Presentor: Norlida Binti SuhaimiModerator: Dr Khairuddin Bin
Ismail Dr Nik Azman Bin Nik Adib
Dr Benedict SimInfectious disease physicianHosp Sg BulohDr. Wan
Noraini ; Surveillance Section, Disease Control DivisionDr.
Shahanizan bt Mohd Zin; Medical Development DivisionDr Anilawati ;
ID Physician, Kota Bahru
What will MERS-CoV look like?Who has MERS-CoV?Who do test?How do
test?When to admit?Where to admit?What infection control needed?How
to treat ?
Coronaviruses :- large family of viruses that can cause a range
of illnesses in humans
- from the common cold to severe acute respiratory syndrome
- cause disease in a wide variety of animal species.
In late 2012, a novel coronavirus that had not previously been
seen in humans was identified for the first time in a resident of
the Middle East - known as the Middle East Respiratory Syndrome
Thus far, all patients infected with MERS-CoV have had a direct
or indirect link to the Middle East
however, local non-sustained human-to-human transmission has
occurred in other countries, in people who had recently travelled
to the Middle East.
The MERS-CoV virus is thought to be an animal virus that has
sporadically resulted in human infections, with subsequent limited
transmission between humans.
MERS CoV : genetic similarity to viruses previously described in
However, even if an animal reservoir is identified, it is
critical to identify the types of exposures that result in
infection and the mode of transmission.
It is unlikely that transmission occurs directly from animals to
humans route of transmission may be complex requiring intermediary
hosts, or through contaminated food or drink.
Human-to-human transmission has occurred in health care
settings, among close family contacts, and in the work place.
Sustained transmission in the community beyond these clusters
has not been observed and would represent a major change in the
epidemiology of MERS-CoV.
Male to female ratio 2.6 : 1.0 Median age 56 years (range: 294
years) All aged >24 years, except 2 children(2 & 14 yrs)
Deaths:Case fatality rate = 31/55 = 56% 4~14d after onset, 2~10d
fever cough shortness of breath gastrointestinal symptoms
diarrhoea vomitingabnormal CXR20/23 (87%) 20/23 (87%) 11/23
5/23 (22%) 4/23 (17%) 20/23
Most - pneumonia. Some - GI symptoms, diarrhoea1
immuno-compromised patient - fever and diarrhoea; pneumonia only on
CXR. Half have died. Complications respiratory failure ARDS with
multi-organ failurerenal failure requiring dialysisconsumptive
coagulopathy pericarditis. Co-infections - influenza, herpes
simplex, and pneumococcus
The date of onset was defined:
among febrile patients as the first day of feverthat persisted
for more than 48 hours
afebrile patients as the first day of new cough or shortness of
As of June 12- 15 patients (65%) died
- 6 patients (26%) had recovered
- 2 patients (9%) remained hospitalized.
A total of 21 of the 23 cases were acquired by person-to-person
transmission in hemodialysis units, intensive care units, or
in-patient units in three different health care facilities.
Among 217 household contacts and more than 200 health care
worker contacts whom identified
- MERS-CoV infection developed in 5 family members (3 with
laboratory- confirmed cases)
- and in 2 health care workers (both with laboratory-confirmed
Where exposure is known or strongly suspected - generally <
In at least one case, 9 to 12 days.
In a minority of cases, may exceed one week but is less than 2
Limited person-to-person transmission
Settings: Hospital, Household
Most family members and HCWs closely exposed did not develop
No evidence at present of sustained person-to-person
transmissionCoinfection with influenza & parainfluenza - ?
Roles in transmissibility and/or the severity of the illness.
Transmissibility pattern ? SARS
Reported case of milder nCoV illness spectrum of clinical
disease maybe wider
UndeterminedPresumably universalPresumable vulnerability in
elder people with pre-existing medical conditionLower risk for
children and women?
Droplet and direct contact probably
Large droplet transmission is suspected as the most likely
route.B Guery et al. Clinical features and viral diagnosis of two
cases of infection with Middle East Respiratory Syndrome
coronavirus: a report of nosocomial transmission. Lancet
Confirmed Case: lab confirm Probable Case:SARI* with clinical,
radiological, or HPE evidence of pulm parenchymal ds [e.g.
pneumonia or ARDS]; ANDno possibility of lab confirmation ANDclose
contact** with lab-confirmed case.
