
institution to arrange for suitable off hospital
residence. 5. Single negative test 6. May consult
with IPC service, regional CCC and /or MOH
central CCC. DC discontinue
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How to avoid MERS CoV infection
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General infection prevention and control
precautions

• Standard Precautions Standard Precautions, a
  cornerstone for providing safe health care and
  reducing the risk of further infection
• Hand hygiene, Glove and other personal protective
  equipment (Gown, face shield, mask or respirator
  etc).
• Respiratory precaution
• 1. Visual Alerts
• 2. Masking and Separation of Persons with
  Respiratory Symptoms
• C. Prevention of overcrowding
•  
•  

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Serial Number Category Number Percentages
1     2     3     4 Total number of cases passes through visual triage (138298) in 2017   Number of cases scored 4 and more from visual triage out of total cases passes (N136916) in 2017   Number of cases admitted in wards from visual triage out of total cases (N136916) in 2017   Number of cases admitted in wards from visual triage out of score 4 and more (N2240) in 2017   1,36,916     2240     181     181 99     1.64     0.13     8  
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Visual Triage for rapid identification of
patients with acute respiratory illness (ARI)

• Visual triage should be used for early
  identification of all patients with ARI in the
  Emergency Room.
• Rapid identification of patients with ARI and
  patients suspected of MERS- CoV infection is key
  to prevent healthcare associated transmission of
  MERS-CoV
• Visual triage station should be placed at the
  entry point of the healthcare facility
• Identified ARI patients should be asked to wear a
  surgical mask.
• Infection control and prevention
  precautions should be promptly implemented

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Placement of MERS CoV Pts

• 1. Critically ill should be placed in single
  patient rooms in an area that is clearly
  segregated from other patient-care areas.
• Critically ill (e.g. pneumonia with respiratory
  distress or hypoxemia) should be placed in
  Airborne Infection Isolation rooms (Negative
  Pressure Rooms) due to the high likelihood of
  requiring aerosol-generating procedures.

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Cont...

• When negative pressure rooms are not available,
  place the patients in adequately ventilated
  single rooms.
• When available, a portable HEPA filter, turned on
  to the maximum power, the side of the patients
  bed, at the head of the bed.

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Exposure risk

• High-risk unprotected exposure (Contact with
  confirmed MERS-CoV case within 1.5 meters for gt
  10 minutes)
• Low-risk unprotected exposure (Contact with
  confirmed MERS-CoV case more than 1.5 meters
  and/or for lt 10 minutes)
• Protected exposure (Contact with confirmed
  MERS-CoV case and having appropriate isolation
  precautions including the PPE)

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Diagnostic sample

• Sample should we collect in negative pressure
  room with using all personal protective measures.
• If suspected MERS CoV case according to
  definition reported in ER and its not required
  admission and sent home after treatment with
  health education, home Isolation, but to be
  investigated for confirmation and samples should
  we collected in ER following IC
  guidelines/precaution.
• If suspected MERS CoV patient required
  admission and send to the concerned department
  than sample will be collected in that
  department after applying all infection control
  precaution.

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Following samples to be collected

• Upper respiratory tract (Both must be taken
  together)
• a) Nasopharyngeal swabs Nasopharyngeal swabs
  Insert a swab into the nostril parallel to the
  hard palate.
• Leave the swab in place for a few seconds to
  absorb secretions. Swab both nasopharyngeal
  areas.
• b) Oropharyngeal swabs Swab the posterior
  pharynx, avoiding the tongue.
• Blood samples
• Serum for serologic testing Please be aware that
  the MERS-CoV serologic test is currently under
  investigation and is for Research/surveillance
  purposes and not yet for diagnostic purposes

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Continue

• 2. Serum for rRT-PCR testing For detection of
  the virus and not for antibodies.
• EDTA blood (plasma) Collect 1 tube (10 ml) of
  heparinized (green-top) or EDTA (purple-top)
  blood.
• Refrigerate specimen at 2-8C and ship on
  ice-pack do not freeze.
• 4. Stool samples Collect 2-5 grams of stool
  specimen (formed or liquid) in sterile,
  leak-proof, Refrigerate specimen at 2-8C up to
  72 hours.

