Sunday, July 01, 2018

WHO Guidance: Home Care For Patients With Mild Or Asymptomatic MERS-CoV Infection


Like with nearly all viral infections, patients infected with MERS-CoV can experience a wide range of symptoms - ranging from asymptomatic carriage (roughly 20%), to mild flu-like symptoms, to severe pneumonia and/or death.
While host co-morbidities (including age) appear to be important contributing factors, we've even seen some young - apparently healthy - individuals develop severe disease.
Ideally, anyone who tests positive for the MERS coronavirus ought to be placed in isolation, and monitored closely by medical staff using standard precautions.
But the reality is, that may not always be possible.
We've a pair of updated guidance documents from WHO to look at this morning, and while they are geared specifically to MERS-CoV, they also highlight some of the challenges - and compromises - we would likely face in any infectious disease outbreak when hospital beds are in very short supply.

Earlier this year the WHO released an updated interim guidance called Management of asymptomatic persons who are RTPCR positive for Middle East respiratory syndrome coronavirus (MERS-CoV) which advised:
The potential for transmission from asymptomatic RT-PCR positive persons is currently unknown.
One study found that within two weeks of a first positive test, 30% of asymptomatic or mildly symptomatic persons (n=13) that had been in contact with a case remained positive for viral RNA in the upper respiratory tract 4 . Another study reported prolonged nasal virus RNA detection (more than 5 weeks) from one asymptomatic RT-PCR positive health-care worker 5.

If feasible and as a cautious approach during outbreaks in health care settings, WHO recommends that all close contacts of confirmed cases of MERS-CoV infection 6 , especially health care workers and other inpatient hospital contacts (e.g. non-health-care workers, patients and visitors), be tested for MERS-CoV regardless of the presence of symptoms.
As this sort of prospective testing is likely to turn up additional RT-PCR positive, but asymptomatic, cases the WHO - recognizing that hospital isolation may not be feasible for all cases - advises:
The place of isolation (hospital or home) shall depend on the health-care system’s isolation bed capacity, its capacity to monitor asymptomatic RT-PCR positive persons daily outside a health-care setting, and the conditions of the household and its occupants 8.

The decision on where to isolate asymptomatic RT-PCR positive persons should be based on careful clinical judgment. The decision should be informed by:
  • patient risk factors for the development of severe MERS-CoV illness, including the presence of co-morbidities;
  • social and environmental conditions of the person’s household 1 such as basic hygiene procedures, and the ability to comply with restrictions like staying awayfrom work and social settings (e.g. shopping, school attendance); and
  • presence of household members with co-morbidities associated with increased risk of severe MERS-CoV infection.
Isolation should continue until two consecutive upper respiratory tract samples (e.g. nasopharyngeal [NP] and/or oropharyngeal [OP] swabs) taken at least 24 hours apart test negative on RT-PCR.

This document then goes on to outline the home care and infection control steps that are required should an asymptomatic patient need to remain at home.
Most are common sense; separating the patient from other household members, staying home, covering coughs, washing hands, and daily monitoring for symptoms, etc.
Things become considerably more complicated (and riskier) if the patient is showing any - even mild - symptoms. Which brings us to June 2018 interim guidance update called:
Home care for patients with Middle East respiratory syndrome coronavirus (‎MERS-CoV)‎ infection presenting with mild symptoms and management of contacts: interim guidance

WHO-MERS-IPC-18.1-eng.pdf (‎363.5Kb)‎

World Health Organization. (‎2018)‎. Home care for patients with Middle East respiratory syndrome coronavirus (‎MERS-CoV)‎ infection presenting with mild symptoms and management of contacts: interim guidance. World Health Organization.

License: CC BY-NC-SA 3.0 IGO

Here, patients may be exhibiting a low grade fever, or mild respiratory and/or gastrointestinal symptoms - and while their ability to transmit the virus remains unquantified - the risks are likely higher.  And the patient, due to age or co-morbidities - may be at a higher risk of developing complications. 

