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| __NOTOC__ | | __NOTOC__ |
| {{CMG}} | | {{MERS}} |
| | {{CMG}} ; '''Associate Editor-In-Chief:''' {{Rim}} |
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| ==Overview==
| | {{SK}} MERS-CoV infection, MERS infection |
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| ==Epidemiology and Demographics== | | ==[[Middle east respiratory syndrome coronavirus infection overview|Overview]]== |
| * The Middle East respiratory syndrome coronavirus (MERS-CoV) was first reported to cause human infection in September 2012. In July 2013, the World Health Organization (WHO) International Health Regulations Emergency Committee determined that MERS-CoV did not meet criteria for a "public health emergency of international concern," but was nevertheless of "serious and great concern".
| | ==[[Middle east respiratory syndrome coronavirus infection historical perspective|Historical Perspective]]== |
| | ==[[Middle east respiratory syndrome coronavirus infection pathophysiology|Pathophysiology]]== |
| | ==[[Middle east respiratory syndrome coronavirus infection differential diagnosis|Differentiating Middle east respiratory syndrome coronavirus infection from other Diseases]]== |
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| * As of September 20, 2013, a total of 130 cases from eight countries have been reported to WHO; 58 (45%) of these cases have been fatal. All cases have been directly or indirectly linked through travel to or residence in four countries: Saudi Arabia, Qatar, Jordan, and the United Arab Emirates (UAE).
| | ==[[Middle east respiratory syndrome coronavirus infection epidemiology and demographics|Epidemiology and Demographics]]== |
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| * The median age of persons with confirmed MERS-CoV infection is 50 years (range: 2–94 years).
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| * The male-to-female ratio is 1.6 to 1.0.
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| * Twenty-three (18%) of the cases occurred in persons who were identified as health-care workers.
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| * Although most reported cases involved severe respiratory illness requiring hospitalization, at least 27 (21%) involved mild or no symptoms.
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| *Despite evidence of person-to-person transmission, the number of contacts infected by persons with confirmed infections appears to be limited. No cases have been reported in the United States, although 82 persons from 29 states have been tested for MERS-CoV infection.
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| Shown below is an image depicting the number of cases of Middle East respiratory syndrome coronavirus infection (58 fatal and 72 nonfatal) reported to the World Health Organization (WHO) as of September 20, 2013, by month of illness onset during 2012-2013. As of September 20, 2013, a total of 130 cases from eight countries have been reported to WHO; 58 (45%) of these cases have been fatal.
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| [[File:Number of cases of Middle East respiratory syndrome coronavirus infection.gif]] | |
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| Shown below is an image depicting confirmed cases of Middle East respiratory syndrome coronavirus infection (N = 130) reported to the World Health Organization as of September 20, 2013, and history of travel from in or near the Arabian Peninsula within 14 days of illness onset during 2012-2013. All cases have been directly or indirectly linked through travel to or residence in four countries: Saudi Arabia, Qatar, Jordan, and the United Arab Emirates.
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| [[File:Confirmed cases of Middle East respiratory syndrome coronavirus infection.gif]]
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| ==Pathophysiology==
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| Potential animal reservoirs and mechanism(s) of transmission of MERS-CoV to humans remain unclear. A zoonotic origin for MERS-CoV was initially suggested by high genetic similarity to bat coronaviruses , and some recent reports have described serologic data from camels and the identification of related viruses in bats. However, more epidemiologic data linking cases to infected animals are needed to determine if a particular species is a host, a source of human infection, or both.
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| ==History and Symptoms==
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| ===History===
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| Suspect MERS-CoV infection in case of:<br>
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| * Fever (≥38°C, 100.4°F) and pneumonia or acute respiratory distress syndrome (based on clinical or radiological evidence);<br>
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| ''AND EITHER'' <br>
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| * History of travel from countries in or near the Arabian Peninsula1 within 14 days before symptom onset;<br>
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| ''OR''<br>
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| * Close contact2 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;<br>
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| ''OR''<br>
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| * Is 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.
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| ===Symptoms===
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| * [[Fever]] (98%)
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| * [[Cough]] (83%)
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| * [[Shortness of breath]] (72%)
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| * Gastrointestinal symptoms
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| ** [[Diarrhea]] (26%)
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| ** Vomiting (21%)
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| All but two patients (96%) had one or more chronic medical conditions, including [[diabetes]] (68%), [[hypertension]] (34%), [[heart disease]] (28%), and [[kidney disease]] (49%). Thirty-four (72%) had more than one chronic condition.
