Middle East Respiratory Syndrome Coronavirus (MERS-CoV):

BY:DR.SATTI MOH’D SALEH

INFECTIOUS DISEASE PHYSICIANMEDICAL DIRECTOR

MEEQAT GENERAL HOSPITALCBAHI INFECTION CONTROL MEMBER

CORONA VIRUS

  -CORONA DERIVED FROM LATIN ( MEANS

CROWN OR HALO) DUE TO SHORT SPIKE LIKE PROJECTIONS (HE)

-MERS CoV

6 NEW TYPE OF CORONA VIRUS 

-2ND OF 4 SUB GROUP ALPHA- B-GAMA & DELTA 

-RNA VIRUS 

-ALPHA & BETA DESCEND FROM BAT GENE POOL

  -DELTA & GAMA FROM AVIAN GENE POOL

NOVEL CORONA VIRUS

NOVEL CORONA VIRUS REPORTED ON 24/9/2012 BY DR. ALI MOHAMMAD ZAKI

 -ISOLATED & IDENTIFIED FROM PATIENT

60 YEARS OLD WITH ACUTE PNEUMONEA & ARF

BY DR. ALI M. ZAKI -POSTED HIS FINDINGS

المصري صور مكتشف الطبيب زكي عليكورونا فيروس

                    

vb.n4hr.com-

Replication of Coronavirus

MERS CoV

NAMED AS NOVEL CORONA VIRUS OR SAUDI’S SARS LIKE CORONA VIRUS

  -INTERNATIONAL COMMITTEE ON

TOXONOMY OF VIRUS NAME IT AS MERS CoV

MERS Cases and Deaths,April 2012 - PresentCurrent as of September 13, 2013, 9:00 AM EDT

Countries Cases (Deaths)

France 2 (1)

Italy 3 (0)

Jordan 2 (2)

Qatar 5 (2)

Saudi Arabia 90 (44)

Tunisia 3 (1)

United Kingdom (UK) 3 (2)

United Arab Emirates (UAE) 6 (2)

Total 114 (54

Countries With Lab-Confirmed MERS CasesApril 2012 - Present

•France•Italy•Jordan•Kuwait•Oman•Qatar•Saudi Arabia•Tunisia•United Kingdom (UK)•United Arab Emirates (UAE)

Globally, from September 2012 to date, WHO has been informed of a total of 198 laboratory-confirmed cases of infection with MERS-CoV, including 84 deaths

-Total number reported are 148 case.-Total death is 61 deaths 41.2%

- Males are 80 and Females are 52 cases.

- Saudi 110 and Non Saudi were 22.- Cases with known animal contacts are

20 out of 132 = 17.8% .- Primary cases are 47 , 11 of them had

contacts with animals = 23.4%

Numbers Reported up-to-date

INTERNATIONAL ALARM FOR TWO REASONS:

VIRUS OFTEN DEADLY 

NO CLEAR TREATMENT

SOURCE UNKNOWN

-SPECULATION

 

BAT VIRUSES    

 INTERMEDIATE HOST

  

CAMELS & OTHERS  

MULTIPLE GEOGRAPHIC SITES (MULTIPLE ZOOTIC EVENTS)

  

COMMON SOURCE

SOURCE

-? AUSTRALIA, U AFRICAN BATS

TO MIDDLE EAST

SORCE

SOURCE

*KNOWN FACTS

-HAS TROPISM TO NON CILIATED BROCHIAL EPITHELIAL CELLS (CONTRA TO OTHER VIRUSES

  -CELLS THAT MERS INFECT WITHIN THE

LUNGS FORM 20 % OF RESPIRATORY EPITHELIAL CELLS

  -LARGE NUMBER OF VIRUSES NEEDED

TO BE INHALED TO CAUSE INFECTION

Is this virus the same as the SARS virus?

No. The novel coronavirus is not the same virus that caused severe acute respiratory syndrome (SARS) in 2003. However, like the SARS virus, the novel coronavirus is most similar to those found in bats. CDC is still learning about this new virus.

