MIDDLE EASTERN RESPIRATORY SYNDROME

CORONAVIRUS
(MERS-COV)




M.ARDARIS ALHUDRI, S.KED

PEMBIMBING:
DR. MACHROZAL, M.KES

CORONAVIRUSES AND HUMAN
DISEASE
Five human respiratory coronaviruses have been
described:
Causers of colds
and URIs
229E
OC43
NL63
Causers of
Pneumonia:
HKU1
SARS
ON SEPTEMBER 23, 2012, WHO
ANNOUNCES:

The first laboratory-confirmed case of
MERS-CoV: a 60-year-old man from Bisha,
the Kingdom of Saudi Arabia, who died of
rapidly progressive community-acquired
pneumonia and acute renal failure

MIDDLE EAST RESPIRATORY SYNDROME
CORONAVIRUS (MERS-COV)
Novel coronavirus that
emerged in 2012
Causes severe acute
respiratory illness
First cluster of 2 cases
occurred near Amman,
Jordan April 2012
MERS-COV TRANSMISSION
Airborne
Incubation period is 10-14 days
The following have been observed:
Transmission between close contacts
Transmission from infected patients to healthcare personnel
Eight clusters of illnesses have been reported by six
countries
So far, all cases have a direct or indirect link to one of
four countries: Saudi Arabia, Qatar, Jordan, and the
United Arab Emirates

CORONAVIRUSES INFECT AND CAUSE DISEASE IN MANY ANIMAL SPECIES:

Bats
Mice
Birds
Dogs
Pigs
Cattle
Viruses tend to be specific for individual
species, but mutation occurs
SOURCES OF CORONAVIRUS
MERS-CoV source still uncertain
South African bat Neoromicia cf.
zuluensis derived CoV is closest
phylogenetically
Intermediate host is considered
possible

First cases of MERS-CoV
associated with camels, sheep,
goats exposure
MERS-COV CASES
MERS Cases and Deaths, April 2012 - Present
Countries Cases (Deaths)
France 2 (1)
Italy 3 (0)
Jordan 2 (2)
Qatar 2 (0)
Saudi Arabia 49 (32)
Tunisia 2 (0)
United Kingdom (UK) 3 (2)
United Arab Emirates (UAE) 1 (1)
Total 64 (38) = 59% MR
Median Age =
56

All patients were
aged 24 yrs
except for a 2yo
and a 14yo



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, 20122013
MMWR. June 14, 2013 / 62(23);480-
483


MERS-COV EPIDEMIOLOGY

Infectious Period
Not clearly established
Likely to extend from the onset of fever until 10
days after fever resolves

Incubation Period
Available data suggest that symptoms have
occurred up to 14 days after last exposure.
PATIENT UNDER INVESTIGATION (PUI)
Any PUI should be reported to state and local
health departments immediately
PUI Criteria:
1. Acute respiratory infection, may include fever
100.4F and cough
2. Suspicion of pneumonia or acute respiratory distress
syndrome based on clinical or radiological evidence
3. History of travel to the Arabian Peninsula or
neighboring countries within 14 days
4. Symptoms not already explained by any other
infection or etiology

PATIENT UNDER INVESTIGATION (PUI)
The following persons may be considered for
evaluation of MERS-CoV:
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
CLOSE CONTACT
Any person who provided care for the patient,
including a healthcare worker or family member, or
had similarly close physical contact

Any person who stayed at the same place (lived with,
visited) as the patient while the patient was ill
PROBABLE CASE DEFINITION
A probable case is any person who:
Meets PUI criteria and has clinical, radiological, or
histopathological evidence of pneumonia or ARDS, but no
possibility of lab confirmation exists, either because patient or
samples are unavailable or no testing available for other
respiratory infections, AND
Is a close contact with a laboratory confirmed case, AND

