ADRIAN MARK
NO known effective treatment or
preventive vaccines
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From 2012- 2018, 37 patients reported direct or
indirect contact with dromedaries in Saudi
Arabia (33 cases), Oman (2 cases), the United
Arab Emirates (one case) and Malaysia (one
case; contact with dromedary was in Saudi
Arabia).
nd
2 Jan 2018
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55 year old male who resides in Malaysia, traveled as a
member of a pilgrimage group to KSA from 13-23
December 2017.
The case reported a history of exposure to dromedary
camels (drinking unpasteurized camel milk and direct
contact with a camel) while visiting a camel farm in
Riyadh on 20 December 2017.
The case developed symptoms on 24 December, was
treated and hospitalized in Malaysia.
1st case in 2014. 2nd case in Jan 2018.
Epidemiology
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Between 2012 and 30 June 2018, 2229 laboratory confirmed
cases of Middle East respiratory syndromecoronavirus
(MERS-CoV) infection were reported to WHO,
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83% of whom were reported by the Kingdom of Saudi
Arabia .
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In total, cases have been reported from 27 countries in the Middle East,
North Africa, Europe, the United States of America, and Asia
To date, 791 individuals have died (crude CFR 35.5%).
21% of the 2228 cases were reported to have no or mild symptoms,
while 46% had severe disease or died.
Overall, 18.6% of the cases reported to date are health care workers
HUMAN TO HUMAN TRANSMISSION IN
HEALTHCARE FACILITY IS COMMON!
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On 20th May 2015, the Republic of Korea notified WHO of the first laboratoryconfirmed case of MERS-CoV.
• The index case had recently travelled to the Kingdom of Saudi Arabia (KSA),
Qatar, the UAE and Bahrain. The source of his infection remains unknown.
• The second case was his wife, the third was his hospital roommate, the fourth
was the daughter of the roommate, the fifth was a healthcare professional who
treated the first patient, and so on.
According to the WHO, the rapid spread of the disease in South Korea was
because of - among other things - a lack of awareness among the public and
healthcare workers about MERS, crowded hospitals and emergency rooms,
visitation by too many friends and family members and the practice of 'doctor
shopping', or seeking care in multiple hospitals.
• In this outbreak, transmission of MERS-CoV has been strongly associated
with health care settings. 14% cases are health care professionals
Clinical Features
About 3 to 4 out of every 10 people reported with MERS have died.
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MERS can affect anyone.
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MERS patients have ranged in age from younger than 1 to 99 years old.
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The groups at highest risk for developing MERSCoV are:
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• Infants/Children
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• Elderly
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• People with immune system problems
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• Chronic Heart, Lung and Kidney problems
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• Pregnant women
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• People with Diabetes
3 CASE DEFINITIONS FOR PUI
MERSCOV
CASE DEFINITIONS (a)
PUI (Patient Under Investigation ) MERS CoV
1)A person with an acute respiratory infection,
which may include history of fever and cough
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2) and indications of pulmonary parenchymal
disease, based on clinical or radiological
evidence of consolidation,
3)who requires admission ( mod to severe )to
hospital
4) who within 14 days before onset of
symptoms has history of residing in/travel to the
Middle East/other affected countries with active
transmission where human infections reported and in
countries where MERS‐CoV is known to be circulating
in dromedary camels”
CASE DEFINITIONS (b)
PUI (Patient Under Investigation ) MERS CoV
Individuals with acute respiratory illness of any degree of
severity who, within 14 days before onset of illness, had any
of the following exposure:
i.close physical contact with a confirmed/probable case of an ill
MERS‐CoV patient
ii.a healthcare facility in a country within 2 months of the last
laboratory confirmed case of hospital‐associated MERS‐CoV
infections have been reported;
iii.direct contact with dromedary camels or consumption
or exposure to dromedary camel products (raw meat,
unpasteurized milk, urine) in countries where MERS‐CoV is
known to be circulating in dromedary camel
Close physical contact
1.Health care associated exposure -providing direct care for MERS‐CoV
