MERS-CoV
From the Middle East
to the Midwest
Shawn Richards, Outbreak Supervisor
Epidemiology Resource Center
Indiana State Department of Health
APIC Conference
October 10, 2014
1
MERS CoV Media
2
Indiana Timeline
• April 30:
• 1:20pm ISDH Laboratory receives call from hospital
requesting specimen submission for MERS testing.
• 1:24 pm ISDH Virology Supervisor calls Respiratory Epi per
established protocol
• 1:34 pm Respiratory Epi calls Community Munster for epi
consult
• Respiratory Epi asks for more information as to why
suspect MERS, to check/collect travel history,
symptoms and see if HCP worked in hospital with
+MERS CoV patients.
3
4.30.14 Timeline Continued
1:56 pm Community Munster calls back with
information and specimens were authorized.
2:20 pm Respiratory Epi informs State Epi that
we have a “Real” suspect MERS CoV case.
2:30 pm Respiratory Epi contact CDC EOC.
2:44 pm ISDH reaches out IL DOH
2:47pm Respiratory Epi notifies ISDH Lab, Field
Epi and Director and State Epi of authorized
specimen.
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4.30.14 Timeline Continued
• 3:33pm CDC provides ISDH with contact info
• 4:00 Samples picked up at Community Hospital
• 4:00pm ISDH updates CDC and sends de-identified
patient record.
• 4:40pm CDC provided Submission Guidelines to ISDH
and PUI form
• 6:27pm a comprehensive contact list with CDC, ISDH,
Lake County HD, IL DOH, Community Hospital Munster
established * and plans made in case it is prelim + on
5.1.14 somewhere between 3-5:30 with update call if +.
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05.01.14 Timeline Continued
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10:35 am ISDH Lab reports to epi that they received NP and
serum, OP and Stool to arrive 5.2.14
– Expect prelim results by close of business.
10:45am- Respiratory Epi notifies CHM receipt of specimens
11:02 am Updated ISDH MERS CoV website*
11:09am Received patient update from IP and travel itinerary from
Community Hospital Munster for CDC and quarantine station
11:16am ERC Digest on MERS CoV article written just in case
11:25am Update CDC on patient status, specimens and expected
time of results
Lake County Health Department receives forms and family info to
start tracking
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5.1.14 Timeline
• 3:26pm results are available and to call NOW- LHO
division secured room by at Sheraton Hotel and set
up for an internal partners conference call at 4pm to
go over plan.
• 3:49pm Respiratory epi sent out message advising
partners that a call was imminent will forward call in
number and time as soon as established.
• 4:30pm call with hospital and CDC
• 6:45pm call with stakeholders ( IL DOH, MA DOH,
Lake County, CDC)
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Other Public Health Actions
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5.2.14 Performed and collected information on contact tracing of household
contacts and HCW’s
5.1.14-5.2.14 Contacted IL Department of Health, Chicago Health
Department, and Massachusetts HD about cases or potential of cases in
their jurisdictions.
5.2.14 Sent an EPIX message on CDC’s secure data network to all states
describing the current situation.
5.2.14 Sent an Indiana Health Alert Network message following the CDC
telebriefing held at 3:00 on 5/2 to alert the Indiana medical community and
provide ISDH call center information.
5.2.14 Assisted in the development of the press release by providing
subject matter expertise.
5.2.14 Consulted with CDC about correction to the International Health
Regulation report to be sent to HHS and the President of the United States.
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Public Health Actions
• 5.2.14 Provided subject matter expertise on a national
telebriefing with the CDC.
• 4.30.14,5.1.14,5.2.14 Participated in numerous conference calls
with CDC
• 5.2.14 Updated the Surveillance and Investigation website to
contain the most up to date MERS CoV documents.
• 5.2.14 Provided standard operating procedure to authorize
specimens to go to lab for testing
• 5.2.14 Expanded the number of persons eligible to grant
submissions for testing.
• Call Center activated for providers and general public 133 calls
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Public Health Actions
• 5.2.14 CDC Epi-Aid six-member team arrives at
ISDH approximately 6:15 p.m. Met with ISDH staff to
provide situational briefing. Conducted conference
call with ISDH District 1 Field Epidemiologist and
Community Hospital Munster to discuss objectives
and logistics of visit.
• Epi-Aid team will meet with District 1 Field
Epidemiologist and hospital staff at 11:00 EDT/10:00
CDT.