*Include hx of fever or measured fever**Close contact anyone who
- Provided care for the pt, including HCW or family member; -
Stayed at the same place (e.g., lived with, visited) while pt
1) Confirmed caseA person with laboratory confirmation of
MERS-CoV infection. molecular diagnostics including either +ve PCR
on at least two specific genomic targets or a single +ve target
with sequencing on a second.
2) Probable case
Febrile ARI with clinical, radiological, or HPE evidence
(C/R/HPE) of pulm parenchymal ds (PPD) e.g. pneumonia or ARDS AND
Testing for MERS-CoV - unavailable / negative on a single
inadequate specimen ANDDirect epid-link with a confirmed MERS-CoV
Febrile ARI with C/R/HPE of PPD AND Inconclusive MERS-CoV (+ve
screening test w/out confirmation) AND A resident of or traveler to
Middle East 14/7 before onset of illness.
Febrile ARI of any severity AND Inconclusive MERS-CoV (+ve
screening test w/out confirmation) AND Direct epid-link with a
confirmed MERS-CoV case.
Inadequate sp NP swab without lower resp sp, sp with improper
handling, judged to be poor quality by lab, taken too late.
A direct epid link may include: Close physical contact Working
together in close proximity or sharing the same classroom
environment Traveling together in any kind of conveyance Living in
the same household 14/7 period before or after the onset of illness
in the case under consideration.
Inconclusive tests :
A positive screening test without further confirmation eg
positive on a single PCR target A serological assay positive.
Should undergo additional virologic and serologic
testing.Strongly advised that lower resp sp such as sputum, ET
aspirate, or BAL be used. If no S&S of LRTI and lower track sp
not available or clinically indicated, both NP and OP swab sp
should be collected. If NP swab is negative in a pt strongly
suspected to have MERS-CoV infection, retest using a lower resp sp
or a repeat NP sp with additional OP sp and paired acute and
SARI, (include history of fever and cough) and indications of
PPD (e.g., pneumonia or ARDS), based on clinical or radiological
evidence of consolidation, (possibility of atypical presentations
in immunocompromised) ANDTravel to the Middle East 10/7 before
ANDNot explained by other aetiology
ARI of any severity, 10 days before onset of illness, close
physical contact* with a confirmed or probable case of MERS-CoV
HCW working where pt with SARI cared for, (esp ICU)without
regard to history of travel (WRTHOT)Not explained by other
1. Detect early, sustained human-to-human transmission. 2.
Determine the geographic risk area for infection with the virus.
Clinical and epidemiological Ix to: 1. Determine clinical
characteristics - incubation period, spectrum of disease, and
natural history. 2. Determine epidemiological characteristics -
exposures that result in infection, risk factors, secondary attack
rates, and MOT
SARI + PPD + either In a cluster (within 14/7) HCW exposed to pt
with severe LRTI Traveled to middle east - 14/7 unexpected clinical
course unexplained by current aetiology
ARI of any severity close contact with confirmed/probable
MERS-CoV within 14/7Middle East, any ventilated pt
cluster (>1 persons in a specific setting -classroom,
workplace, household, extended family, hospital, other residential
institution, military barracks or recreational camp) that occurs
within 14-days, WRTHOT unless another aetiology identified (UAAI).
HCW working with severe ARI patients (particularly ICU) WRTHOT
travel to the Middle East within 14 days before onset of
unusual or unexpected clinical course, especially sudden
deterioration despite appropriate treatment, WRTHOT , even if
another aetiology has been identified, if it does not fully explain
the presentation or clinical course of the patient.
Stronger recommendations for lower respiratory specimens, rather
than NP swabs, to be used to diagnose MERS-CoV infection.
A longer period of observation for contacts of cases.
