CDC HAN: Updated Guidelines For Evaluation Of MERS-CoV

 

 

# 7376

 

 

Along with last night’s early release MMWR (see MMWR: MERS-CoV Update – June 7th) the CDC released an updated HAN Health Update on the MERS coronavirus.

 

Although no cases have been reported in the United States - with the source of the virus still unknown, and millions of religious pilgrims expected to travel to Saudi Arabia over the next four months – the chances of that remaining the case are far from sure.

 

Hence the flurry of activity this week at the CDC on MERS-CoV and the the H7N9 virus (see CDC: Updated H7N9 Guidance Docs).

 

This HAN update is geared primarily towards Health Care Providers and public health officials, so I’ll not reproduce the entire document.  Those interested in the specifics will want to follow the link to read the update in its entirety.

 

This is an official

CDC HEALTH UPDATE

Distributed via the CDC Health Alert Network
June 7, 2013, 20:00 ET 08:00 PM ET
CDCHAN-00348

Notice to Health Care Providers: Updated Guidelines for Evaluation of Severe Respiratory Illness Associated with Middle East Respiratory Syndrome Coronavirus (MERS-CoV)

Summary

The Centers for Disease Control and Prevention (CDC) is working closely with the World Health Organization (WHO) and other partners to better understand the public health risk posed by Middle East Respiratory Syndrome Coronavirus (MERS-CoV), a novel coronavirus that was first reported to cause human infection in September 2012. No cases have been reported in the United States. The purpose of this HAN Advisory is to provide updated guidance to state health departments and health care providers in the evaluation of patients for MERS-CoV infection including expansion of availability of laboratory testing and, in consultation with WHO, expansion of the travel history criteria for patients under investigation from within 10 to 14 days for investigation and modification of the case definition. Please disseminate this information to infectious diseases specialists, intensive care physicians, internists, infection preventionists, as well as to emergency departments and microbiology laboratories.

<SNIP>

Surveillance

As a result of investigations suggesting incubation periods for MERS CoV may be longer than 10 days, the time period for considering MERS in persons who develop severe acute lower respiratory illness days after traveling from the Arabian Peninsula or neighboring countries* has been extended from within 10 days to within 14 days of travel.

 

In particular, persons who meet the following criteria for “patient under investigation” (PUI) should be reported to state and local health departments and evaluated for MERS-CoV infection:

• 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 of consolidation); AND
• History of travel from the Arabian Peninsula or neighboring countries* within 14 days; AND
• Symptoms not already explained by any other infection or etiology, including clinically indicated tests for community-acquired pneumonia† according to local management guidelines.

In addition, the following persons may be considered for evaluation for MERS-CoV infection:

• Persons who develop severe acute lower respiratory illness of known etiology within 14 days after traveling from the Arabian Peninsula or neighboring countries* but who do not respond to appropriate therapy; OR
• Persons who develop severe acute lower respiratory illness who are close contacts‡ of a symptomatic traveler who developed fever and acute respiratory illness within 14 days of traveling from the Arabian Peninsula or neighboring countries.*

In addition, CDC recommends that clusters of severe acute respiratory illness (SARI) should be investigated and, if no obvious etiology is identified, local public health officials should be notified and testing for MERS-CoV conducted if indicated.

 

CDC requests that state and local health departments report PUIs for MERS-CoV and clusters of SARI with no identified etiology to CDC. To collect data on PUIs, please use CDC’s Interim Health Departments MERS-CoV Investigation  Form available at  http://www.cdc.gov/coronavirus/mers/guidance.html.

State health departments should FAX completed investigation forms to CDC at 770-488-7107 or attach in an email to eocreport@cdc.gov (subject line: MERS-CoV Patient Form).

(Continue . . . )

 

 

MMWR: MERS-CoV Update – June 7th

FIGURE 1. Number of confirmed cases of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) (N = 55) reported as of June 7, 2013, to the World Health Organization, by month of illness onset — worldwide, 2012–2013 – CDC MMWR

# 7375

 

 

The CDC has been busy this week, yesterday issuing three new guidance documents (see CDC: Updated H7N9 Guidance Docs) and a HAN Health Update (Human Infections with Avian Influenza A (H7N9) Viruses) on the emerging avian flu virus.

 

Late yesterday, the CDC also released an updated HAN Health Update on the novel coronavirus (MERS-CoV), along with an early release MMWR.  We’ll start with the MMWR, and I’ll highlight the HAN in my next post.

 

Some of the ambiguity in this MMWR report (source of virus, incubation time, genetic analysis of samples, mode of transmission, spectrum of illness, etc.) can no doubt be traced to the Saudi’s reluctance to share information and virus samples with the rest of the world.

 

Helen Branswell’s absolutely terrific reporting yesterday in her SciAm article Saudi Silence on Deadly MERS Virus Outbreak Frustrates World Health Experts and Canadian Press report Saudi paperwork demands delay work to research to find MERS source: CDC are `must reads’, and help to explain why this virus has elicited such alarm in public health circles.

 

As the graphic at the top of the page shows, while the numbers of lab-confirmed cases of MERS-CoV remain small, the trend over the past couple of months is less than reassuring.  