Hospitalization, as the following excerpt states, is the preferred option. 
In view of the currently limited knowledge of the disease and its transmission, WHO recommends that confirmed (2) symptomatic cases of the MERS-CoV infection be isolated and monitored in a hospital setting. This would ensure both safety and quality of health care (in case patients’ symptoms worsen) and public health security. 

However, for several possible reasons, including situations when inpatient care is unavailable or unsafe (i.e. limited capacity and resources unable to meet demand for health care services), or in a case of informed refusal of hospitalization, alternative settings 2 for health care provision may need to be considered.
While preferred, the WHO accepts that in-hospital care may not always be an option.  The specific recommendations for in-home patient care and infection control are too long to list here, so you'll want to download and read the full guidance document.
Although MERS specific, much of the advice given would apply to any infectious disease outbreak, including pandemic flu.
The reality is that during any large-scale epidemic, hospital resources could be severely limited, and many of the infected will have to be treated at home by family and or friends.
Hospital beds - at least once the number of patients exceeds max capacity - will be reserved for the `sickest of the sick'.  And at some point, even those who are severely ill may find no beds available (see Pandemic Realities: Ventilator Shortages).
And in all honesty, it doesn't take a pandemic.  During last summer's outbreak of H3N2 in Hong Kong, hospitals were at 130% of capacity for weeks, and last winter many U.S. hospitals were severely overloaded with flu patients, and beds were in short supply.
For many, riding it out at home was a far more attractive option than sitting in an ER waiting room for 12 hours or more  - along side hundreds of sick people - waiting to be seen. 
The ability to care for yourself or a loved one at home during an outbreak is one of those things that few people think about, until it happens.

In 2009, many of the items you would have wanted to have (hand sanitizer, gloves, face masks, thermometers, NSAIDs or acetaminophen, etc.) disappeared overnight from the store shelves in the opening weeks of the H1N1 pandemic. A few blogs from July of 2009 include:

UK: More Supply Chain Woes
`Exceptional Demand’ For Hand Sanitizers In NZ
A Cautionary Tale From The UK
The lesson being, if you expect to have any of those supplies during a pandemic, you'd better get them now.  Lest you think I exaggerate, has a pandemic preparedness page, where they recommend: 
Before a Pandemic
  • Store a two week supply of water and food.
  • Periodically check your regular prescription drugs to ensure a continuous supply in your home.
  • Have any nonprescription drugs and other health supplies on hand, including pain relievers, stomach remedies, cough and cold medicines, fluids with electrolytes, and vitamins.
  • Get copies and maintain electronic versions of health records from doctors, hospitals, pharmacies and other sources and store them, for personal reference. Get help accessing electronic help records.
  • Talk with family members and loved ones about how they would be cared for if they got sick, or what will be needed to care for them in your home.
We constantly hear that `we' aren't ready for a pandemic, and then are told about the many things that our government - and other governments around the world - are doing to get ready for what they believe to be inevitable.
While creating, and deploying a vaccine, keeping the lights on, trade routes open, and maintaining civil order are all incredibly important - it may come down to your ability to care for a sick child, or loved one, to determine how well you and your family come through the next public health crisis.
For caring for a family member, a friend, or a neighbor with flu-like illness  you may wish to revisit last January's When Flu Hits Home. And everyone - but most particularly those who live alone, or who are the sole adult caregiver in a household - should find and cultivate one or more `flu buddies'.
A `Flu buddy’ is simply someone you can call if you get sick, who will then check on you every day, make sure you have the medicines you need (including fetching antiviral meds if appropriate), help care for you if needed, and who can call for medical help if your condition deteriorates.
About 8 years ago, after the 2009 pandemic was ended, I reworked this `flu buddy’ idea into a more generic `Disaster buddy’ concept (see In An Emergency, Who Has Your Back? ).
And lastly, in Pandemic Unpreparedness Revisited, you'll find more resources  for you, your family, your neighbors, and your workplace to better prepare for a pandemic.
I could go on, but I'll simply close with one of the more quotable quotes from the lead up to the last pandemic, one that sums up the pandemic preparedness dilemma in a nut shell.

“Everything you say in advance of a pandemic seems alarmist.  Anything you’ve done after it starts is inadequate."- Michael Leavitt,  Former Secretary of HHS

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