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Timeline
April 18
Index Case
started feeling
unwell
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20
21
22
23
24 Case flew
Riyadh
London
Chicago
Bus- Highland
25 Case visits
business
associate in IL
26 Case visits
business
associate in IL
27 Case
develops
fever, SOB,
cough
28 Case visits
ED and
admitted
29 CXR shows
bilateral
infiltrates
30 Case placed
in contact
isolation
2
CDC confirms
MERS CoV at
1:30 pm
3
Call Center
resumes daily
operations
Placed in resp
isolation
Hosp, ISDH
lab/epi authorize
specimen
May 1
Specimen
received at
ISDH 10:35am
tests + around
3:40pm
ERC begins IC
Collect spec
from HCW’s
Notified and
sent to CDC
Call Center set
up in prep for
news release
ISDH contacts
CDC EOC
ISDH staff
contacted
4
HCW and HH -
5
CDC Press
Conference
IHAN update
6
CDC COCA Call
7
Sit rep q2h
CDC HAN
IHAN, PR sent
CDC EOC call;
Epi-Aid
requested
Epi-Aid arrives
8
9
Case negative
per CDC testing
IHAN issued
Call Center
closed
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MERS-CoV Investigation
• Detailed investigation of case clinical
syndrome, travel history, occupation
• Contact tracing: detailed information on
exposures and symptom monitoring
• Specimen collection, authorization,
transportation, and testing
• Communication of findings
– Conference calls
– Situational briefings
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MERS-CoV Investigation
• Activated call center for health care providers
and public
• Issued messaging to health care providers
and public
• Conducted media event at hospital
• Provided guidance on infection control
• Developed algorithms and tools
– Case definition
– Specimen authorization
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Contact Tracing
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53 health care workers (HCW)
7 household (HH) contacts
1 business associate (April 25-26)
All asked to monitor twice daily for symptoms and
fever 14 days after exposure
• HCW and HH contacts
– quarantine at home for 14 days after last exposure
(HCW on paid leave)
– wear mask outside home or in contact with other HH
members
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Travelers
•
CDC and ISDH conducted
contact tracing to identify U.S.
travelers possibly exposed to
the case and provided
information to international
partners about non-U.S. citizens
who were identified
•
27 states were involved in
contact tracing due to the flights
of the U.S. cases
•
Almost all exposed were
contacted; none had evidence
of infection with MERS-CoV
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Laboratory Testing Algorithm for Patients with MERS-CoV
Document last
updated: 5/9/2014
Patient must meet clinical criteria AND exposure criteria for testing authorization!
CLINICAL CRITERIA
Does patient have fever (≥38°C, 100.4°F) and acute respiratory illness (not
necessarily pneumonia) , based on clinical or radiological evidence?
YES
NO
Patient meets CLINICAL criteria.
Determine if patient meets at least
one of the exposure criteria.
Patient DOES NOT meet clinical
criteria. No specimen authorized.
Instruct patient if symptoms
worsen to return for re-evaluation.
If NO to all three, then
the patient DOES NOT
meet exposure criteria. No
further action needed. Can
call ISDH for consultation.
Evaluate for EXPOSURE CRITERIA
Did patient have history of travel
from countries in or near the
Arabian Peninsula within 14 days
before symptom onset?
NO
Did patient have recent close contact with
a symptomatic traveler who developed
fever and acute respiratory illness (not
necessarily pneumonia) within 14 days after
traveling from countries in or near the
Arabian Peninsula?
YES
NO
NO
Is patient a member of a cluster of patients
with severe acute respiratory illness (e.g.
fever and pneumonia requiring
hospitalization) of unknown etiology in
which MERS-CoV is being evaluated, in
consultation with state and local health
departments.
YES
YES
Patient meets EXPOSURE criteria.
Place patient in contact/airborne
isolation Call ISDH for testing
authorization at 317-233-7125.
After hours, call 317-233-1325.
Patient meets EXPOSURE criteria.
Place patient in contact/airborne
isolation Call ISDH for testing
authorization at 317-233-7125.
After hours call 317-233-1325.
Patient meets EXPOSURE criteria.
Place patient in contact/airborne
isolation Call ISDH for testing
authorization at 317-233-7125.
After hours call 317-233-1325.
