MERS coronavirus: public health preparations

Middle East Respiratory Syndrome Coronavirus (MERS-CoV)
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The Saudi Arabia Health Ministry announced three more laboratory-confirmed cases of patients with Middle East respiratory syndrome coronavirus (MERS-CoV), according to a World Health Organization (WHO) update June 17.

In addition, four previously laboratory-confirmed cases have died.

This brings the MERS-CoV global total to 64 laboratory-confirmed cases of infection with MERS-CoV, including 38 deaths. Saudi Arabia accounts for the majority of cases and deaths with 49 and 32, respectively.

All reported cases were directly or indirectly linked to one of four countries: Saudi Arabia, Qatar, Jordan, and the United Arab Emirates. However, new reports of cases outside the region raise concerns about importation to other geographic areas--the United Kingdom (UK), Italy, France, and Tunisia have reported cases in returning travelers and their close contacts.

Although there are no reports of anyone in the U.S. getting infected with MERS-CoV to date, what has public health officials in the US doing to prepare for the possibility?

Guidelines for surveillance, infection control measures and laboratory testing and specimen collection are available to help public health officials and health care providers in dealing with the possibility of MERS-CoV.

Case definitions have been established for reporting suspicious or confirmed patients.

First there is the Patient Under Investigation (PUI).

A PUI is a person with an acute respiratory infection, which may include fever (≥ 38°C , 100.4°F) and cough and there is the suspicion of pulmonary parenchymal disease (e.g., pneumonia or acute respiratory distress syndrome based on clinical or radiological evidence of consolidation).

In addition, the CDC reports that the period for considering evaluation for MERS-CoV infection in persons who develop severe acute lower respiratory illness days after traveling from the Arabian Peninsula or neighboring countries (Bahrain, Iraq, Iran, Israel, Jordan, Kuwait, Lebanon, Oman, Palestinian Territories, Qatar, Saudi Arabia, Syria, the United Arab Emirates, and Yemen) has been extended from within 10 days to within 14 days of travel.

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Persons who develop severe acute lower respiratory illness within 14 days after traveling from the Arabian Peninsula or neighboring countries should be evaluated according to current guidelines

Also, people who develop severe acute lower respiratory illness who are close contacts (family member, health care worker) of a symptomatic traveler who developed fever and acute respiratory illness within 14 days after travel from the Arabian Peninsula or neighboring countries.

A "Probable case" is a person who meets the criteria PUI and has clinical, radiological, or histopathological evidence of pulmonary parenchyma disease (e.g. pneumonia or ARDS), but no possibility of laboratory confirmation exists, either because the patient or samples are not available or there is no testing available for other respiratory infections, is a close contact with a laboratory-confirmed case and has illness not already explained by any other infection or etiology, including all clinically indicated tests for community-acquired pneumonia according to local management guidelines.

Lastly, a confirmed case is a person with laboratory confirmation of infection with MERS-CoV.

Concerning infection control guidelines, standard, contact, and airborne precautions are recommended for management of hospitalized patients with known or suspected MERS-CoV infection.

Health care providers should wear the appropriate personal protective equipment to include gloves, gowns, eye protection and respiratory protection that is at least as protective as a fit-tested NIOSH-certified disposable N95 filtering face piece respirator.

In addition, patients should be placed in Airborne Infection Isolation Room (AIIR).

Laboratory testing is available and the CDC recommends collection of specimens from different sites (e.g., a nasopharyngeal swab and a lower respiratory tract specimen, such as sputum, bronchoalveolar lavage, bronchial wash, or tracheal aspirate). Specimens should be collected at different times after symptom onset, if possible. Stool and serum samples are acceptable also.

Testing of specimens for MERS-CoV currently is being conducted at CDC. According to the Food and Drug Administration (FDA), on June 5, 2013, the FDA issued an Emergency Use Authorization (EUA) for the CDC Novel Coronavirus 2012 Real-time RT-PCR Assay. This test is for the presumptive detection of Middle East Respiratory Syndrome Coronavirus (MERS-CoV).

The test is used in conjunction with clinical and epidemiological risk factors. This device will be distributed by CDC to qualified laboratories.

The virus is clearly virulent, shows evidence of person-to-person spread and people with underlying medical conditions are at greater risk of severe disease.

In addition, there is evidence of importation of MERS-CoV and US public health and health care professionals should be alert.

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