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| | ==[[Middle east respiratory syndrome coronavirus infection risk factors|Risk Factors]]== |
| | ==[[Middle east respiratory syndrome coronavirus infection natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| ==Diagnosis== | | ==Diagnosis== |
| CDC has changed its guidance to indicate that testing for MERS-CoV and other respiratory pathogens can be conducted simultaneously and that positive results for another respiratory pathogen should not necessarily preclude testing for MERS-CoV. Health-care providers in the United States should continue to evaluate patients for MERS-CoV infection if they develop fever and pneumonia or acute respiratory distress syndrome (ARDS) within 14 days after traveling from countries in or near the Arabian Peninsula. Providers also should evaluate patients for MERS-CoV infection if they have ARDS or fever and pneumonia, and have had close contact§ with a recent traveler from this area who has fever and acute respiratory illness.
| | [[Middle east respiratory syndrome coronavirus infection history and symptoms|History and Symptoms]] | [[Middle east respiratory syndrome coronavirus infection physical examination|Physical Examination]] | [[Middle east respiratory syndrome coronavirus infection laboratory findings|Laboratory Findings]] |
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| CDC continues to recommend that clusters¶ of patients with severe acute respiratory illness (e.g., fever and pneumonia requiring hospitalization) be evaluated for common respiratory pathogens and reported to local and state public health departments. If the illnesses remain unexplained, particularly if the cluster includes health-care providers, testing for MERS-CoV should be considered, in consultation with state and local health departments. In this situation, testing should be considered even for patients without travel-related exposure.
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| ===Confirmed Case===
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| A confirmed case is a person with laboratory confirmation of MERS-CoV infection.
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| ===Probable Case===
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| A probable case is a PUI with absent or inconclusive laboratory results for MERS-CoV infection who is a close contact of a laboratory-confirmed MERS-CoV case.
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| ==Laboratory Tests==
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| * Confirmatory laboratory testing now requires a positive [[polymerase chain reaction]] (PCR) of at least two, instead of one, specific genomic targets or a single positive target with sequencing of a second.
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| * Lab tests (PCR) for MERS-CoV are available at state health departments, CDC, and some international labs. Otherwise, MERS-CoV tests are not routinely available. There are a limited number of commercial tests available, but these are not FDA-approved.
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| ==Collecting, Handling, and Testing Clinical Specimens==
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| ===Respiratory Specimens===
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| ====Lower respiratory tract Broncheoalveolar lavage, tracheal aspirate, pleural fluid====
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| Collect 2-3 mL into a sterile, leak-proof, screw-cap sputum collection cup or sterile dry container. Refrigerate specimen at 2-8°C up to 72 hours; if exceeding 72 hours, freeze at -70°C and ship on dry ice.
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| ====Sputum====
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| Have the patient rinse the mouth with water and then expectorate deep cough sputum directly into a sterile, leak-proof, screw-cap sputum collection cup or sterile dry container. Refrigerate specimen at 2-8°C up to 72 hours; if exceeding 72 hours, freeze at -70°C and ship on dry ice.
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| ===Upper respiratory tract===
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| ====Nasopharyngeal AND oropharyngeal swabs (NP/OP swabs)====
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| Use only synthetic fiber swabs with plastic shafts. Do not use calcium alginate swabs or swabs with wooden shafts, as they may contain substances that inactivate some viruses and inhibit PCR testing. Place swabs immediately into sterile tubes containing 2-3 ml of viral transport media. NP/OP specimens can be combined, placing both swabs in the same vial. Refrigerate specimen at 2-8°C up to 72 hours; if exceeding 72 hours, freeze at -70°C and ship on dry ice.
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| ====Nasopharyngeal swabs====
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| Insert a swab into the nostril parallel to the palate. Leave the swab in place for a few seconds to absorb secretions. Swab both nasopharyngeal areas.
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| ====Oropharyngeal swabs====
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| Swab the posterior pharynx, avoiding the tongue.
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| ====Nasopharyngeal wash/aspirate or nasal aspirates====
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| Collect 2-3 mL into a sterile, leak-proof, screw-cap sputum collection cup or sterile dry container. Refrigerate specimen at 2-8°C up to 72 hours; if exceeding 72 hours, freeze at -70°C and ship on dry ice.
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| ===Blood Components===
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| ====Serum (for serologic testing)====
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| For serum antibody testing: Serum specimens should be collected during the acute stage of the disease, preferably during the first week after onset of illness, and again during convalescence, ≥ 3 weeks after the acute sample was collected. However, since we do not want to delay detection at this time, a single serum sample collected 14 or more days after symptom onset may be beneficial. Serologic testing is currently available at CDC upon request and approval. Please be aware that the MERS-CoV serologic test is for research/surveillance purposes and not for diagnostic purposes - it is a tool developed in response to the MERS-CoV outbreak. Contact CDC’s Emergency Operations Center (EOC) (770-488-7100) for consultation and approval if serologic testing is being considered.