OR any person with:
SARI with no known etiology, AND
An epidemiologic link to a confirmed MERS case
CONFIRMED CASE DEFINITION
A confirmed case is any person with laboratory
confirmation of infection with MERS-CoV (PCR)
INFECTION CONTROL RECOMMENDATIONS
Standard, contact, and airborne precautions are
recommended for management of hospitalized
patients with known or suspected MERS-CoV
infection.
Airborne Infection Isolation Room (AIIR)
If unavailable, transport to another facility
Place facemask on patient and isolate in a single-patient room
with door closed. Air should not recirculate without HEPA
filtration
COLLECTION OF LABORATORY SPECIMENS
Determine if patient meets PUI criteria
Collect:
An upper respiratory specimen:
Nasopharyngeal AND oropharyngeal swab
A lower respiratory specimen:
Broncheoalveolar lavage, OR
Tracheal aspirate, OR
Pleural fluid, OR
Sputum
Serum for eventual antibody testing (tiger top tube)
Should be collected during acute phase during first week after
onset, and again during convalescence 3 weeks later

MERS-COV FROM SEPTEMBER, 2012-
PRESENT
MERS COV CLUSTERS
Multiple clusters of human cases have
occurred
Healthcare associated events
Family clusters
Human to human transmission has
occurred, though no sustained community
transmission
REVIEW OF 47 PATIENTS WITH MERS-
COV
Cases of laboratory-confirmed MERS-CoV
reported from Saudi Arabia between Sept 1,
2012, and June 15, 2013
46 adults, one child
36 (77%) male
28 (60%) died
Case-fatality rate rose with increasing age
Two of the 47 cases were previously healthy
TheLancet.com Published Online 7/26/13
45 (46%) had underlying comorbid medical disorders
Diabetes
Hypertension
Chronic cardiac
disease
Chronic renal
disease
32 [68%]
16 [34%]
13 [28%]

23 [49%]
No. (%)
TheLancet.com Published Online 7/26/13
MERS-COV SYMPTOMS
Severe acute respiratory illness:
Fever
Cough
Shortness of breath
Illness onsets were from April 2012 through June
2013
Some cases have had atypical presentations:
Initially presented with abdominal pain and diarrhea and
later developed respiratory complications
MERS-COV CLINICAL CASE DEFINITION

A person with an acute respiratory infection,
which may include fever ( 38C , 100.4F)
and cough; AND
Suspicion of pulmonary parenchymal disease;
AND
History of travel from the Arabian Peninsula or
neighboring countries within 14 days; AND
Not already explained by any other infection
or etiology
MERS-COV CLINICAL
PRESENTATION
Fever
Cough
Shortness of breath
Myalgia
Diarrhea
Vomiting
Abdominal pain
46 [98%]
39 [83%]
34 [72%]
15 [32%]
12 [26%]
10 [21%]
8 [17%]
TheLancet.com Published Online 7/26/13
MERS COV INFECTIVITY
Human-to-human transmissibility of MERS
CoV appears to be low
Sustained community transmission has not
been seen
Close monitoring of health-care workers
and household contacts has not revealed
large numbers of secondary infections
MERS-COV SPECIMEN COLLECTION AND TESTING

PCR testing should be performed with samples from:
Lower respiratory tract specimens:
Broncheoalveolar lavage, tracheal aspirate, pleural
fluid and/or sputum
Typically have highest yield
Upper respiratory tract specimens
Nasopharyngeal and oropharyngeal swabs
Serum
Stool
OCHCA can arrange testing
MERS COV TREATMENT
Minimal evidence to indicate antiviral or
adjunctive therapy
Management should be performed as for
community acquired pneumonia. Appropriate
specimens should also be collected for
MERS-CoV PCR testing.
Supportive care
Mechanical ventilation
Some studies have shown that interferon may
have beneficial effects in the treatment of
SARS
CURRENT STATUS
No cases of MERS-CoV or Influenza A H7N9 have
been identified in the United States to date

CDC advises travelers to China to take some
common sense precautions, like not touching birds
or other animals and washing hands often. Poultry
and poultry products should be fully cooked.

WHO advised that persons with chronic medical
conditions and want to go on Hajj pilgrimage should
discuss the risks with their healthcare provider
THANK YOU!