Location of Bat Sampling Sites

A- Ghana B-

Europe

MERS-CoV INCUBATION period

The available data suggest that symptoms have occurred up to 14 days after last exposure .

SYMPTOMS:FeverCoughChillsSore throatMyalgiaArthralgia followed by dyspneaMay present with fever and diarrheaFollowed by ARDS, septic shock, multiorgan failure

MERS-CoV CLINICAL CASE definition

A person with an acute respiratory infection, which may include fever (≥ 38°C , 100.4°F) and cough; AND

Suspicion of pulmonary parenchymal disease (e.g., pneumonia or acute respiratory distress syndrome based on clinical or radiological evidence); AND

History of travel from the Arabian Peninsula or neighboring countries* within 14 days .

CDC Case Definitions :

Probable Case •Any person who -

–meets the criteria above for “Patient Under Investigation” 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, AND

–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 .

•OR any person with -–severe acute respiratory illness with no known etiology,

AND –an epidemiologic link to a confirmed MERS case .

.

Confirmed Case

•A person with laboratory confirmation of infection with MERS-CoV

Positive PCR for confirmation

Confirmed cases of MERS-CoV (n=55) and history of travel from the Arabian Peninsula

Check for co – infection with other viruses e.g.: H1N1, bacterial infection, fungal infection.

MERS-CoV CLOSE CONTACT definition

A close contact* is defined as a person who : Did not use respiratory protection (N95 or

higher level respirator); AND Shared the same airspace within 10 feet for

at least 5 minutes. Examples of close contact include providing care for the case (e.g., a healthcare worker or family member), or having similar close physical contact; or stayed at the same place (e.g., lived with, visited) as the case during their infectious period .

First Reported MERS-CoV Case

60 year old Saudi man •Presented on June 13th with 7d h/o fever

and cough; recent shortness of breath •Increasing blood urea nitrogen (BUN) and

creatinine, starting day 3 of admission •White cell count normal on admission

(but 92.5% neutrophils) and increased to a peak of 23,800 cells per cubic millimeter on day 10 with neutrophilia, lymphopenia, and progressive thrombocytopenia

First Case: Chest Radiographs

Bilateral enhanced pulmonary hilar vascular shadows (more prominent on the left) and accentuated bronchovascular lung markings. Multiple patchy opacities in middle and lower lung fields Opacities more confluent and dense

A: On admission

B: 2 days later

Radiographs of Patient 2

B. 4 days after onset of illness, Ground glass opacity and consolidation of left lower lobe

.Consolidation of right upper lobe, 1 day after onset of illness

C and D. Bilateral ground-glass opacities and consolidation, 7 days and 9 days after onset of illness, respectively

First Case Outcome

•Patient developed acute respiratory distress syndrome (ARDS) and multiorgan dysfunction syndrome

•Died June 24th •No close contacts with severe

illnesses reported

Saudi Arabia Household Cluster

•A cluster of 4 respiratory illnesses in a family who lived in an apartment

–All males; ages 16-70y •All hospitalized

•3 of 4 confirmed with MERS-CoV •3 of 4 patients with gastrointestinal

symptoms: diarrhea, abdominal pain, anorexia )

•2 deaths

Types of clusters

1 )Older clusters post alhassa (contained) are in Eastren, Hasa, Aseer and Riyadh.

2 )Resent Clusters started August, 17-12-/2013 (Almadina, Riyadh (hospitals), Hafralbatin)

MERS-CoV Outbreak in Saudi Arabia April – May 2013

•Al-Ahsa governorate in eastern region •Cluster currently being investigated

•25 confirmed cases, 14 confirmed deaths •18 males, 7 females; Ages 14 - 94 years, median

age: 58 •Initial cases associated with one hospital but

now also :–Family contacts

–Healthcare workers –Cases with no link to hospital

•Most cases with comorbidities

MERS CoV positive cases by sex and Nationalitya

Male Female Saudi Non Saudi0

20

40

60

80

100

120

80

52

110

22

MERS CoV positive cases by sex and Nationality

Male Female Saudi Non Saudi0

20

40

60

80

100

120

80

52

110

22

Al-Madina AlMunawara cluster

Resident 55

Dialysis (1)