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Management of MERS CoV

• Call MOH hotline 937 to report any suspected
  MERS patient or to arrange for transfer of the
  patient to a MERS-designated centre.
• For community acquired pneumonia, a 3rd
  generation cephalosporin (e.g. ceftriaxone) to
  cover Streptococcus pneumoniae and a macrolide
  (e.g. erythromycin, clarithromycin, or
  azithromycin) to cover atypical organisms (e.g.
  Mycoplasma pneumoniae and Chlamydophila
  pneumonia) should be initiated.

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Continue

• The use of respiratory quinolones (e.g.
  levofloxacin or moxifloxacin) is NOT advisable
  because of their valuable anti-tuberculosis (TB)
  activity and the fact that TB is common in our
  community.
• Oseltamivir (Tamiflu) should also be empirically
  added when viral pneumonia is suspected (e.g. a
  patient whose illness started with an influenza
  like illness for a few days followed by
  pneumonia).

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For hospital-acquired pneumonia

• For hospital-acquired pneumonia, Gram-negative
  bacteria should be primarily covered.
• A third-generation cephalosporin effective
  against Pseudomonas aeruginosa (e.g.
  ceftazidime), anti-psuedomonal penicillin (e.g.
  Pipaeracillin/tazobactam), or a carbapenem (e.g.
  imipenem or meropenem) should be used for empiric
  treatment and subsequently modified per the
  respiratory and blood culture results.
• If the patient is known to be colonized with
  methicillin-resistant Staphylococcus aureus,
  vancomycin should also be added to the anti-Gram
  negative coverage.

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Prevention

• No vaccine or preventive drug is available. CDC
  recommends that practice general hygiene
  precautions such as frequent hand washing
  avoiding touching the eyes, nose, and mouth and
  avoiding contact with sick people.
• WHO recommend avoid contact with camels, do not
  drink raw camel milk or raw camel urine, and do
  not eat undercooked meat, particularly camel meat.

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Case series

• DESIGN AND SETTINGS
• A case series of 6 patients admitted with a
  confirmed diagnosis of MERS CoV were treated with
  ribavirin and IFN-a2b in addition to supportive
  management.
• The patients' demographics, clinical parameters,
  and outcomes were recorded. Fifty-four close
  contacts of these patients were screened for MERS
  CoV.
• METHODS
• Six patients with MERS CoV infection were
  included in this study. Four cases featured
  symptomatic disease, including pneumonia and
  respiratory failure, while 2 were asymptomatic
  close contacts of the MERS CoV patients.
• The MERS CoV infection was confirmed by reverse
  transcription-polymerase chain reaction detection
  of the consensus viral RNA targets upstream of
  the E gene (UPE) and open reading frame (ORF1b)
  on a sputum sample.
• The patients' demographics, comorbid conditions,
  time to diagnosis and initiation of treatment,
  and clinical outcomes were recorded.

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RESULTS

• Three out of 6 patients who had co morbid
  conditions died during the study period, while 3
  had successful outcomes.
• The diagnosis and treatment was delayed by an
  average of 15 days in those patients who died.
• Only 2 close contacts out of the 54 screened
  (3.7) were positive for MERS CoV.
• CONCLUSION
• Treatment with ribavirin and IFN-a2b may be
  effective in patients infected with MERS CoV.
  There appears to be a low infectivity rate among
  close contacts of MERS CoV patients.
• Ann Saudi Med. 2014 Sep-Oct34(5)396-400. doi
  10.5144/0256-4947.2014.396
• Khalid M1, Khan B, Al Rabiah F, Alismaili
  R, Saleemi S, Rehan-Khaliq AM, Weheba I, Al
  Abdely H, Halim M, Nadri QJ, Al Dalaan
  AM, Zeitouni M, Butt T, Al Mutairy E.

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Take home message

• Good visual triage with hand hygiene and
  effective use of personal protective equipments
  and timely isolation of the patients is key of
  prevention and control of MERS CoV.

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References

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