 

A few highlights from the MMWR (bolding mine) include:

 

• As of June 7, 2013, a total of 55 laboratory-confirmed cases have been reported to WHO
• Illness onsets have occurred during April 2012 through May 29, 2013 (Figure 1)
• All reported cases were directly or indirectly linked to one of four countries: Saudi Arabia, Qatar, Jordan, and the United Arab Emirates (Figure 2)
• To date, no cases have been reported in the United States.
• The median age of patients is 56 years (range: 2–94 years), with a male-to-female ratio of 2.6 to 1.0.
• All patients had respiratory symptoms during their illness, with the majority experiencing severe acute respiratory disease requiring hospitalization
• Thirty-one of the 55 patients are reported to have died (case-fatality rate: 56%)
• Patients with comorbidities or immunosuppression might be at increased risk for infection, severe disease, or both.
• Eight clusters (42 cases) have been reported by six countries (France, Italy, Jordan, Saudi Arabia, Tunisia, and the UK) (5) among close contacts or in health-care settings and provide clear evidence of human-to-human transmission of MERS-CoV.
• Importantly, the incubation period might be longer than previously estimated.

 

Here then is the link to last night’s MMWR and the opening passages.  By all means, read it in its entirety.

 

Update: Severe Respiratory Illness Associated with Middle East Respiratory Syndrome Coronavirus (MERS-CoV) — Worldwide, 2012–2013

Early Release

June 7, 2013 / 62(Early Release);1-4

CDC continues to work in consultation with the World Health Organization (WHO) and other partners to better understand the public health risk posed by the Middle East Respiratory Syndrome Coronavirus (MERS-CoV), formerly known as novel coronavirus, which was first reported to cause human infection in September 2012 (1–4).

 

The continued reporting of new cases indicates that there is an ongoing risk for transmission to humans in the area of the Arabian Peninsula. New reports of cases outside the region raise concerns about importation to other geographic areas. Nosocomial outbreaks with transmission to health-care personnel highlight the importance of infection control procedures. Recent data suggest that mild respiratory illness might be part of the clinical spectrum of MERS-CoV infection, and presentations might not initially include respiratory symptoms. In addition, patients with comorbidities or immunosuppression might be at increased risk for infection, severe disease, or both.

 

Importantly, the incubation period might be longer than previously estimated. Finally, lower respiratory tract specimens (e.g., sputum, bronchoalveolar lavage, bronchial wash, or tracheal aspirate) should be collected in addition to nasopharyngeal sampling for evaluation of patients under investigation. An Emergency Use Authorization (EUA) was recently issued by the Food and Drug Administration (FDA) to allow for expanded availability of diagnostic testing in the United States.

(Continue . . . )

The Name Game

 

 

# 7307

 

We’ve called it the Novel coronavirus, nCoV, NCoV, HCoV-EMC, MERS, MERS-CoV, and even  betacoronavirus 2c EMC2012 . . .

 

Not since Shirley Ellis hit the top of the charts in 1964 with her `Bo-nana song’ have there been so many names used to describe a single entity.

 

A little over two weeks ago, Martin Enserink reported the details of a new naming convention (see Picking A Novel Name For A Novel Virus) for the novel coronavirus, proposed by an international group of experts. 

 

Their solution?

Call it Middle East respiratory syndrome coronavirus (MERS-CoV). Or just MERS.

 

Their paper was published last week in the Journal of Virology (see Middle East Respiratory Syndrome Coronavirus (MERS-CoV); Announcement of the Coronavirus Study Group) and the World Health Organization  appeared to embrace the term in an update released on May 16th.

 

Novel coronavirus update – new virus to be called MERS-CoV

 

The issue would seem to have been settled.

 

But as recently as this morning’s update (see WHO Coronavirus (nCoV) Update On Tunisian Cases), the WHO continues to use nCoV instead of MERS or MERS-CoV – leaving journalists and bloggers more than a bit confused about what we are supposed to call it.

 

Apparently I’m not alone in this quandary, as Reuters has a report this morning from Kate Kelland, their Health and Science Correspondent, where she asks the WHO about this disparity.

 

 

When it comes to deadly viruses, what's in a name?

By Kate Kelland, Health and Science Correspondent

LONDON | Wed May 22, 2013 6:24pm IST

(Reuters) - For a pathogen with such a short history, the mysterious new virus killing people in the Middle East and Europe has already had an amazing array of names.

 

(Continue . . . )

 

 

Follow the link to read the entire article, but the bottom line – which is literally reported in the bottom line of the article – is that an unnamed `WHO spokesman’ is quoted as saying today:

 

". . . . we are going to be using the new name in all our updates".

 

Perhaps this will finally settle the issue.

WHO Coronavirus (nCoV) Update On Tunisian Cases

 

 

# 7305

 

We’ve an update this morning from the World Health Organization that provides more clarity on the Tunisian coronavirus cluster (see Tunisia Reports Coronavirus Fatality – Ex Gulf States) reported on Monday.

 

The story originally suggested the 66 y.o. fatality was laboratory confirmed, and his two children were `suspected’ cases – but as it turns out, it’s exactly the opposite.

 

These new cases extend the geographic range of the virus into Africa, but more importantly, we learn the two adult children both experienced mild symptoms and did not require hospitalization.

 

With a handful of exceptions (see here and here) previously identified nCoV infections have produced serious, often fatal illness.

 

Last March, in Eurosurveillance: H2H Transmission of NCoV In UK Family Cluster, we looked at a detailed report which discussed the third member of the UK family cluster who only developed mild symptoms. That was the first clear indication that NCoV could cause mild infection, giving rise to the following commentary from the authors:

 

. . .  This first reported case of a milder nCoV illness raises the possibility that the spectrum of clinical disease maybe wider than initially envisaged, and that a significant proportion of cases now or in the future might be milder or even asymptomatic.