Countries considered in or near the Arabian Peninsula: Bahrain, Iraq, Iran, Israel, Jordan, Kuwait, Lebanon, Oman, Palestinian territories, Qatar, Saudi Arabia, Syria, the
United Arab Emirates (UAE), and Yemen.
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Close contact is defined as a) any person who provided care for the patient, including a healthcare worker or family member, or had similarly close physical contact; or b) any
person who stayed at the same place (e.g. lived with, visited) as the patient while the patient was ill. Consult CDC website at www.cdc.gov for more information.
Specimen Authorization
• Pre-authorization and epidemiology consultation must be
obtained before specimens will be tested by ISDH
Labs. Unauthorized specimens will NOT be tested.
• Prior to calling, collect the following information: name, date of
birth, travel history (including dates, locations, and mode(s) of
travel), signs and symptoms (current),illness onset date with
signs/symptoms and current patient status.
• For authorization during normal business hours contact the
ISDH Surveillance and Investigation Division at 317-233-7125 or
Shawn Richards at 317-233-7740. If after hours, call the ISDH
Duty Officer at 317-233-1325. Advise person answering the
phone that you are requesting a MERS-CoV consult and
guidance in specimen submission.
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Specimen Authorization
• Upon authorization, facility will be given an
authorization number that should be included in
Section 7 of the Virology submission form under
Influenza Sentinel Physician Number. All
unauthorized specimens will not be tested.
• Specimens will be submitted using LIMSNET. To
sign up for a LIMSNET account, the ISDH Lab can
be contacted at the LIMS HelpDesk 317-921-5506
or 1-888-535-0011.
• Specimen collection guidance is available at:
http://www.cdc.gov/coronavirus/mers/downloads/gu
idelines-clinical-specimens.pdf
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Acceptable Specimens
• Broncheoalveolar lavage, tracheal
aspirate, pleural fluid
• Sputum
• Nasopharyngeal swab
• Oropharyngeal swab
• Serum (for rRT-PCR testing)
• Stool
Specimens from suspected MERS cases must be packaged, shipped, and transported according
to the current edition of the International Air Transport Association (IATA) Dangerous Goods
Regulations at http://www.iata.org/whatwedo/cargo/dgr/Pages/infectious_substances.aspx.
Shipments from outside of the United States may require an importation permit that can be
obtained from CDC.
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Bottom Line
• No other cases
identified
• All case contacts tested
negative for MERS-CoV
• Data from contact
investigation will be
used to create guidance
for future investigations
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Strengths
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Relationships between ISDH Lab and hospital labs
Relationship between ISDH Lab and ERC staff
Established laboratory capability and capacity
Early CDC EOC notification
Rapid deployment of skilled Epi-Aid team
Communication with CDC-Atlanta/Epi-Aid team
Daily and afterhours contact list
Engaged hospital and RFID tags/cameras to track HCW
locations
• Surveillance of HCW and HH contacts
• Indiana MERS CoV case provided fresh blood for future MERS
CoV studies and development
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Strengths
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Local support of field epidemiologists
Creation of MERS-CoV website and documents
Algorithms for case definition, specimen submission
Online specimen authorization instructions
Rapid call center activation-133 calls
Preparedness team taking over situation reports
Messaging to public
Mobile technology
Prior experience with H3N2v and H1N1
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Lessons Learned
• Lack of MERS-CoV knowledge and US experience
• Delayed isolation at hospital
• Specimen collection—Lower respiratory specimens much
better than NP and OP
• Non-use of LIMSNet to submit specimens—many extra
hours per day of prep for lab staff and communication with
epi
• Changing case history information
• Frequency of situational reports
• Investigating additional “suspect cases”
• “Feeding the beast” of information
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Acknowledgements
• ISDH Staff
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–
–
–
–
Epidemiology
Laboratory
Acute Care Division
Public Health Preparedness
Office of Public Affairs
• Lake County Health
Department
• Community Hospital Munster
• CDC-Atlanta
– National Center for
Immunization and
Respiratory Diseases
– Division of Global Migration
and Quarantine
• CDC Epi-Aid Team
–
–
–
–
–
–
Danny Feikin
Nora Chea
Kim Pringle
Lucy Breakwell
Nicole Cohen
Dave Dagle
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Hospital Media Event
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ISDH Lab and Epi Staff
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Shawn Richards
Indiana State Department of Health
Epidemiology Resource Center
317-233-7740
srichard@isdh.in.gov
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