patients/visiting patients/staying in the same close environment
3.Working together in close proximity or sharing the same classroom
environment
4.Traveling together in any kind of conveyance
5.Household contact
CASE DEFINITIONS (c)
PUI (Patient Under Investigation ) MERS CoV
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A person with an acute respiratory infection,
which may include history of fever and cough
and indications of pulmonary parenchymal
disease, based on clinical or radiological
evidence of consolidation, who requires
admission to hospital
AND
Part of a cluster of patients with SARI of
unknown aetiology in which MERS-COV is being
evaluated , In consultation with state and local
health departments in Malaysia”
Probable Case
1)A person with a febrile acute respiratory illness with clinical,
radiological, or histopathological evidence of pulmonary
parenchymal disease (e.g.pneumonia or Acute Respiratory
Distress Syndrome); AND
2)MERS-CoV test is unavailable/negative (on single inadequate
specimen*) or inconclusive** AND
i)
ii)
direct epidemiologic-link with confirmed case OR
direct contact with dromedary camels or consumption or exposure to
dromedary camel products (raw meat, unpasteurized milk, urine) in
countries where MERS‐CoV is known to be circulating in dromedary
camel OR
iii)
with hx of residing in/ travelling to countries with active
transmission in last 14 days
*Inadequate specimen = NP swab without LRT
specimen/sample of poor quality/taken too late in course of
illness
**Inconclusive test = positive screening test without
confirmation/positive serological assay
Confirmed Case:
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A person with laboratory confirmation of
infection with the MERS-CoV
Step 1
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Patient comes to ED with symptoms of
respiratory infection ( fever, cough, runny nose,
sorethroat, shortness of breath)
IF NO = NOT PUI MERCOV
Step 2
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Any POSITIVE history of :
1) Travelling/residing middle east/countries with
MERSCOV
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2) Hx of visiting camel farm / direct contact with camel
3) Hx of drinking unpasteurised camel milk/ urine / raw
meat
4) Hx of being in contact with a probable or confirmed
case of MERS COV
IF NO = NOT PUI MERSCOV
Step 3
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Is it within 14 days prior to onset of symptoms?
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If more than 14days ; MERSCOV Unlikely
Step 4
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Any evidence of lung parenchymal disease,
either clinical ( pneumonia/ hypoxia/
tachypnoea/ ARDS) ) or chest xray finding of
consolidation?
IF NO ( lungs clear, xray normal, clinically
comfortable on room air) = Not PUI MERCOV
STEP 5
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Assess Severity
IF 1 YES IS CONSIDERED MODERATE TO SEVERE ILLNESS
AND NEEDS ADMISSION
IF ALL NO, MILD ILLNESS
Clinical Assessment of Severity
STEP 6
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IF Severity Mild, Not considered PUI
MERSCOV
However if severity Mild, with contact with
camels or confirmed cases of MERCOV, To
admit ward as PUI MERCOV.
Step 7
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1) Hx of Respiratory symptoms = Yes
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2) Hx of travel to middle east/camel = Yes
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3) Hx within 14 days prior to onset = Yes
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4) Evidence of lung parenchymal disease = Yes
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5) Severity Mod/Severe = PUI MERSCOV and Admit
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6) Severity Mild ( NO contact with camels or confirmed
cases) = Not PUI MERSCOV, discharge with advice
7) Severity Mild ( Contact with camels or confirmed
cases) = Admit as PUI MERSCOV
Step 8
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Severity Mild ( NO contact with camels or confirmed cases)
= Not PUI MERSCOV, discharge with home assessment
tool
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No need to be notified
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No need throat swab
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Treast as outpatient assessment eg, URTI, or ILI with tamiflu
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TCA stat if worsening symptoms
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Provide clinic contact number for patients to contact if
symptoms worsen
Step 9 ( Mild Symptoms)
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Contact patient daily for 72 hours, to enquire
health status and condition
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If well, can be discharged.
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If worsens, for patient to seek medical attention.