The news today of two more mild cases would seem to bolster their concerns, and raises questions over the ability of surveillance systems around the globe to detect the virus should it begin to spread more widely.

 

 

 

Novel coronavirus infection - update

22 May 2013 - The Ministry of Health in Tunisia has notified WHO of two laboratory-confirmed cases and a probable case of infection with the novel coronavirus (nCoV).

 

The two laboratory confirmed cases are a 34-year-old man and a 35-year-old woman. They are siblings. Both of them had mild respiratory illness and did not require hospitalization. Retrospective investigation into the cases revealed that the probable case, their father, 66 year old, became ill three days after returning from a visit to Qatar and Saudi Arabia on 3 May 2013. He was admitted to a hospital after developing acute respiratory disease. His condition deteriorated and he died on 10 May 2013. He had an underlying health condition. Initial laboratory tests conducted on the probable case tested negative for nCoV.

 

Further investigation into this outbreak is ongoing and close contacts of the family are being monitored for any unusual signs of illness. These are the first confirmed cases of infection with nCoV in Tunisia.

 

In Saudi Arabia, a patient earlier reported as part of the ongoing investigation into an outbreak that began in a health care facility since the beginning of April 2013, has died. To date, a total of 22 patients including 10 deaths have been reported from this outbreak in the Eastern part of Saudi Arabia. The government is conducting an ongoing investigation into the outbreak.

 

Globally, from September 2012 to date, WHO has been informed of a total of 43 laboratory-confirmed cases of infection with nCoV, including 21 deaths. Several countries in the Middle East have been affected. They are Jordan, Qatar, Saudi Arabia, and the United Arab Emirates (UAE). Cases have also been reported by four additional countries: France, Germany, Tunisia and the United Kingdom. All of the cases have had a direct or indirect connection to the Middle East, including two cases with recent travel history from the UAE. In France and the United Kingdom, there has been limited local transmission among close contacts who had not been to the Middle East but had been in contact with a traveler who recently returned from the Middle East.

 

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 travelers returning from the Middle East who develop SARI should be tested for nCoV as advised in the current surveillance recommendations. Specimens from patients’ lower respiratory tracts should be obtained for diagnosis where possible. Clinicians are reminded that nCoV infection should be considered even with atypical signs and symptoms, such as diarrhoea, particularly in patients who are immunocompromised.

 

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 with suspected nCoV 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 nCoV, 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.

 

WHO does not advise special screening at points of entry with regard to this event nor does it currently recommend the application of any travel or trade restrictions.

 

WHO continues to closely monitor the situation.

 

MERS, Mass Gatherings & Public Health

Credit Wikipedia

 

 

# 7302

 

In Saudi Arabia, religious tourism – most notably Umrah, which runs from December to the end of Ramadan (August 7th) - and the Hajj, which falls in mid October this year – are big business, accounting for roughly 3% of their Gross National Product.

 

According to a recent Arab News report, more than 7 million pilgrims visit Saudi Arabia each year, adding more than $16 billion dollars to the local economy.

 

Egypt, Turkey, Pakistan and Iran provide the most pilgrims, but devout Muslims come from nearly every nation on earth to take part in `lesser pilgrimages’, called (Umrah), and in the Hajj.

 

Yesterday we learned that a Tunisian tourist, recently returned from a trip to Qatar and Saudi Arabia, died from the novel coronavirus (and two of his relatives were infected) raising concerns that visitors to the Gulf States could spread the virus around the globe (see KUNA Report On Tunisian Coronavirus Case).

 

What little we do know about the progression of this disease suggests that it has a prolonged incubation period  - estimated at 10 days – giving travelers plenty of time to become infected, and travel home, before they become symptomatic.

 

The Hajj this October will likely see 4 million pilgrims over a relatively short time span, while between now and the end of Ramadan, a couple of million tourists are expected to visit Saudi Arabia.

 

All of which means that public health officials must decide upon, and implement, prudent measures to minimize the risk of spreading this virus further. 

 

 

This, as you might well guess, isn’t a new concern. And considerable thought has been devoted to it.  So a brief review of the topic of mass gatherings and public health:

 

Last fall, just before the Hajj of 2012 - and just weeks after we learned of the first novel coronavirus cases in Saudi Arabia – we saw the following report in the ECDC’s  journal Eurosurveillance. 

 

 

Eurosurveillance, Volume 17, Issue 41, 11 October 2012

Rapid communications

The Hajj: updated health hazards and current recommendations for 2012

J A Al-Tawfiq¹, Z A Memish

---

This year the Hajj will take place during 24–29 October. Recent outbreaks of Ebola haemorrhagic fever in Uganda and the Democratic Republic of the Congo, cholera in Sierra Leone, and infections associated with a novel coronavirus in Saudi Arabia and Qatar required review of the health recommendations of the 2012 Hajj. Current guidelines foresee mandatory vaccination with quadrivalent meningococcal vaccine for all pilgrims, and yellow fever and poliomyelitis vaccine for pilgrims from high-risk countries. Influenza vaccine is strongly recommended.

---

The annual Hajj is one of the greatest assemblies of humankind on earth. Each year, three million Muslims attend the Hajj in Mecca, Saudi Arabia. Of these, 1.8 million non-Saudi Arabians usually come from overseas countries and 89% (1.6 millions) of them arrive by air [1]. Pilgrims come from more than 180 countries worldwide and about 45,000 pilgrims each year arrive to Saudi Arabia from the European Union [2].

