Photo Credit WHO
# 7291
The end of yesterday’s straight talking WHO: MERS-CoV (nCoV) Update warned:
WHO expects that more cases will be identified. Control of the disease will require urgent multisectoral investigations aimed at identifying the source of the virus and the exposures that result in infection. It is critical for member states to report these cases and related information urgently to WHO, as required by the International Health Regulations, to inform effective international alertness, preparedness and response.
If you think you detect more than a hint of concern in the above statement, you’d be right. It’s unusual enough to see the words `critical’, `urgent’, `urgently’, and `required’ in a WHO update, much less all four used in the final paragraph.
Equally blunt was yesterday’s ECDC’s Risk assessment which stated:
At this stage, it is not possible to exclude a SARS-like scenario, especially in the light of the hospital-related outbreaks in Jordan and Al-Hasa, Saudi Arabia.
- and -
It is unusual to have such a degree of uncertainty at this stage in an outbreak.
Yesterday’s WHO update called for a `high level of vigilance and low threshold for testing’, accordingly the World Health Organization followed up today with new, aggressive interim surveillance guidance designed to help detect early, sustained human-to-human transmission and to determine the geographic risk area for infection with the virus.
While several testing categories are broadened, probably the most noticeable change is the inclusion of the phrase `without regard to place of residence or history of travel’ for several of the testing categories.
Changes that should ensure substantially more testing for the virus takes place, in the Middle East, and around the globe. I’ve excerpted some highlights (bolding & italics mine), but follow the link to read the entire document.
Interim surveillance recommendations for human infection with novel coronavirus
As of 18 May 2013
Key clinical points in this update: It is now evident that non-sustained human-to-human transmission has occurred. Co-infection of novel coronavirus with influenza A has also been reported. However, a number of unanswered questions remain, including what the virus reservoir is, how seemingly sporadic infections are being acquired, the mode of transmission between infected persons, the clinical spectrum of infection, and the incubation period.
<SNIP>
All confirmed cases have had respiratory disease and most have had pneumonia. However, one immunocompromised patient presented initially with fever and diarrhea and was only incidentally found to have pneumonia on a radiograph. Half of all confirmed cases have died.
Complications during the course of illness have included severe pneumonia with respiratory failure requiring mechanical ventilation, acute respiratory distress syndrome (ARDS) with multi-organ failure, renal failure requiring dialysis, consumptive coagulopathy and pericarditis. A number of cases have also had gastrointestinal symptoms including diarrhea during the course of their illness.
Limited evidence suggests that nasopharyngeal swabs may not be as sensitive as lower respiratory
specimens for detecting nCoV infections. Lower respiratory specimens such as sputum, endotracheal
aspirate or bronchoalveolar lavage should be used when possible in addition to nasopharyngeal swab
until more information is available. If initial testing of a nasopharyngeal swab is negative in a patient
strongly suspected to have nCoV infection, consideration should be given to retesting using a lower respiratory specimen.
All cases have had some link to the Middle East, although local transmission from recent travelers has
been observed in France and the United Kingdom.
The following people should be investigated and tested for novel coronavirus:
1. A person with an acute respiratory infection, which may include history of fever and cough and
indications of pulmonary parenchymal disease (e.g. pneumonia or ARDS), based on clinical or radiological evidence of consolidation, who requires admission to hospital. In addition, clinicians should be alert to the possibility of atypical presentations in patients who are
immunocompromised.
AND any of the following:
• The disease is in a cluster1 that occurs within a 10-day period, without regard to place of residence or history of travel, unless another aetiology has been identified.
• The disease occurs in a health care worker who has been working in an environment where patients with severe acute respiratory infections are being cared for, particularly patients requiring intensive care, without regard to place of residence or history of travel, unless another aetiology has been identified. 3
• The person has history of travel to the Middle East2 within 10 days before onset of illness, unless another aetiology has been identified.3
• The person develops an unusual or unexpected clinical course, especially sudden deterioration despite appropriate treatment, without regard to place of residence or history of travel, even if another aetiology has been identified, if that alternate aetiology does not fully explain the presentation or clinical course of the patient.
2. Individuals with acute respiratory illness of any degree of severity who, within 10 days before onset of illness, were in close physical contact4 with a confirmed or probable case of novel coronavirus infection, while that patient was ill.
3. For countries in the Middle East, the minimum standard for surveillance should be testing of patients with severe respiratory disease requiring mechanical ventilation. The minimum standard should also include investigation of all those in three categories listed above—patients with unexplained pneumonia or ARDS occurring in clusters; health care workers requiring admission for respiratory disease and patients with unusual presentation or clinical course.
However, countries in the Middle East are also strongly encouraged to consider adding testing for nCoV to current testing algorithms as part of routine sentinel respiratory disease surveillance and, if local capacity can support it, some testing of patients with milder, unexplained, community-acquired pneumonia requiring admission to hospital.
WHO does not advise special screening at points of entry with regard to this event nor does it recommend that any trade or travel restrictions be applied.1 A “cluster” is defined as two or more persons with onset of symptoms within the same 10-day period and who are associated with a specific setting, such as a classroom, workplace, household, extended family, hospital, other residential institution, military barracks or recreational camp.
2 For a map of the Middle East, see: http://www.un.org/Depts/Cartographic/map/profile/mideastr.pdf.
3 Testing should be according to local guidance for management of community-acquired pneumonia. Examples of other aetiologies include Streptococcus pneumoniae, Haemophilus influenzae type B, Legionella pneumophila, other recognized primary bacterial pneumonias, influenza, and respiratory syncytial virus.
4 Close contact is defined as:
• Anyone who provided care for the patient, including a health care worker or family member, or who had other similarly close physical contact;
• Anyone who stayed at the same place (e.g. lived with, visited) as a probable or confirmed case while the case was ill