Date of Onset

17/8/2013

Male 56 date of

18/8/2013

HCW

74 years old male on HD

Dead case

Alive

35 y on HD 89 y

54 y F

39 y M

HCW

Hafr Albatin cluster

3 cases asymptomatic Age 26,16,7

2 cases asymptomatic Age 3 and 18

38 y of age male (son)

8/8/2013

79 y mother

Cousin 47 y 23/8/2013

74 Mother the above

Dead caseAlive

MERS CoV cases by contact with animals and chronic disease total (111 cases) contact with animals 19

admitted animal contact no animal contact

chronic diseaseno disease

0

10

20

30

40

50

60

70

80

90

100

19

9288

23

-Camel 10 -Goat 2 ,

-Cat 2 , -Chicken 2 ,

- Bat 2,

- Others 1

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.

Reported up-to-date

Droplet precautions should be added to the standard precautions when providing care to all patients with symptoms of acute respiratory infection. Contact precautions and eye protection should be added when caring for probable or confirmed cases of MERS-CoV infection. Airborne precautions should be applied when performing aerosol generating procedures .

precautionsReported up-to-

date

HAND HYAGIENEة

Gloves

•Gowns •Eye protection (goggles

or face shield) •Respiratory protection

that is at least as protective as a fit-tested NIOSH-certified disposable N95 filtering face piece respirator

Personal Protective Equipment (PPE) for Healthcare personnel (HCP)

Recommended PPE should be worn by HCP upon entry into patient rooms or care areas .

•Upon exit from the patient room or care area, PPE should be removed and either :

–Discarded, or –For re-useable PPE, cleaned and

disinfected according to the manufacturer’s reprocessing instructions .

Environmental Infection Control

•Follow standard procedures, per hospital policy and manufacturers’ instructions, for cleaning and/or disinfection of :

–Environmental surfaces and equipment

–Textiles and laundry –Food utensils and dishware

Infection Control Recommendations for Hospitalized Patients

•These recommendations are for hospitalized patients who meet the case definition and are based on the following issues :

–Poorly characterized clinical signs and symptoms, and a suspected high rate of morbidity and mortality among infected patients

–Unknown modes of transmission of MERS-CoV

–Lack of a vaccine and chemoprophylaxis –Evidence of limited, not sustained,

human-to-human transmission

Patient Placement Airborne Infection Isolation Room (AIIR)

–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 .

•Once in an AIIR, the patient’s facemask may be removed .

•When outside of the AIIR, patients should wear a facemask to contain secretions .

Patient Placement

Limit transport and movement of the patient outside of the AIIR to medically-essential purposes .

•Implement staffing policies to minimize the number of personnel who must enter the room .

Health-care providers are advised to maintain vigilance .

  -NO SUSTAINED TRANSMISSION IN

COMMUNITY 

-PEOPLE WITH COMORBIDITY OR IMMUNOSUPPRESSION

INCREASE INFECTION ,INCREASE COMPLICATION,

INCREASE MORBIDITY

PERSON TO PERSON TRANSMISSION (VERY LOW)

People at high risk

of severe disease due to MERS-CoV should avoid close contact with animals when visiting farms or barn areas where the virus is known to be potentially circulating. 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.

Complications

Complications have included severe 1 -pneumonia, acute respiratory distress

syndrome 2- (ARDS) with multi-organ failure,

3 -renal failure requiring dialysis, consumptive 4- coagulopathy and

pericarditis .

