MERS
Middle Eastern Respiratory Syndrome
Riam Jamil & Saleema Bhaidani
School of Pharmacy, University of Waterloo
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About The Authors
Riam Jamil
Saleema Bhaidani
Riam Jamil is a fourth year
student at the University of
Waterloo School of Pharmacy.
In her time at pharmacy
school, she has developed an
interest in infectious diseases
and their management. She
has donated her time to
several extra-curricular
activities, including peer
mentorship and event
organization for on campus
groups. After graduation, she
looks forward to working as a
hospital pharmacist and seeing
where the ever-changing world
of pharmacy takes her!
Saleema Bhaidani is a
Science graduate from
McMaster University in
Hamilton and in her final
year of Pharmacy at the
University of Waterloo. In
her 4 years at UWO,
Saleema has taken many
leadership roles including
President of her pharmacy
student council and Vice
President of Canada’s
national pharmacy student
council. She is excited to
move back to Toronto as a
practicing pharmacist and
provide innovative care in
the rapidly evolving
profession.
MERS: Outline
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MERS in the News
The Basics of MERS
Diagnosis
Prevention including travel consultation
Treatment
Impact on public health
Emergency preparedness plan
Role of the pharmacist
1
MERS in the News
O 2012
April: Several pneumonia cases observed in healthcare
workers in an ICU in Jordan2
-Two of these cases were fatal and were later linked to MERS2
June: A novel coronavirus was isolated from the sputum from
a man with pneumonia in Saudi Arabia2,3
MERS in the News-2
O 2014
May: First case seen in United States of America4
- The patient, an American health care worker, had travelled to Saudia Arabia for work
4
4
“The virus is not highly
contagious and this case
‘represents a very low
risk to the ... general
public’ 4"
The Basics
O Acronym Meaning
MERS-CoV
Middle Eastern Respiratory Syndrome2
O Causative Agent
- A beta coronavirus2
CoronaVirus2
MERS vs. SARS
Similarities
- Both are coronaviruses5
- Both similar to the
coronavirus found in bats5
Differences
- Countries of origin:
→ SARS: China6
→ MERS: Saudi Arabia5
- Mortality rates:
→ SARS: ~10%6
→ MERS: 38%7
- Ease of Transmission:
→ SARS: Easy8
→ MERS: Difficult4
The Basics-2
O Mode of Transmission
-Not completely clear8, but the CDC is recommending
contact and airborne precautions9
-Spreads between people IN CLOSE CONTACT5
→ Considered being within 2 meters of the patient or in his/her room
for a prolonged period of time, having direct contact with his/her
infectious secretions while not wearing protective equipment5
O Reservoir
-Not completely clear; potentially bats4,8
The Basics-3
O Geographic Distribution
- Began in the Arabian Peninsula, but has spread to other
parts of the world through travellers5,10
5
5
Symptoms
- Fever5
- Cough5
- Shortness of breath5
**Variable presentations (renal failure, diarrhea seen also)11
Those with underlying conditions8 and those working in, visiting
or admitted to health care facilities10 seem to be at a higher risk
CDC Case Definitions12
Patient Under Investigation (PUI)12
Comprises either A or B:
A) Fever AND pneumonia or acute respiratory distress syndrome
AND EITHER
a) Travel to or around the Arabian peninsula in the 14 days prior to symptom onset
OR
b) Close contact with a symptomatic traveller
OR
c) Part of a group of patients who are being investigated for MERS-CoV
B) Fever AND symptoms of any respiratory illness AND being in a healthcare facility in or
around the Arabian Penninsula in which healthcare-associated cases of MERS have
been found.
Arabian Peninsula and Surrounding Area
Countries include5:
- Bahrain
- Iraq
- Iran
- Israel, the West Bank and Gaza
- Jordan
- Kuwait
- Lebanon
- Oman
- Qatar
- Saudi Arabia
- Syria
- United Arab Emirates
- Yemen
CDC Case Definitions-212
Probable Case12
A PUI without
definitively positive
lab testing AND who
came in close
contact with a labconfirmed case.
Confirmed Case12 Contact Under
A patient with lab
Investigation of a
testing confirming a
Confirmed Case of MERS12
MERS-CoV infection.
A patient who came in close
contact with an acutely ill
confirmed case AND developed
symptoms of respiratory illness
within 14 days of contact. He/she
should be investigated for MERS.