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| ===Serum (for rRT-PCR testing)===
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| * For rRT-PCR testing (i.e., detection of the virus and not antibodies), a single serum specimen collected optimally during the first week after symptom onset, preferably within 3-4 days, after symptom onset, may be also be beneficial.
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| * Children and adults: Collect 1 tube (5-10 mL) of whole blood in a serum separator tube. Allow the blood to clot, centrifuge briefly, and separate sera into sterile tube container. The minimum amount of serum required for testing is 200 µL. Refrigerate the specimen at 2-8°C and ship on ice- pack; freezing and shipment on dry ice is permissible.
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| * Infants: A minimum of 1 mL of whole blood is needed for testing of pediatric patients. If possible, collect 1 mL in an EDTA tube and in a serum separator tube. If only 1 mL can be obtained, use a serum separator tube.
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| ===EDTA blood (plasma)===
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| Collect 1 tube (10 mL) of heparinized (green-top) or EDTA (purple-top) blood. Refrigerate specimen at 2-8°C and ship on ice-pack; do not freeze.
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| ===Stool===
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| Collect 2-5 grams of stool specimen (formed or liquid) in sterile, leak-proof, screw-cap sputum collection cup or sterile dry container. Refrigerate specimen at 2-8°C up to 72 hours; if exceeding 72 hours, freeze at -70°C and ship on dry ice.
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| ==Treatment== | | ==Treatment== |
| There are no specific treatments recommended for illnesses caused by MERS-CoV. Medical care is supportive and to help relieve symptoms.
| | [[Middle east respiratory syndrome coronavirus infection medical therapy|Medical Therapy]] | [[Middle east respiratory syndrome coronavirus contact and airborne precautions|Contact and Airborne Precautions]] | [[Middle east respiratory syndrome coronavirus infection primary prevention|Primary Prevention]] |
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| ==Standard, Contact, and Airborne Precautions==
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| Standard, contact, and airborne precautions are recommended for management of hospitalized patients with known or suspected MERS-CoV infection
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| ===Patient Placement in Airborne Infection Isolation Room (AIIR)===
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| * If an AIIR is not available, the patient should be transferred as soon as is feasible to a facility where an AIIR is available. Pending transfer, place a facemask on the patient and isolate him/her in a single-patient room with the door closed. The patient should not be placed in any room where room exhaust is recirculated without high-efficiency particulate air (HEPA) filtration.
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| * Once in an AIIR, the patient’s facemask may be removed; the facemask should remain on if the patient is not in an AIIR.
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| * When outside of the AIIR, patients should wear a facemask to contain secretions
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| * Limit transport and movement of the patient outside of the AIIR to medically-essential purposes.
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| * Implement staffing policies to minimize the number of personnel that must enter the room.
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| ===Personal Protective Equipment (PPE) for Healthcare Personnel (HCP)===
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| *PPE include:
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| **Gloves
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| **Gowns
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| **Eye protection (goggles or face shield)
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| **Respiratory protection that is at least as protective as a fit-tested NIOSH-certified disposable N95 filtering facepiece respirator.
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| ***If a respirator is unavailable, a facemask should be worn. In this situation respirators should be made available as quickly as possible.
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| *Recommended PPE should be worn by HCP upon entry into patient rooms or care areas.
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| *Upon exit from the patient room or care area, PPE should be removed and either
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| **Discarded, or
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| **For re-useable PPE, cleaned and disinfected according to the manufacturer’s reprocessing instructions
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| ===Environmental Infection Control===
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| Follow standard procedures, per hospital policy and manufacturers’ instructions, for cleaning and/or disinfection of:
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| *Environmental surfaces and equipment
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| *Textiles and laundry
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| *Food utensils and dishware
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| ==Interim Home Care and Isolation Guidance for MERS-CoV==
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| This guidance is for local and state health departments, infection prevention and control professionals, healthcare providers, and healthcare workers who are coordinating the home care and isolation of ill people who are being evaluated for Middle East Respiratory Syndrome Coronavirus (MERS-CoV) infection. The guidance is based on what is currently known about viral respiratory diseases and MERS-CoV. CDC will update this guidance as needed.
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| Ill people who are being evaluated for MERS-CoV infection and do not require hospitalization for medical reasons may be cared for and isolated in their home. Isolation is defined as the separation or restriction of activities of an ill person with a contagious disease from those who are well.