<SNIP>

Pre- and post-Hajj travel advice

The Hajj is a unique event with possible impact on international public health. Healthcare practitioners around the world must be attentive to the potential risks of disease transmission during the Hajj. They must recommend appropriate strategies for the prevention and control of communicable diseases before, during and after the completion of the Hajj. The current international collaboration in planning vaccination campaigns, developing visa quotas, arranging rapid repatriation, and managing health hazards at the Hajj are crucial steps in this process. The Saudi Arabian Ministry of Health publishes the Hajj requirements for each Hajj season. This year’s Hajj recommendations have recently been published [3].

Recent outbreaks of Ebola haemorrhagic fever in Uganda and the Democratic Republic of the Congo (DRC), cholera in Sierra Leone, and infections associated with a novel coronavirus in Saudi Arabia and Qatar required review of the health recommendations of the 2012 Hajj. We present here the changes and additions made in the recommendations for these diseases. For completeness, we also summarise the existing recommendations [3,4].

(Continue . . . )

 

Similarly, in January of last year, The Lancet ran a six-part series on mass gatherings and health issues, which becomes all the more relevant today.

 

Mass Gatherings Health

Published January 16, 2012

Executive summary

A six-part series describes the scope of the emerging specialty of mass-gatherings health. Mass gatherings are events such as religious occasions, music festivals, or sports events that attract enough people to exceed the capacity of routine health and public safety measures. Managing such events requires providing for all eventualities from infectious disease outbreaks to security against terrorist attacks. Thus mass gatherings health is a topic that goes beyond the scope of typical public health provision.

 

The first paper in the series describes the influence that the Hajj pilgrimage has had on the development of mass gatherings health. The second paper looks at the prevention of infectious diseases associated with mass gatherings. In the third paper, non-communicable disease risks associated with mass gatherings are reviewed. The fourth paper looks at crowd and environmental management during mass gatherings. Fifth is a review of infectious diseases surveillance and modelling. The final paper sets out a research agenda for the mass gatherings health specialty. This series is timely as London prepares to host the 2012 Olympic Games.

Series Comment

Mass gatherings health Series

John McConnell

Full Text | PDF

Series Papers

Emergence of medicine for mass gatherings: lessons from the Hajj

Ziad A Memish, Gwen M Stephens, Robert Stephen, Qanta A Ahmed

Summary | Full Text | PDF

Global perspectives for prevention of infectious diseases associated with mass gatherings

Ibrahim Abubakar, Philippe Gautret, Gary W Brunette, Lucille Blumberg, David Johnson, Gilles Poumerol, Ziad A Memish, Maurizio Barbeschi, Ali S Khan

Summary | Full Text | PDF

Non-communicable health risks during mass gatherings

Robert Steffen, Abderrezak Bouchama, Anders Johansson, Jiri Dvorak, Nicolas Isla, Catherine Smallwood, Ziad A Memish

Summary | Full Text | PDF

Crowd and environmental management during mass gatherings

Anders Johansson, Michael Batty, Konrad Hayashi, Osama Al Bar, David Marcozzi, Ziad A Memish

Summary | Full Text | PDF

Infectious disease surveillance and modelling across geographic frontiers and scientific specialties

Kamran Khan, Scott J N McNabb, Ziad A Memish, Rose Eckhardt, Wei Hu, David Kossowsky, Jennifer Sears, Julien Arino, Anders Johansson, Maurizio Barbeschi, Brian McCloskey, Bonnie Henry, Martin Cetron, John S Brownstein

Summary | Full Text | PDF

Research agenda for mass gatherings: a call to action

John S Tam, Maurizio Barbeschi, Natasha Shapovalova, Sylvie Briand, Ziad A Memish, Marie-Paule Kieny

Summary | Full Text | PDF

 

Each year there are multiple mass gatherings which could conceivably facilitate disease transmission; including the Super bowl, Mardi Gras, and Carnival in Rio, and the Hajj.

 

The good news is, that while mass gatherings may provide greater opportunities for disease outbreaks, history has shown that major epidemic outbreaks have been a rarity (for an exception, see The Impact Of Mass Gatherings & Travel On Flu Epidemics).

 

Still, public health authorities must anticipate and prepare for the worst.

 

Because the old saying is true, `When public health works, nothing happens’.

Tunisia Reports Coronavirus Fatality – Ex Gulf States

 

 

# 7296

 

News this morning trickling out of Tunisia (h/t @HelenBranswell) and already blogged by Crof (see Tunisia: MERS death confirmed (confusingly)) on the first confirmed MERS-CoV case to be reported on the African continent – this time in a traveler who recently visited Qatar and the Gulf States.

 

Despite news reports of a MOH announcement, a quick check of Tunisia’s Ministry of Health website (in Arabic & French) fails to turn up anything on the front page.

 

FluTrackers has a thread of French media reports, some of which suggest that two sons of the deceased may have been infected (and have since recovered) as well.

 

Hopefully we’ll get a clearer explanation - including a timeline showing when this individual traveled to Qatar, and returned, and when he was hospitalized – in the coming hours or days.

Saudi MOH Reports 16th Coronavirus Fatality

 

# 7295

 

A new update from the Saudi MOH that, like many we’ve seen, is long on words and short on useful information.

 

We basically are informed a previously known coronavirus patient has died (making 16 KSA fatalities), while another has recovered and been discharged from the hospitals.

 

No details regarding the two cases are provided, and no new cases are reported.