Prevention
● Individuals should follow basic measures to help prevent the illness:13
o Wash hands often with soap and water
o Cover nose/mouth when coughing sneezing
o Avoid close contact with sick individuals
o Clean and disinfect frequently touched surfaces
o Avoid unnecessary contact with camels & avoid
raw camel milk/camel products from the
Middle East
● Is there a vaccine? NO.13
o Animal studies are underway and there is potential to develop a MERS-CoV
vaccination in the next few months
o However to date, the level of interest from scientific funding agencies to develop
a vaccine has been modest
14
Travel Precautions
● Can I still travel? YES.13
o The CDC does not recommend anyone changing their travel plans
o Those traveling to countries in or near the Arabian Peninsula should
pay special attention to their health during and after their trip
 Specifically, travelers should see their doctor right away if they
develop fever and sx of lower
respiratory illness within 14 days
after traveling to these countries
o General prevention precautions should
be followed
13
Travel Precautions-2
● Can I still perform Hajj? YES.15
o During Hajj, Saudi Arabia draws in over
3 million pilgrims around the world
o Saudi Ministry of Health recommends
that those at highest risk of the
complications of MERS refrain from Hajj
(although this is poorly adhered to)
o Public health agencies recommend pilgrims
wear their own protective measures against
respiratory infections including face masks
16
Travel Precautions-3
● Can I travel to the Arabian Peninsula to provide health care? YES.13
o HCPs travelling to work in the hospitals in these countries should be
aware of all precautions recommended by the CDC
Component
Recommendation(s)
Patient
Placement:
Airborne Infection Isolation Room (AIIR)
Healthcare Provider
Personal Protective Equipment:
- Gloves, gowns, eye protection
- Respiratory protection: at least as protective as
a fit-tested NIOSH-certified disposable N95
filtering facepiece respirator
Treatment
● Currently there are no treatments available for MERS13
● Researchers have recently identified 3 human monoclonal antibodies
that target and neutralize the virus17
● As for now, medical care is supportive to help relieve symptoms18,19
o Eg. organ support, empiric use of broad-spectrum antimicrobials to
minimize the risk of co-infections with opportunistic pathogens (but
none of these have proven to be successful in improving severe
disease progression)
Impact on Public Health
● Are public health professionals concerned? YES, to a certain degree.18
o Thus far, the virus does not appear to spread easily between humans
and it is relatively easy to halt
o There is no indication of international spread, except when infected
people have traveled from affected countries
o MERS has been shown to develop in individuals with close and
prolonged contact time with infected individuals:
● family members & health care professionals = concerning
o Unfortunately, if someone becomes infected, the mortality rate is very
high (compared to SARS) = concerning
Impact on Public Health-2
● Has there been an impact? YES. 14,19,20
o Since there have been an increasing number of infections among
healthcare workers, many Public Health Agencies across the world
have developed infection prevention and control guides for acute
care settings to protect healthcare workers
o Extra travel precautions with respect to
prevention in those traveling to
Middle Eastern Countries
o Vaccine research development
13
Emergency Preparedness Plan
● Is there an emergency preparedness plan in place? YES.13
o The CDC has released two checklists to enhance preparedness for
infection control
o http://www.cdc.gov/coronavirus/mers/preparedness/index.html
 Checklists:
●
●
Healthcare Provider Preparedness Checklist for MERS-CoV
Healthcare Facility Preparedness Checklist for MERS-CoV
Role of the Pharmacist21
● Front line surveillance
● Alerting public health officials of potential outbreaks
● Educating patients, especially those who will be traveling to the Middle
Eastern Countries
22
● Possible vaccine administration?
● Hospital pharmacists should be
well versed on preparedness plans
and extra precautions in the
hospital in the event of an
infected patient
May 06, 2014
Surveillance - visit
coronamap.com
Surveillance
- visit
coronamap.com
July 06, 2014
Surveillance - visit
coronamap.com
Surveillance
- visit
coronamap.com
Resources for Further Information
CDC Travel Notices:
http://wwwnc.cdc.gov/travel/notices
Public Health Agency of Canada re: MERS:
http://www.phac-aspc.gc.ca/eri-ire/coronavirus/index-eng.php
WHO World - travel advice on MERS-CoV for pilgrimages: http://www.who.int/ith/updates/20130725/en/
CTV News article on first American Case: http://www.ctvnews.ca/health/american-hospitalized-with-mers-first-case-inu-s-1.1803820 CTV News article on first Lebanese Case: http://www.ctvnews.ca/health/lebanon-records-first-case-ofmers-coronavirus-infection-1.1813653 CDC Frequently Asked
Questions: http://www.cdc.gov/coronavirus/mers/faq.html WHO Frequently Asked
Questions: http://www.who.int/csr/disease/coronavirus_infections/faq/en/
References
1) The Associated Press. Lebanon records its first case of potentially fatal Middle East respiratory virus. CTV News Web site. http://www.ctvnews.ca/health/lebanon-recordsfirst-case-of-mers-coronavirus-infection-1.1813653. Published May 9, 2014. Updated 2014. Accessed 05/09, 2014.