NP swabs are not as sensitive as lower respiratory specimens
BAL, tracheal aspirate, sputum
If patients do not have LRTI or specimens not possible, both NP
and OP should be collected
Respiratory impairment: any of the followingTachypnoea,
respiratory rate > 24/minInability to complete sentence in one
breathUse of accessory muscles of respiration, supraclavicular
recessionOxygen saturation < 92% on pulse oximetryDecreased
effort tolerance since onset of ILIRespiratory exhaustionChest
painsEvidence of clinical dehydration or clinical shockSystolic BP
< 90mmHg and/or diastolic BP < 60mmHgCapillary refill time
> 2 seconds, reduced skin turgorAltered Conscious level (esp. in
extremes of age)New confusion, striking agitation or seizuresOther
clinical concerns:Rapidly progressive (esp. high fever > 3 days)
or serious atypical illnessSevere & persistent vomiting
Most importantFrom door to doorInfrastructures and
equipmentEducation of HCWsPrevent overcrowding in waiting
areasPlacement of hospitalized patientsOccupational health; seeking
medical careMonitoring of compliance. Rapid identification of
Adequate ventilationRegular environmental cleaningSpatial
separation of at least 1 m
Rational and consistent use of PPE and appropriate hand
Airborne for aerosol generating proceedures
Recognize SARIInitiate infection control measures Give
supplemental O2 therapy Collect respiratory and other sp for lab
testing Empiric antimicrobials for suspected pathogensConservative
fluids when no shockNo high-dose steroids or other adjunctive
therapies outside the context of clinical trialsWatch for clinical
deterioration, eg severe resp distress/resp failure; tissue
Recognize severe cases, where high flow of O2 are
inadequateMechanical ventilation - early in pt with tachypneoa or
hypoxemia that persists despite high-flow O2 Consider NIV if local
expertise is available, when immunosuppression is also present, or
mild ARDS without impaired consciousness or CV failure If equipment
available and staff trained, proceed with ET intubation to deliver
invasive mechanical ventilationUse lung-protective ventilation
strategy (LPV) for ARDSIn severe ARDS, consider adjunctive
therapeutics early, especially if failing to reach LPV targetsUse
conservative fluid mx for non shocked ARDS pt
Recognize sepsis-induced shock - hypotension (SBP < 90 mm Hg)
that persists after initial fluid challenge or signs of tissue
hypoperfusion (lactate concentration > 4 mmol/L) and initiate
resuscitation by protocolEarly and rapid infusion of crystalloid
for septic shockVasopressors when shock persists despite fluid
resus Consider iv hydrocortisone (up to 200 mg/day) or prednisolone
(up to 75 mg/day) in persistent shock requiring escalating doses of
H7N9No new casesInfluenza virusOseltamivirIP 10/7Droplet
precautionHigh mortality Source avianHTHT uncertain MERS-COVOn
goingCoronavirusNo antiviral available2/52Droplet? airborne?High
mortalitySource - ? animalsHTHT limited
In consultation with WHO, 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* has been extended from within 10 days to
within 14 days of travel. In new outbreaks, it is common for cases
with the shortest incubation period to surface first, and for
estimates of incubation periods to increase. Also, it would appear
that respiratory symptoms may be mild or even absent at the outset
of illness caused by the Middle East respiratory syndrome
coronavirus. Clinicians should be alert to the possibility of
infection with this pathogen and should contact the CDC if they
encounter patients who develop severe acute lower respiratory
illness within 14 days after returning from the endemic area or are
close contacts of such individuals.
*We found that the index case in this cluster was co- infected
with influenza. Type 2 parainfluenza virus was detected in the two
secondary cases. This raises ques- tions about what roles these
other infections might play in relation to nCoV transmissibility
and/or the severity of the illness. In addition, as the index case
was diag- nosed initially with influenza, this lead to a delay in
recognition of nCoV. This highlights the importance of considering
a diagnosis of nCoV in atypical cases (in this case the poor
response to antiviral drugs), even if a putative alternative
diagnosis has already been made. HPA guidance has been adapted
accordingly . irst reported case of a milder nCoV illness raises
the possibility that the spectrum of clinical disease maybe wider
than initially envisaged, and that a significant propor- tion of
cases now or in the future might be milder or even
*Bats are the suspected host for this presumed-to-be-zoonotic
MERS-CoV, based on the finding of genetically related CoVs (found
in the Japanese pipistrelle, Pipistrellus BatCoV-HKU5 and the
lesser bamboo bat, Tylonycteris BatCoV-HKU47). Most of the ground
breaking work in finding CoVs in bats comes from The University of
Hong Kong.7One case from Abu Dhabi in the United Arab Emirates
(UAE) had been exposed to a sick camel.No animal host for the
MERS-CoV has been confirmed to date but animal samples are to
undergo analysis in US labs.