 

 

Statement Related to the Updates of the Novel Coronavirus

 

20 May 2013

Within the framework of its continuous monitoring and the epidemiological surveillance of Coronavirus, the Ministry of Health (MOH) has announced the demise of one patient, whom has been previously announced be infected with this virus in Al-Ahsa region, as he was suffering from chronic heart diseases, diabetes and high blood pressure, in addition to kidney failure, May Allah bestow mercy upon him. Thus, the number of mortality due to this virus, up to the date of this statement, reached to 16 cases.

 

MOH has further declared that one of the injured cases, whom has been previously announced be infected among the Health staff with this virus, has recovered and been released from the hospital. It is noteworthy that no new Coronavirus cases, up to the last announcement, has been recorded, Allah be praised.

WHO: Updated Guidance On nCoV (MERS-CoV) Surveillance Recommendations

 

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

MERS-CoV: Singapore Issues Umrah Health Advisory

 

 

 

# 7288

 

The sudden uptick in MERS-CoV (aka nCoV) cases in Saudi Arabia over the past month has led to cautions being issued today to Muslims in Singapore planning to visit the Middle East this summer.

 

All able bodied Muslims are required to make at least one major pilgrimage to Mecca during their lifetime, at the time of the hajj. This is known as the fifth pillar of Islam, and is one of the duties incumbent upon all Muslims.

 

The faithful may also make `lesser pilgrimages’, called  omra (or sometimes Umrah), at other times of the year.  These minor pilgrimages don’t absolve the faithful of making the hajj journey.

 

The hajj is roughly five months away (it occurs mid-October this year), but millions of Muslims take these lesser pilgrimages over the summer months.  

 

This from News Channel Asia.

 

MUIS, MOH issue health advisory on coronavirus to pilgrims

The Islamic Religious Council of Singapore (MUIS), working with the Health Ministry, has issued a health advisory on the novel coronavirus, now known as the Middle East Respiratory Syndrome Coronavirus (MERS-CoV).

(Continue . . . )

 

 

The advisory strongly advises Muslims with plans to visit the Kingdom of Saudi Arabia this summer to:

 

• Get vaccinated against influenza and meningitis
• If over 65, or suffering from chronic illness, to get the pneumococcal pneumonia vaccine
• Observe good personal hygiene and hand washing
• Observe good flu etiquette (cover coughs, sneezes, dispose of tissues properly)
• If unwell with fever or respiratory symptoms while traveling, or within 10 days of returning from the Middle East to don a mask and seek medical treatment promptly.
• Inform your doctor of any recent travel history to the Middle East. 

 

The long incubation period (believed to be approx. 10 days) - along with few clues as to the kinds of exposures that increase the risk of infection - have many countries with strong travel ties to Saudi Arabia on heightened alert.

 

Yesterday, in their updated rapid risk assessment, the ECDC had this to say:

 

ECDC supports the WHO travel advice which imposes no travel or trade restrictions in relation to novel coronaviruses. However, EU citizens travelling to the Arabian Peninsula and neighbouring countries need to be aware of the presence of MERS-CoV in this geographical area and of the small risk of infection. Member States may consider active information efforts for travellers to areas most at risk. 

 

 

While the absolute risk of contracting MERS is considered very low - with tens of thousands of pilgrims traveling to and returning from the Kingdom of Saudi Arabia each week - no one would be terribly surprised if sporadic MERS cases started turning up outside of the Middle East.

KSA Reports Their 31st MERS-CoV Case – No Details

Screenshot from KSA Coronavirus update page

# 7287

 

A barebones report (h/t to @Ironorehopper) appears today on the Saudi Ministry of Health website, announcing a 31st confirmed infection with the novel coronavirus.

The following is machine translation.

 

Register new cases for the new Corona virus in the eastern region

July 07, 1434

Within the framework of continuous monitoring and epidemiological investigation of the new Corona virus, have been recorded cases of a new one in the eastern region, where he receives treatment and is subject to medical care. This brings the total of confirmed infected cases 31 cases.

 

While KSA’s Ministry of Health announcements are often  parsimonious in the way of case information, today’s may set a record both in brevity and lack of useful details.

 

Hopefully a more substantive report is in the offing.

ECDC MERS-CoV Rapid Risk Assessment

 

 

# 7286

 

The ECDC has updated their rapid risk assessment on the novel coronavirus (formerly nCoV) dubbed MERS-CoV, based on information received since their last update on May 7th.

 

As we saw earlier in the day from the World Health Organization, the ECDC is warning that  nasopharyngeal swabs are not an optimal sample collection method, and that deeper respiratory sampling may be required.

 

Below you’ll find their press summary, links to the update, and some excerpts from the actual update.

 

 

ECDC updates Rapid Risk Assessment on Middle East respiratory syndrome coronavirus (novel coronavirus)

17 May 2013

ECDC

ECDC has published an update of its rapid risk assessment on Middle East respiratory syndrome coronavirus (MERS-CoV), previously referred to as the novel coronavirus. It focuses on developments since the previous ECDC risk assessment, and provides updated threat assessment and recommendations for Europe.

 

As of 14 May 2013, 38 cases of MERS-CoV have been reported worldwide, including 20 deaths. All cases remain associated with transmission in the Arabian Peninsula and Jordan. This includes indirect association following secondary person-to-person transmission in the UK and France.

 

The report of 19 new infections in Saudi Arabia in the past two weeks – including one infection with the novel coronavirus acquired in the United Arab Emirates and later imported to Europe – indicate that there is an ongoing source of infection and risk of transmission to humans in the Arabian Peninsula and Jordan.