2) de Groot RJ, Baker SC, Baric RS, et al. Middle east respiratory syndrome coronavirus (MERS-CoV); announcement of the coronavirus study group. J Virol. 2013;87(14):7790.
3) Zaki AM, van Boheemen S, Bestebroer TM, Osterhaus AD, Fouchier RA. Isolation of a novel coronavirus from a man with pneumonia in Saudi Arabia. N. Engl. J. Med.
2012;367:1814–1820.
4) Stobbe M. American hospitalized with MERS first case in U.S.. CTV News Web site. http://www.ctvnews.ca/health/american-hospitalized-with-mers-first-case-in-u-s1.1803820. Published May 2, 2014. Updated 2014. Accessed 05/07, 2014.
5) Center for Disease Control. MERS- frequently asked questions and answers. http://www.cdc.gov/coronavirus/mers/faq.html. Updated 2014. Accessed 06/07, 2014.
6) Center for Disease Control. SARS-frequently asked questions. http://www.cdc.gov/sars/about/faq.html. Updated 2012. Accessed 06/07, 2014.
7) CoronaMap. CoronaMap: Realtime tracking of MERS Corona virus on world map. http://coronamap.com. Updated 2014. Accessed 07/05, 2014.
8) Kaye, D, Pollack, MP. MERS vs. SARS: Compare and contrast. Infectious Disease News. http://www.healio.com/infectious-disease/emergingdiseases/news/print/infectious-disease-news/%7B422866a7-0445-49b3-ac14-54b39bebbba6%7D/mers-vs-sars-compare-and-contrast. Published February 2014. Accessed
07/06, 2014.
9) Center for Disease Control. Interim infection prevention and control recommendations for hospitalized patients with middle east respiratory syndrome coronavirus
(MERS-CoV). http://www.cdc.gov/coronavirus/mers/infection-prevention-control.html. Updated 2014. Accessed 05/07, 2014.
10) World Health Organization. Middle east respiratory syndrome coronavirus (MERS-CoV) summary and literature update–as of 20 january 2014
http://www.who.int/csr/disease/coronavirus_infections/MERS_CoV_Update_20_Jan_2014.pdf?ua=1. Updated 2014. Accessed 05/08, 2014.
11)Public Health England. Key facts - MERS-CoV.
http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/MERSCoV/GeneralInformation/respqandanovelcoronavirus2013/. Updated 2013. Accessed 06/08, 2014.
12) Center for Disease Control. Middle eastern respiratory syndrome (MERS) case definitions. http://www.cdc.gov/coronavirus/mers/case-def.html. Updated 2013.
Accessed 05/07, 2014.
References-2
13) Centers for Disease Control and Prevention. Middle Eastern Respiratory Syndrome (MERS). CDC. http://www.cdc.gov/coronavirus/mers/index.html.
Published November 22, 2013. Updated May 5, 2014. Accessed May 7, 2014.
14) Canadian Press. MERS virus from camels and humans called indistinguishable. CBC News. http://www.cbc.ca/news/health/mers-virus-from-camels-andhumans-called-indistinguishable-1.2625624. Published April 29, 2014. Last Updated April 29, 2014. Accessed May 09, 2014.
15) Gautret P. Middle East Respiratory Syndrome (MERS) coronavirus. What travel health advice should be given to Hajj pilgrims? Travel medicine and
infectious disease. Sep-Oct 2013;11(5):263-265.
16) McElroy, D. Hajj pilgrims to wear masks to prevent spread of Mers virus. The Telegraph. Published July 13, 2013. Accessed May 9, 2014
17) Ying T, Du L, Ju TW, et al. Exceptionally potent neutralization of MERS-CoV by human monoclonal antibodies. Journal of virology. Apr 30 2014.
18) World Health Organization. Coronavirus Infections. http://www.who.int/csr/disease/coronavirus_infections/en/. Accessed May 7, 2014.
19) The Who Mers-Cov Research G. State of Knowledge and Data Gaps of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) in Humans. PLoS
currents. 2013;5.
20) Public Health Agency of Canada. Public Health Notice: Middle East Respiratory Syndrome Coronavirus (MERS-CoV).
21) Canadian Pharmacists Association. Pandemic Influenza: A Pharmacist’s Guide to Pandemic Preparedness. http://www.pharmacists.ca/cphaca/assets/File/education-practice-resources/PandemicGuideEN.pdf. Updated October 2009. Accessed May 7, 2014.
22) Fletcher, T. 1.4 million flu shots a B.C. record. Alberni Valley News. http://www.albernivalleynews.com/news/256423151.html. Published April 23, 2014.
Accessed May 09, 2014