# 8565
For well over a year the CDC has been preparing for the day when a MERS-CoV infected individual arrived in the United States. As most of my readers already know, that day finally happened last week (see CDC: First Imported MERS Coronavirus Case In the United States), prompting a full public health response by state, local, and national health authorities.
As long as the virus continued to circulate in the Middle East, its arrival in the United States was pretty much a foregone conclusion – the only question being: when? And as the number of cases in Saudi Arabia and the UAE increase, the odds favor additional introductions of the virus in the future.
Late yesterday the CDC released a HAN (Health Alert Network) advisory for clinicians, healthcare facilities, and those working in public health on dealing with a confirmed or suspected MERS cases, that builds upon a growing library of guidance documents released over the past 12 months.
As we saw with the H1N1 pandemic of 2009, guidance on emerging infectious disease threats tends to evolve over time, as more is learned about the threat. Some of the CDC guidance documents we’ve looked at over the past year include:
CDC: Infection Control Guidance For Home Care Of MERS-CoV Cases
MMWR: Updated MERS-CoV Guidance For The Public, Clinicians & Public Health Workers
CDC HAN: Updated Guidelines For Evaluation Of MERS-CoV
MMWR: MERS-CoV Update – June 7th
Below you’ll find excerpts from the latest HAN Alert. I’ve skipped the `background’ section in order to focus on their recommendations. Follow the link to read it in its entirety. I’ll have a bit more when you return.
Confirmed Middle East Respiratory Syndrome Coronavirus (MERS-CoV) Case in Indiana, 2014
Recommendations
Healthcare providers should be alert for and evaluate patients for MERS-CoV infection who 1) develop severe acute lower respiratory illness within 14 days after traveling from countries in or near the Arabian Peninsula, excluding those who only transited at airports in the region; or 2) are close contacts of a symptomatic recent traveler from this area who has fever and acute respiratory illness; or 3) are close contacts of a confirmed case. For these patients, testing for MERS-CoV and other respiratory pathogens can be done simultaneously. Positive results for another respiratory pathogen (e.g H1N1 Influenza) should not necessarily preclude testing for MERS-CoV because co-infection can occur.
Clusters of patients with severe acute respiratory illness (e.g., fever and pneumonia requiring hospitalization) without recognized links to cases of MERS-CoV or to travelers from countries in or near the Arabian peninsula should be evaluated for common respiratory pathogens. If the illnesses remain unexplained, providers should consider testing for MERS-CoV, in consultation with state and local health departments. Healthcare professionals should immediately report to their state or local health department any person being evaluated for MERS-CoV infection as a patient under investigation (PUI). Additional information, including criteria for PUI are at http://www.cdc.gov/coronavirus/mers/interim-guidance.html. Healthcare providers should contact their state or local health department if they have any questions.
Persons at highest risk of developing infection are those with close contact to a case, defined as any person who provided care for a patient, including a healthcare provider or family member not adhering to recommended infection control precautions (i.e., not wearing recommended personal protective equipment), or had similarly close physical contact; or any person who stayed at the same place (e.g. lived with, visited) as the patient while the patient was ill.
Healthcare professionals should carefully monitor for the appearance of fever (T> 100F) or respiratory symptoms in any person who has had close contact with a confirmed case, probable case, or a PUI while the person was ill. If fever or respiratory symptoms develop within the first 14 days following the contact, the individual should be evaluated for MERS-CoV infection. 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.).
Providers should contact their state or local health department to determine whether home isolation, home quarantine or additional guidance is indicated since recommendations may be modified as more data becomes available. Additional information on home care and isolation guidance is available at http://www.cdc.gov/coronavirus/mers/hcp/home-care.html. Healthcare providers should adhere to recommended infection-control measures, including standard, contact, and airborne precautions, while managing symptomatic contacts and patients who are persons under investigation or who have probable or confirmed MERS-CoV infections. For CDC guidance on MERS-CoV infection control in healthcare settings, see Interim Infection Prevention and Control Recommendations for Hospitalized Patients with MERS-CoV at http://www.cdc.gov/coronavirus/mers/infection-prevention-control.html.
For suspected MERS-CoV cases, healthcare providers should collect the following specimens for submission to CDC or the appropriate state public health laboratory: nasopharyngeal swab, oropharyngeal swab (which can be placed in the same tube of viral transport medium), sputum, serum, and stool/rectal swab. Recommended infection control precautions should be utilized when collecting specimens. Specimens can be sent using category B shipping containers. Providers should notify their state or local health departments if they suspect MERS-CoV infection in a person. State or local health departments should notify CDC if MERS-CoV infection in a person is suspected. Additional information is available at http://www.cdc.gov/coronavirus/mers/guidelines-clinical-specimens.html.
Additional or modified recommendations may be forthcoming as the investigation proceeds.
For More Information
For more information, for consultation, or to report possible cases, please contact the CDC Emergency Operations Center at (770) 488-7100.
During the SARS epidemic of 2003, the isolation of those who were symptomatic, and the (usually) home quarantining of those who were exposed (but not showing signs of illness) proved to be a powerful public health tool in places like Canada, Hong Kong, and Singapore.
The CDC defines these terms as:
- Isolation applies to persons who are known to be ill with a contagious disease.
- Quarantine applies to those who have been exposed to a contagious disease but who may or may not become ill.
During the SARS epidemic, Isolation was used in the United States for patients who were ill, but since transmission of the virus was very limited here, quarantine was not recommended for those exposed (cite).
For a look at the use of quarantines for the control of infectious disease, including with SARS, you may wish to revisit EID Journal: A Brief History Of Quarantine. For now, the CDC is simply advising:
Providers should contact their state or local health department to determine whether home isolation, home quarantine or additional guidance is indicated since recommendations may be modified as more data becomes available.
I would suspect that until more is learned about the ability (or inability) of the MERS virus to transmit from pre-symptomatic or asymptomatic cases, public health officials are likely to approach these early imported cases with an abundance of caution.
Local news reports indicate that exposed HCWs in Indiana have been asked to remain home, and to monitor their health, during the 14 day incubation period (see RTV 6 coverage). Since they are not ill, technically they are in home quarantine, not isolation, as indicated by the report.
As we’ve seen in the past with Dengue, West Nile Virus and last January with the H5N1 virus (see CDC Statement On 1st H5N1 Case In North America) - and more recently in Minnesota: Rare Imported Case Of Lassa Fever – rare or exotic diseases are skilled international travelers.
Vast oceans, long travel times, and political borders are no longer obstacles to their spread.
A reminder that an outbreak of a disease anywhere in the world can – given enough time – end up in our own backyard. Making it in our best interests to promote better global surveillance and response, no matter how far removed from us they may seem at the time.