 

The confirmed infection in France of a patient who shared a hospital room with a patient returning from the United Arab Emirates indicates the risk of nosocomial transmission. This is the second nosocomial transmission in Europe. The first one took place when an imported case in the UK visited a relative in the hospital in February 2013.

Resources:

• Updated ECDC rapid risk assessment on MERS-CoV
• ECDC epidemiological update, 7 May 2013, on additional confirmed cases of novel coronavirus in Kingdom of Saudi Arabia
• More information on novel coronavirus (Middle East respiratory syndrome coronavirus) on ECDC website

 

 

Severe respiratory disease associated with Middle East respiratory syndrome coronavirus (MERS-CoV)

(Excerpts)

Summary

• As of 14 May 2013, 38 cases of Middle East respiratory syndrome coronavirus (MERS-CoV) have been reported worldwide, including 20 deaths. All cases remain associated (including indirect association following secondary person-to-person transmission in the UK and France) with transmission in the Arabian Peninsula and Jordan. The age of cases ranges from 24 to 94 years (N=34 cases), with a mean of 55.5 years and a male/female ratio of 1:0.2.

• The report of 19 new infections in Saudi Arabia in the past two weeks – including one infection with the novel coronavirus acquired in the United Arab Emirates and later imported to Europe – indicate that there is an ongoing source of infection and risk of transmission to humans in the Arabian Peninsula and Jordan.

• The most recent imported case, which resulted in a nosocomial transmission, originated in the United Arab Emirates and then moved to France. Both patients had underlying conditions and a degree of immunosuppression. One of the transmissions in the UK also affected an immunosuppressed person. These underlying conditions may be increasing vulnerability and the risk of transmission.

• The first French case raises the possibility that presentations may not include respiratory symptoms initially, especially in those with immunosuppression or underlying chronic conditions. This needs also to be taken into account when revising case-finding strategies.

• The confirmed infection in France of a patient who shared a hospital room with a patient returning from the United Arab Emirates indicates the risk of nosocomial transmission. This is the second nosocomial transmission in Europe. The first one took place when an imported case in the UK visited a relative in the hospital in February 2013.

• These conclusions should be seen in the light of the many uncertainties that still continue with the investigation of cases in the Arabian

Recommendations

• Healthcare workers in the EU should be vigilant in identifying patients that may require further investigation; they should also follow ECDC and national guidance for case finding. Patients developing severe respiratory infections and who have been in the Arabian Peninsula or neighbouring countries in the preceding 10 days should be investigated rapidly. Special attention should be given to medical evacuated patients from the Arabian Peninsula and neighbouring countries.

• Patients with chronic underlying conditions who develop severe infections (not just respiratory infections) should also be investigated rapidly for novel coronavirus if they have been in the Arabian Peninsula or neighbouring countries in the preceding 10 days.

• Since routine microbiological sampling (nasopharyngeal swabs) may give misleading negative results in persons later shown to be infected with the coronavirus, tests should be repeated with deeper respiratory sampling if a person fits into a category that requires investigation, especially if their condition is worsening.

• As demonstrated by a case with dual influenza and novel coronavirus infections, there is a possibility of co-infection and this should be considered by healthcare personnel. Identification of one causative agent should not exclude testing for novel coronavirus where indicated.

• Mapping of international routes of medical evacuation or emergency medical care from the Arabian Peninsula and neighbouring countries to the EU could be considered in order to determine the most vulnerable centres in the EU where these cases might arrive.

• Companies undertaking medical evacuations from affected areas should be reminded of the risk of transferring infections across borders and of their obligations to protect staff engaged in the transfer; the same holds true for the staff of institutions which receive patients.

• Healthcare workers caring for patients under investigation for MERS-CoV should exercise standard infection control measures following national or international guidance.

• Close contacts of confirmed cases must be monitored for symptoms for 10 days after the last exposure, and should be tested, and should be informed what to do should they become ill. This should be carried out according to guidance, such as that developed by Public Health England UK (See ‘Sources of additional information’ below).

• Healthcare workers caring for confirmed cases should be monitored for early symptoms of infection and advised to seek testing and thereafter self-isolate if they become unwell.

• Clusters of severe acute respiratory infections in the community or in healthcare settings, either among patients or healthcare workers, should always be reported rapidly and investigated for a range of pathogens, regardless of where in the world these infections occur.

• ECDC does not currently consider a need for testing individual patients with unexplained pneumonias or other respiratory symptoms unless they fall under one of the above categories.

• Any probable or confirmed case being diagnosed in the EU/EEA should be reported to national authorities through the Early Warning and Response System (EWRS) and to WHO under the International Health Regulations (2005). Reporting through EWRS qualifies as IHR notification and avoids double reporting. Patients still under investigation do not need to be reported internationally before confirmation, but information on outcome of such testing exercises should be shared with ECDC.

• ECDC supports the WHO travel advice which imposes no travel or trade restrictions in relation to novel coronaviruses. However, EU citizens travelling to the Arabian Peninsula and neighbouring countries need to be aware of the presence of MERS-CoV in this geographical area and of the small risk of infection. Member States may consider active information efforts for travellers to areas most at risk.

• Although the reservoir of infection in the Middle East is unknown, other novel coronaviruses are zoonoses and have come from animal sources. Travellers should therefore follow standard good hygiene practise and avoid contact with animals or their waste products.

(Continue . . .)