The number of people who came for Umra this year 1434 – 2013 are:

5,138,301NO cases

Umra statistics During

1434

ADVISES IN HAJJ & UMRA

FREQUENT HAND WASHING CONTACT WITH OTHERS

NOT TO TOUCH EYE NOSE & MOUTH WITHOUT HAND WASHING

COVER MOUTH, NOSE WITH TISSUES (NOT TO INFECT OTHERS ON COUGHING & SNEEZING)

CDC does not recommend that travelers change their plans because of MERS. However, the Saudi Arabia Ministry of Health has made special recommendations for travelers to Hajj and Umrah. Because of the risk of MERS, Saudi Arabia recommends that the following groups should postpone their plans for Hajj and Umrah this year:People over 65 years oldChildren under 12 years oldPregnant womenPeople with chronic diseases (such as heart disease, kidney disease, diabetes, or respiratory disease)People with weakened immune systemsPeople with cancer or terminal illnessesCDC encourages people traveling to Saudi Arabia to perform Hajj or Umrah to consider this advice. People who are concerned about MERS should discuss their travel plans with their doctor.

How Can Travelers Protect Themselves?

Taking these everyday actions can help prevent the spread of germs and protect against colds, flu, and other illnesses:Wash your hands often with soap and water. If soap and water are not available, use an 

- alcohol based hand sanitizer.Avoid touching your eyes, nose, and mouth. Germs spread this way.Avoid close contact with sick people.Be sure you are up-to-date with all of your shots, and if possible, see your healthcare provider at least 4–6 weeks before travel to get any additional shots.

.If you are sick:Cover your mouth with a tissue when you cough or sneeze, and throw the tissue in the trash.Avoid contact with other people to keep from infecting them.

Investigations

Chest x – ray findings:

Bilateral hailer infiltrate Bilateral patchy infiltrate Segmental or lobar opacity Pleural effusion

Laboratory Testing Lower respiratory specimens

(sputum, bronchoalveolar lavage, endotracheal) are a priority respiratory specimen for real time reverse transcription polymerase chain reaction (RT-PCR) testing

•Respiratory (lower and upper tracts), stool, and

serum specimens •Specimen collection at different

times

Positive PCR for confirmation

Emergency Use Authorization

•FDA issued an EUA on June 5, 2013, to authorize use of CDC's “Novel coronavirus 2012 real-time reverse transcription–PCR assay” to test for MERS-CoV in clinical respiratory, blood, and stool specimens .

•Assay will be deployed to Laboratory Response Network (LRN) laboratories in all 50 states over the coming weeks .

Approach to Serology

•Identify and generate candidate CoV antigens

–Using proteins from similar bat viruses •Develop ELISA-based assay

•Evaluate assay with an extensive panel of negative (specificity) and positive sera (sensitivity)

Therapeutics

•No vaccines developed as of yet

•antivirals identified as of yet •Treatment

USED IN MONKEY-

SYMPTOMS, SLOW VIRAL GROWTH DAMAGE TO LUNGS, BREATHING

(ONLY USED IN FEW MONKEYS WITHIN 8 HOURS OF INFECTIONS)

USED

I

N

MONKEY

Management:

  Isolation: standard + droplet

±airborne precautions Organ support Prevention of complications

Empiric use of:

Broad spectrum antibiotic Antiviral (oseltamivir) Plus or minus antifungal Lung protective ventilator Strategies for ARDS Treatment of complication (RENAL

FAILURE) Steroids (no benefits) Treatment of HCAI

IF YOU HAVE A DYING PATIENT SHOULD ,

؟؟YOU TRY IT AS LAST EFFORT

FUTURE TREATMENT

INTERFERON ALFA 2 + RIBAVERIN

USED IN MONKEY-

SYMPTOMS, SLOW VIRAL GROWTH DAMAGE TO LUNGS, BREATHING

(ONLY USED IN FEW MONKEYS WITHIN 8 HOURS OF INFECTIONS)

USED

I

N

MONKEY

Selection criteria:

To be considered eligible for oral ribavirin and subcutaneous pegylated interferon therapy, the patient

must fulfill ALL the following criteria:

1. Laboratory-confirmed MERS-CoV infection

2. Clinical and radiological evidence of pneumonia

3. The patient requires invasive or non-invasive ventilatory support or showing progressive

hypoxemia

4. Approval by one consultants in Adult Infectious Diseases

Administration Protocol:

CrCl‡ > 50ml/min Ribavirin 2000mg po loading dose, followed by 1200mg po q8h for 4 days then 600mg po q8h for 4-6 days

CrCl 20-50 ml/min

2000mg po loading dose, followed by 600mg po q8h for 4 days then 200mg po q6h for 4-6 days

CrCl <20 ml/min or on dialysis

2000mg po loading dose, followed by 200mg po q6h for 4 days then 200mg po q12h for 4-6 days

Pegelated interferon

Pegelated interferon alfa 2a 180 mcg subcutaneously once per week

(up to 2 weeks)

Monitoring :

1. Both ribavirin and Peg-interferon are associated with considerable potential adverse effects. In

addition to any clinical or laboratory monitoring that is dictated by the patient’s condition, the

following investigations are essential before starting

a. Complete blood count b. Renal function c. Liver function

2. Conscious patients must have a formal psychiatric assessment if there is any clinical evidence

of psychosis or acute confusion Changes to the treatment protocol: 1. Changes in the treatment

protocol in response to toxicity or clinical developments are permitted. A

psychiatric assessment

LAST REMINDER, NO UNNECESSARY PANIC…

ALWAYS COMPLY WITH INFECTION CONTROL & PREVENTION STANDARDS

الفاشيات

متفرقة( 1 احادية تكون ان يمكن الحاالت (Sporadic.)تم( 2 حيث فاشيات شكل في تكون ان يمكن الحاالت

- – - الرياض الشرقية االحساء في فاشيات عدة رصدالمنورة – المدينة عسير

بمجهودات وذلك جميعا عليها السيطرة تم الله وبحمدوالمختبرات والمناطق الوزارة ديوان في العاملين

بالمستشفيات العدوى مكافحة قواعد اتباع تم حيثالوقائية والجراءات بالمنزل المخالطين وتوعية

. العامة الصحة وكالة اتخذتها التي االخرى

SUMMARY ●According to the investigations made for the 148

cases we do not know the source of the infection ( possible animal? Camels, Possible human.. GOK

●Human transmission is there we do not know how? Possible close contact or droplet???

●Chronic disease is a risk factor specially kidney disease.

●Serological investigation are not yet done but samples are available for testing.

●we will continue surveillance and research.

ما قامت به وزارة الصحة

الوباء ( 2 هذا لمواجهة مفصلة خطة بإعداد الوزارة قامتبالنسبة الوقاية وطرق االجرائية الخطوات على والمرتكزة

وتم بالمنزل للمرضى المخالطين الى باإلضافة الصحيين للعامليناالعالم وسائل تزويد تم كما الصحية المنشآت جميع على توزيعها

بذلك.

المرافق( 3 جميع الى بالنماذج مدعم شامل تعميم اصدار تمتحديث وتم المشتبهة الحاالت عن لالبالغ بالمملكة الصحية

. للمرض المستجدات ليواكب مرات عدة التعميم

ما قامت به وزارة الصحة

أطباء( 1 تضم المعدية لألمراض علمية وطنية لجنة وجودوطب العامة والصحة المعدية االمراض في استشاريونبالمملكة الصحية القطاعات جميع من والمجتمع االسرة

والداخلية ) الدفاع بوزارات والطبية الصحية الخدمات يمثلون ) فيصل الملك ومستشفى والتعليم والتربية الوطني والحرسالطب كلية في ممثلة والجامعات االبحاث ومركز التخصصيمع السعودية أرامكو ومستشفى سعود الملك بجامعة

للصحة الصحة وزارة وكيل وبرئاسة الصحة وزارة استشارييواللجنة الوقائي العامة العمل سياسات وضع ومهامها

وتحديثها الكورونا التهاب ومنها األهمية ذات المعدية لألمراضدوريا́.