Step 10: For PUI MERSCOV
Immediate referral for admission
Notify immediately if at OPD
If at ED notify in ward
Initial management PUI Mers
CoV (OPD/ED)
Initial management PUI Mers
CoV (OPD/ED)
Management of PUI Mers CoV in
ward
Respiratory Specimens
Lower respiratory tract
specimens has better yield
1. Sputum - Deep cough sputum
2. Broncheoalveolar lavage,
tracheal aspirate, pleural fluid
3. If collection of lower tract
specimens is not possible a
combined nasopharyngeal and
oropharyngeal swabs may be
collected
Also pls request for influenza PCR/IF /sputum culture & sensitivity
Respiratory Specimens
Positive result
Lower respiratory tract
specimens has better yield •Send second sample for
1. Sputum - Deep cough sputum
2. Broncheoalveolar lavage,
tracheal aspirate, pleural fluid
3. If collection of lower tract
specimens is not possible a
combined nasopharyngeal and
oropharyngeal swabs may be
collected
confirmation
•Repeat test every 2-4 days until 2
consecutive negative test at least
24 hours apart
Negative result
• If highly suspicious, repeat
sample every 4 days until negative
till 14 days
Also pls request for influenza PCR/IF /sputum culture & sensitivity
MERS-CoV Infection: Management Of Close
Contacts To A Probable / Confirmed Case
Asymptomatic
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Hand-out / pamphlet about
MERS-CoV
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Mild symptoms
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Home Assessment Tool
14 days surveillance (i.e.
from the date of last
exposure
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no restriction of movement
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HOME SURVEILLANCE
RESTRICTION on his / her
daily movement.
hand-out / pamphlet about
MERS-CoV infection modified
Home Assessment Tool
-To conduct 14 days
surveillance (i.e. from the date
of last exposure
To send the diagnostic
specimen
INFECTION CONTROL
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1) MERS: SCREENING AND TRIAGING
• A special area should be set up for PUI of MERS, to which he / she can come
directly.
The PUI should be managed by a dedicated team where possible.
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Clinical triage - rapid case identification of patients at risk
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• Spatial separation of at least 1m between patients in the waiting rooms
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• Provide resources for performing hand hygiene (alcohol hand rub bottles
made available)
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• Offer surgical mask (not N95 mask) if patient able to tolerate (not
tachypneic, not hypoxic)
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• Adequate environmental ventilation and environmental cleaning at waiting
and triage areas
2) Designated Pathway
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From ED Decontamination room, need to have
assigned pathway ( designated lift) for direct
admission to negative pressure room
Need to establish designated portable xray
machine
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Personal Protective Equipment (PPE)
(Standard And Droplets Precaution)
In addition to Standard Precautions, all individuals (visitors and
healthcare workers), when in close contact (within 1 metre) or
upon entering the room or cubicle of patients, should always wear:
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A 3 ply surgical mask
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Eye protection (i.e. goggles or a face shield)
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A clean, non-sterile, long-sleeved gown
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Nonsterile Gloves
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Use dedicated equipment (e.g. stethoscopes, blood pressure cuffs
and thermometers)
PPE When Performing Aerosol-Generating Procedures (Standard And
Airborne Precautions) – Wear N95
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• An aerosol-generating procedure (AGP) is defined as any medical
procedure that can induce the production of aerosols of various sizes,
including small (< 5 μm) particles. The aerosol-generating procedures
include:
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Intubation - the strongest evidence for needing airborne precaution
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Manual ventilation
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Non-invasive ventilation (e.g., BiPAP, BPAP) – avoid if possible
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Tracheostomy insertion
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Bronchoscopy
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Sputum induction
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Nebulization (some recent guidelines disqualified this as AGP)
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• Airborne precaution also recommended when taking oropharyngeal/
nasopharyngeal swab
3) Isolation Rooms
In descending order of preference:
i. Negative pressure single room en-suite bath (if available
within the health care facility)
ii. Single room (nursed with door closed) and en-suite bath
iii. Single room
( IF No negative pressure room in ICU for intubated cases,
need to be ventilated in ward with designated nurse)
VISITOR POLICY
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• Limit the number of family members and visitors in
contact with a probable or confirmed case MERS
infection.
• Family members and visitors who may come into
contact with a patient should be limited to those
essential for patient support and should be trained on
the risk of transmission and on the use of the same
infection control precautions as HCWs who are
providing routine care.
THANK YOU