 

Hong Kong CHP: Update On Novel Coronavirus

 

# 7281

 

Hong Kong’s CHP publishes an online "Communicable Diseases Watch" on a bi-weekly basis, that takes a close look at 2 or 3 infectious disease topics that are currently of concern.  

 

Today’s edition, in addition to carrying reports on listeriosis infection in Hong Kong and summary charts select notifiable diseases and outbreaks in Hong Kong, has a review of the novel coronavirus that has emerged on the Arabian peninsula.

 

Given their history with the SARS virus a decade ago (see SARS And Remembrance), outbreaks of a novel coronavirus anywhere in the world is understandably of of great interest to their public health community.

 

Follow the link to read:

 

Update on Severe Respiratory Disease Associated with Novel Coronavirus

Reported by Dr Henry Mou, Medical Officer, Respiratory Disease Office, Surveillance and EpidemiologyBranch, CHP.

Since September 23, 2012 (as of May 15, 2013), a total of 40 patients have been confirmed suffering from Severe Respiratory Disease associated with Novel Coronavirus (NCoV) worldwide, including 30 from the Kingdom of Saudi Arabia (KSA), three from the United Kingdom (UK), two from Qatar, two from Jordan, two from France and one from the United Arab Emirates (UAE). Most patients are male (79%; 30 of 38 cases with sex reported) and aged from 24 to 94 years (median 56 years).The first case had onset of illness in late March or early April 2012; whereas the most recent case reported had onset on May 8, 2013. Most patients presented with severe acute respiratory disease requiring hospitalisation and eventually required mechanical ventilation or other advanced respiratory support.To date, the case fatality rate is around 50%.
(Continue . . . )

 

While the H7N9 outbreak on the mainland may be closer to home, Hong Kong’s government website www.info.hk.gov carries almost daily updates on the novel coronavirus as well.

 

Two additional overseas cases of Severe Respiratory Disease associated with Novel Coronavirus closely  Monitored by DH

The Department of Health (DH) is today (May 16) closely monitoring two additional cases of Severe Respiratory Disease associated with Novel Coronavirus reported to the World Health Organization (WHO) by the Kingdom of Saudi Arabia (KSA).

According to the WHO, the two patients are health-care workers who were exposed to patients confirmed with novel coronavirus. The first patient is a 45-year-old man who became ill on May 2 and is currently in critical condition while the second patient is a 43-year-old woman with underlying illness who became ill on May 8 and is now in stable condition.

To date, a total of 21 patients have been reported from the outbreak primarily linked to the same health-care facility in Eastern KSA since the beginning of May. Investigation by the KSA government is ongoing.

This brings the latest global number of confirmed cases of Severe Respiratory Disease associated with Novel Coronavirus to 40.

The WHO noted that this is the first time health-care workers have been diagnosed with Severe Respiratory Disease associated with Novel Coronavirus after exposure to patients. In view of recent clusters reported in health-care facilities, health-care workers and hospitals are reminded to maintain vigilance against novel coronavirus and adhere to strict infection control measures while handling suspected cases in order to reduce the risk of transmission to other patients and health-care workers.

"The Centre for Health Protection (CHP) of the DH will seek more information on the cases from the WHO and the relevant health authority. The CHP will stay vigilant and continue to work closely with the WHO and overseas health authorities to monitor the latest developments of this novel infectious disease," a DH spokesman said.

Locally, the CHP will continue its surveillance mechanism with public and private hospitals, practising doctors and the airport for any suspected case of severe respiratory disease associated with novel coronavirus.

(Continue. . . )

France: 2nd nCoV Patient Deteriorates, Placed On ECMO

 

Extracorporeal membrane oxygenation (ECMO) machine in a ICU patient in Santa Cruz

 

# 7280

 

While I’ve yet to find the official release, it is being widely reported this morning that the Centre Hospitalier Regionale et Universitaire de Lille has announced the condition of their second novel coronavirus patient has deteriorated since our last update (see France: Both Coronavirus Patients Remain In `Poor’ Condition) and he has now been placed on ECMO.

 

This from AFP.

 

Coronavirus: the health of the French second patient deteriorated

(AFP)

LILLE - The health of the roommate of the first confirmed case of novel coronavirus in France deteriorated Wednesday, Thursday announced the Lille University Hospital where both hospitalized patients.

 

"The health status of the second patient deteriorated in the last day. He was placed on ECMO (extracorporeal membrane oxygenation) to take over from his lung function," said the University Hospital in a statement

 

"His condition has stabilized but remains a serious concern," the statement said.

(Continue . . .)

 

 

France’s index case, a 65-year-old man who had recently traveled to the UAE, was hospitalized on April 23rd, and was placed on ECMO support on May 8th.

 

Both cases illustrate just how devastatingly virulent this infection can be.  Of 40 known cases, 20 have died, and many of the survivors have required significant and prolonged medical intervention.

 

For more on ECMO, and how it has been used for severe respiratory disease, you may wish to revisit.

 

JAMA: H1N1, ECMO, and Survivability

The ECMO Option

nCoV: PPE Adherence & Infection Control

 

 

# 7278

 

While we don’t know exactly how two healthcare workers (HCWs) in Saudi Arabia came to be infected with the novel coronavirus, the fact that it happened – not once . . but twice – should provide a clear signal on the the importance of maintaining proper infection control procedures in healthcare settings.

 

As we aren’t in possession of the facts, I don’t intend to speculate on what factors led to these two HCWs becoming infected.

 

Regardless of what happened, the best defense against this – or any other contagion – in a healthcare environment are solid infection control procedures and strict adherence to wearing the appropriate PPEs (Personal Protective Equipment).