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| Before the ill person is isolated at home, the healthcare professional should:
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| * Assess whether the home is suitable and appropriate for isolating the ill person. You can conduct this assessment by phone or direct observation.
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| ** The home should have a functioning bathroom that only the ill person and household members use. If there are multiple bathrooms, one should be designated solely for the ill person.
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| ** The ill person should have his or her own bed and preferably a private room for sleeping.
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| ** Basic amenities, such as heat, electricity, potable and hot water, sewer, and telephone access, should be available.
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| ** If the home is in a multiple-family dwelling, such as an apartment building, the area in which the ill person will stay should use a separate air-ventilation system, if one is present.
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| ** There should be a primary caregiver who can follow the healthcare provider’s instructions for medications and care. The caregiver should help the ill person with basic needs in the home and help with obtaining groceries, prescriptions, and other personal needs.
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| * Contact your local or state health department if you have not already done so.
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| ==Prevention==
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| * Enhancing infection prevention and control awareness and measures is critical to prevent the possible spread of MERS‐CoV in health care facilities. Health‐care facilities that provide care for patients suspected or confirmed to be infected with MERS‐CoV infection should take appropriate measures to decrease the risk of transmission of the [[virus]] from an infected patient to other patients, health‐care workers and visitors. It is not always possible to identify patients with MERS‐CoV early because some have mild or unusual symptoms. For this reason, it is important that health‐care workers apply standard precautions consistently with all patients – regardless of their diagnosis – in all work practices all the time.
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| * Urgent investigations are required to better understand the transmission pattern of this virus. The most urgent include detailed [[outbreak]] investigations, [[case‐control studies]] to understand risk factors for infection, enhancing community studies and surveillance of [[pneumonia|community‐acquired pneumonia]] to assess whether significant numbers of mild cases resulting from human to human transmission are being missed, and identifying risk factors for infection in the hospital setting. Detailed information on the surveillance strategy and contact tracing would help understand limitations of current data.
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| * Although the immediate focus should be on clarifying the magnitude of the human‐to‐human transmission, no control will be possible until the transmission from the animal/environment source to humans is understood and interrupted. Based on current information, it is prudent for people at high risk of severe disease due to MERS‐CoV, including those with [[diabetes]], chronic [[lung disease]], pre‐existing [[renal failure]], or those who are immunocompromised, to take appropriate precautions when visiting farms, barn areas or market environments where camels are present. These measures might include avoiding contact with camels, good hand hygiene, and avoiding drinking raw milk or eating food that may be contaminated with animal secretions or products unless they are properly washed, peeled, or cooked. For the general public, when visiting a farm or a barn, general hygiene measures, such as regular hand washing before and after touching animals, avoiding contact with sick animals, and following food hygiene practices, should be adhered to.
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| * WHO recommends increasing efforts to raise awareness of MERS among travelers going to and traveling from MERS‐affected countries but otherwise does not advise special screening at points of entry with regard to this event nor does WHO currently recommend the application of any travel or trade restrictions.
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| ===Travel Guidance===
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| The peak travel season to Saudi Arabia is July through November, coinciding with the religious pilgrimages of Hajj and Umrah. CDC encourages pilgrims to consider recommendations from the Saudi Arabia Ministry of Health regarding persons who should postpone their pilgrimages this year, including persons aged ≥65 years, children, pregnant women, and persons with chronic diseases, weakened immune systems, or cancer. WHO advises that persons with preexisting medical conditions consult a health-care provider before deciding whether to make a pilgrimage.
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| CDC continues to recommend that U.S. travelers to countries in or near the Arabian Peninsula protect themselves from respiratory diseases, including MERS-CoV, by washing their hands often and avoiding contact with persons who are ill. If travelers to the region have onset of fever with cough or shortness of breath during their trip or within 14 days of returning to the United States, they should seek medical care. They should tell their health-care provider about their recent travel.
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| ===Infection Control===
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| With multiple health-care–associated clusters identified (8,10), infection control remains a primary means of preventing and controlling MERS-CoV transmission. CDC has recently made checklists available that highlight key actions that health-care providers and facilities can take to prepare for MERS-CoV patients. CDC's infection control guidance has not changed. Standard, contact, and airborne precautions are recommended for management of hospitalized patients with known or suspected MERS-CoV infection.
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| ==References==
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| {{Reflist|2}}
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| | ==Case Studies== |
| | [[Middle east respiratory syndrome coronavirus infection case study one|Case #1]] |
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| [[Category:Viral diseases]] | | {{WH}} |
| [[Category:Zoonoses]] | | {{WS}} |
| | [[category:disease]] |
| | [[Category:Infectious disease]] |
| | [[category:virology]] |
| | [[Category:Up-To-Date]] |