Photo Credit WHO
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The World Health Organization, CDC, and the ECDC have all recommended heightened surveillance and testing for the MERS coronavirus – with particular attention to be paid to recent travelers to the Middle East. The Mantra, published by WHO with every MERS notification over the past few months, reads:
Based on the current situation and available information, WHO encourages all Member States to continue their surveillance for severe acute respiratory infections (SARI) and to carefully review any unusual patterns.
Health care providers are advised to maintain vigilance. Recent travellers returning from the Middle East who develop SARI should be tested for MERS-CoV as advised in the current surveillance recommendations.
Patients diagnosed and reported to date have had respiratory disease as their primary illness. Diarrhoea is commonly reported among the patients and severe complications include renal failure and acute respiratory distress syndrome (ARDS) with shock. It is possible that severely immunocompromised patients can present with atypical signs and symptoms.
Health care facilities are reminded of the importance of systematic implementation of infection prevention and control (IPC). Health care facilities that provide care for patients suspected or confirmed with MERS-CoV infection should take appropriate measures to decrease the risk of transmission of the virus to other patients, health care workers and visitors.
All Member States are reminded to promptly assess and notify WHO of any new case of infection with MERS-CoV, along with information about potential exposures that may have resulted in infection and a description of the clinical course. Investigation into the source of exposure should promptly be initiated to identify the mode of exposure, so that further transmission of the virus can be prevented.
Despite these appeals, somehow the case identified yesterday in Spain (see ECDC: Rapid Risk Assessment On MERS-CoV) managed to present at a hospital in Mecca on October 28/29th- be diagnosed with pneumonia - but was not isolated, or identified as having the MERS virus. As a consequence, she was able to fly back to Spain two days later, potentially exposing others.
All of which makes the following UMEM Educational Pearl, posted by the University of Maryland School of Medicine, particularly timely. Titled: Isolation criteria for MERS-CoV, it discusses a `hypothetical’ case history, and whether or not MERS testing and isolation are indicated.
Title: Isolation criteria for MERS-CoV
Keywords: MERS-CoV, Viral Illness, Respiratory (PubMed Search)
Posted: 11/6/2013 by Andrea Tenner, MD
Click here to contact Andrea Tenner, MDCase Presentation:
A 56y/o man with diabetes presents with fever, cough, and diarrhea x 2 days.
V/S: T:38.7 BP:165/88 P: 105 R:24 O2 sat:91% on room air
CXR: left lower lobe infiltrate.
On further history you learn he has just returned from visiting family in Saudi Arabia 7 days ago. While there, he visited a cousin that was ill.
Clinical Question:
Should this patient be isolated for Middle Eastern Respiratory Syndrome – Corona Virus (MERS-CoV)?
Answer:
Yes, there are 150 cases to date and 64 have died. None confirmed in the US yet but 6 confirmed in Europe.
Patients who should be isolated in an airborne iso room with N95 mask use (similar to TB) are:
Patients with fever + pneumonia/ARDS AND one of the following:
- Travel to the Arabian Peninsula within 14 days of symptom onset
- Close contact with a person with fever and respiratory illness within 14 days of travel to the Arabian Peninsula
- Member of a cluster of patients with severe ARI being evaluated for MERS-CoV
Bottom Line:
In patients with febrile respiratory illness requiring hospitalization and recent travel to the Arabian Peninsula: isolate for MERS-CoV and contact the health department.
In September, the CDC updated their guidance on the surveillance for, and testing of suspected MERS cases, in their MMWR report:
Updated Information on the Epidemiology of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) Infection and Guidance for the Public, Clinicians, and Public Health Authorities, 2012–2013
(EXCERPT)
Evaluating patients. 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.
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. Additional information about CDC's interim guidance regarding who should be evaluated for MERS-CoV infection is available at http://www.cdc.gov/coronavirus/mers/interim-guidance.html.
Dr. Ian Mackay on his Virology Down Under blog has some choice comments regarding the failure to detect this case while still in Saudi Arabia, as well. Follow the link to read:
MERS-CoV case in Spain, imported from Saudi Arabia during visit for Hajj pilgrimage [UPDATED]