 

Lest anyone think that lapses in taking protective measures  are in anyway unique to hospitals located in `other’ countries, a brief review of the literature shows a different story.

 

Whether due to inadequate infection control protocols, lack of education - or worse, supplies - or simple non-compliance on the part of the HCWs (PPEs can be hot, uncomfortable, and a considerable bother to put on and take off properly), lapses in infection control happen in hospitals around the world on a regular basis.

 

Exhibit A:

 

Infect Control Hosp Epidemiol.

2011 Mar;32(3):293-5. doi: 10.1086/658911.

Factors associated with unprotected exposure to 2009 H1N1 influenza A among healthcare workers during the first wave of the pandemic.

Banach DB, Bielang R, Calfee DP.

Abstract

Protecting healthcare workers (HCWs) from occupational exposure to 2009 H1N1 influenza was a challenge. During the first wave of the pandemic, many HCWs reported that they had been exposed to 2009 H1N1 when they were not using respiratory personal protective equipment. Unprotected exposures tended to be more frequent among HCWs caring for patients with atypical clinical presentations.

In a related article that appeared in Infection Control Today, the findings were discussed.  Excerpts below:

 

Lack of Adherence to Respiratory PPE Seen During First Wave of H1N1 Pandemic

March 8, 2011

(Excerpt)

The researchers note, "The identification of almost five unprotected healthcare exposures for each patient who presented with ILI was a more unexpected finding. Potential explanations include inconsistent use of the screening and isolation protocol, communication barriers, and suboptimal adherence to recommended PPE use. Each of these warrants further research. Previous studies have demonstrated that healthcare worker compliance with respiratory protection guidance, including that related to influenza, is generally poor. A recent study of healthcare workers’ opinions about respirator use identified the need for new equipment that better meets the needs of healthcare workers."

 

Banach, et al. add, "Since substantial numbers of unprotected exposures occurred during this period of heightened awareness of influenza and at a time when vaccination was not an option, it is likely that similar or perhaps even more exposures occur during typical influenza seasons. This highlights the importance of healthcare worker immunization, when available, and the need for a better understanding of barriers to effective implementation of screening protocols and adherence to recommended respiratory PPE use among healthcare workers."

 

Moving on to Exhibit B:

The use of personal protective equipment for control of influenza among critical care clinicians: A survey study.

Daugherty EL, Perl TM, Needham DM, Rubinson L, Bilderback A, Rand CS.

DESIGN, SETTING, AND PARTICIPANTS:

A survey of 292 internal medicine housestaff, pulmonary/critical care fellows and faculty, nurses, and respiratory care professionals working in four ICUs in two hospitals in Baltimore, MD.

MEASUREMENTS AND MAIN RESULTS:

Of those surveyed, 88% (n = 256) completed the survey. Only 63% of respondents were able to correctly identify adequate influenza PPE, and 62% reported high adherence (>80%) with PPE use for prevention of nosocomial influenza. In multivariable modeling, odds of high adherence varied by clinician type. Respondents who believed adherence was inconvenient had lower odds of high adherence (odds ratio 0.42, 95% confidence interval 0.22-0.82), and those reporting likelihood of being reprimanded for nonadherence were more likely to adhere (odds ratio 2.40, 95% confidence interval 1.25-4.62).

CONCLUSIONS:

ICU HCWs report suboptimal levels of influenza PPE adherence. This finding in a high-risk setting is particularly concerning, given that it likely overestimates actual behavior.

 

Both suboptimal adherence levels and significant PPE knowledge gaps indicate that ICU HCWs may be at a substantial risk of developing and/or transmitting nosocomial respiratory viral infection. Improving respiratory virus infection control will likely require closing knowledge gaps and changing organizational factors that influence behavior.

 

I could provide more references (such as Addressing the Challenges of PPE Non-Compliance) but the point is, compliance wearing appropriate PPEs in healthcare facilities is far too often  – as they phrase it above - `suboptimal’.

 

Last week the World Health Organization released their Interim Infection Control Guidance On nCoV, and earlier this month PHAC released their Guidance On Handling H7N9 Cases.

 

Taking an even tougher stance, the CDC released their Interim H7N9 Infection Control Guidelines in the middle of April and are currently recommending their guidance for SARS when dealing with the novel coronavirus (see 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings).

 

These guidance documents will likely change and evolve as we learn more about this virus, but they provide a solid foundation for interim HCW protection.

 

Even though the novel coronavirus is not SARS, there are lessons we can learn from how that epidemic was eventually contained. Hospitals turned out to be an ideal breeding ground for the SARS virus, and it required bold, and difficult steps to stop its spread.

 

With no vaccine or antivirals available containment was accomplished primarily through the use of isolation, quarantine, and stringent infection control measures.

 

For more on how these measures have been successfully used in the past to contain epidemics, you may wish to revisit EID Journal: A Brief History Of Quarantine.

 

Today, in response to the news that two HCWs in Saudi Arabia have been infected, WHO issued a statement  offering the following advice:

 

Health care facilities that provide care for patients with suspected nCoV infection should take appropriate measures to decrease the risk of transmission of the virus to other patients and health care workers. Health care facilities are reminded of the importance of systematic implementation of infection prevention and control (IPC).

 

While the future of this virus is unknowable - if it plays out anything like SARS did in 2003 - the battle against this virus may very well end up being won or lost in the trenches of the health care environment.

 

The good news is - that with the proper precautions in place - that’s a battle that experience has shown we can win.