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Presentor : Norlida Binti Suhaimi Moderator : Dr Khairuddin Bin Ismail Dr Nik Azman Bin Nik Adib

Presentor: Norlida Binti Suhaimi Moderator: Dr Khairuddin Bin Ismail Dr Nik Azman Bin Nik Adib

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Text of Presentor: Norlida Binti Suhaimi Moderator: Dr Khairuddin Bin Ismail Dr Nik Azman Bin Nik Adib

  • 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 (SARS).

    - 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 Coronavirus (MERS-CoV)

    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 bats.

    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 after hospitalization

  • fever cough shortness of breath gastrointestinal symptoms diarrhoea vomitingabnormal CXR20/23 (87%) 20/23 (87%) 11/23 (48%)8/23 (35%)

    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 breath.

  • 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 cases).

  • Where exposure is known or strongly suspected - generally < 1/52

    In at least one case, 9 to 12 days.

    In a minority of cases, may exceed one week but is less than 2 weeks

  • Limited person-to-person transmission

    Settings: Hospital, Household

    Most family members and HCWs closely exposed did not develop disease

    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?

  • Undetermined

    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 (2013).

  • 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 ill

  • 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 case

    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 convalescent sera.

  • 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 infection

    HCW working where pt with SARI cared for, (esp ICU)without regard to history of travel (WRTHOT)Not explained by other aetiology

  • 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 UAAI

  • travel to the Middle East within 14 days before onset of illness, UAAI.

    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 patients.

  • Adequate ventilationRegular environmental cleaningSpatial separation of at least 1 m

  • Rational and consistent use of PPE and appropriate hand hygiene.

  • ??

  • Standard precautions


    Droplet precautions

    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 hypoperfusion/shock

  • 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 vasopressors

  • 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 [7]. 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 asymptomatic.

    *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.