Download Middle East Respiratory Syndrome Corona Virus

“Updates on Emerging &
Re-emerging Infectious Diseases”
• Emerging Infections
– Newly identified or previously unknown infections
– New or drug-resistant infections whose incidence in
humans has increased within the past two decades
or whose incidence threatens to increase in the
near future
• Re-emerging Infections
– Secondary to the reappearance of a previously
eliminated infection or an unexpected increase in
the number of a previously known infectious
disease
Disease Prevention & Control Bureau, DOH
The Global Threat of Infectious Diseases
Emerging and re-emerging diseases
Adapted from Morens, Folkers, Fauci 2004 Nature 430; 242-9
Disease Prevention & Control Bureau, DOH
Major Factors Contributing to
Emerging Infections
•
•
•
•
•
•
•
Human demographics and behavior
Technology and Industry
Economic development and land use
International travel and commerce
Microbial adaptation and change
Breakdown of public health measures
Human vulnerability
Disease Prevention & Control Bureau, DOH
Major Factors Contributing to
Emerging Infections
•
•
•
•
•
•
Climate & weather
Changing ecosystems
Poverty & social inequality
War & famine
Lack of political will
Intent to harm
Disease Prevention & Control Bureau, DOH
Prevention of Emerging Infectious Diseases
Will Require Action in Each of These Areas
•
•
•
•
Surveillance and Response
Applied Research
Infrastructure and Training
Prevention and Control
Disease Prevention & Control Bureau, DOH
Surveillance and Response
Detect, investigate, and monitor emerging
pathogens, the diseases they cause, and the
factors influencing their emergence, and
respond to problems as they are identified.
Disease Prevention & Control Bureau, DOH
Applied Research
Integrate laboratory science and
epidemiology to increase the
effectiveness of public health practice.
Disease Prevention & Control Bureau, DOH
Infrastructure & Training
Strengthen public health infrastructures to support
surveillance, response, and research and to implement
prevention and control programs.
Provide the public health work force with the knowledge and
tools it needs.
Disease Prevention & Control Bureau, DOH
Prevention & Control
Ensure prompt implementation of
prevention strategies and enhance
communication of public health
information about emerging diseases.
Disease Prevention & Control Bureau, DOH
Preventing Emerging
Infectious Diseases: More to Do
• Enhance communication: locally, regionally,
nationally, globally
• Increase global collaboration
• Share technical expertise and resources
• Provide training and infrastructure support
globally
• Ensure political support
• Ensure judicious use of antibiotics
• Vaccines for all
Disease Prevention & Control Bureau, DOH
DR. JOANRI T. RIVERAL, FPLS
DEPARTMENT OF HEALTH RO7
Middle East Respiratory
Syndrome Corona Virus
( MERSCOV )
Coronaviruses
• Human CoVs first isolated in the 1960s
• Six human CoVs identified to date:
– HCoV – 229E
– HCoV – OC43
– HCoV – NL63
– HCoV – HKU1
– SARS – CoV
– Middle East Respiratory Syndrome Coronavirus
(MERSCoV)
Non-SARS Human CoVs
•
•
•
•
•
Worldwide
Winter & spring in temperate climates
Exposure common in early childhood
Droplet, contact & indirect contact
Symptoms & viral loads high first few days of
illness
• Incubation period 2-5 days
Non-SARS Human CoVs
• Most often associated with upper respiratory
tract infections in children
• Pneumonia & lower tract infections in
immunocompromised individuals & the
elderly
• May play a role in exacerbations of underlying
respiratory diseases
SARS
• 1st recognized in Nov. 2002 as sporadic cases
in Guandong province, China
• Outbreak period 2002 – 2003
• Hong Kong hotel contributed to spread of
virus to several countries
Chain of transmission among guests at Hotel M—Hong Kong, 2003
2 family
members
2 close contacts
4 family
members
Guangdong
Province,
China
4 HCWs*
Hospital 2
Hong Kong
F
A
A
F
156 close
contacts
of HCWs
and
patients
Hospital 3
Hong Kong
H
Hospital 1
HK
J
B
C
28 HCWs
4 other
Hong Kong
Hospitals
Vietnam
B
D
HCW
HCW
United
States
M§
D
E
Singapor
e
HCW
34 HCWs
Bangkok
Data as of 3/28/03
I
Germany
0 HCWs
Hospital 4
Hong Kong
Ireland
L§
E
C
B
K†
I
Hotel M
Hong
Kong
J
99 HCWs
(includes 17
medical students)
K†
A
H
Canada
G†
G†
3 HCWs
10 HCWs
37 HCWs
37 close contacts
HCW
2 family
members
Unknown
number close
contacts
* Health-care workers; † All guests except G and K stayed on the 9 th floor of the hotel. Guest G
stayed on the 14th floor, and Guest K stayed on the 11th floor; § Guests L and M (spouses) were not
at Hotel M during the same time as index Guest A but were at the hotel during the same times as
Guests G, H, and I, who were ill during this period.
SARS
• Incubation period 2-10 days
• Droplet transmission
– Aerosol spread
– Fomites
– Fecal – respiratory transmission at an apartment
complex in Hong Kong
• Transmission most likely during 2nd week of
illness
• Super spreading events
Middle East Respiratory Syndrome
Corona Virus
• 1st identified in September 2012
• Cases retrospectively identified as early as
March 2012
• Different from other coronaviruses in humans,
including SARS
• Most similar to coronaviruses found in bats
MERS-CoV
• Several studies have identified MERS-CoV in
high proportion of camels
– Likely reservoir
• Identical gene segment found in one bat
• Mode of transmission is unclear
– Respiratory?
– Foodborne?
– Few primary cases with direct camel contact
MERS-CoV
• Range of presentation
– 62% severe respiratory illness
– 5% mild symptoms
– 21% asymptomatic
• Data from early cases
– High mortality
– Lower respiratory tract illness, fever
• Data from more recent cases
– Lower mortality
– Higher proportion with upper respiratory tract illness
• No vaccine, no specific treatment
MERS-CoV
• Most people who got infected with MERS-CoV
developed severe acute respiratory illness
with symptoms of fever, cough, and shortness
of breath
• Common symptoms are acute, serious
respiratory illness with fever, cough, shortness
of breath and breathing difficulties
MERS-CoV
• Case demographics
– Males > Females
– Median age 49 years (9 months – 94 years)
• Incubation period 2 – 14 days
• Infection period
– Under investigation
– Not believed to be contagious before onset
MERS-CoV
• 75% identified as ‘secondary’
– Mostly healthcare workers (19% of all cases)
– Many with no or minor symptoms
• Many clusters identified
– Healthcare
– Household (estimated 1.3% secondary attack rate)
• No sustained human to human transmission
MERS-CoV
• MERS-CoV has been shown to spread between
people who are in close contact*
• Transmission from infected patients to
healthcare personnel has also been observed
• Clusters of cases in several countries are being
investigate
*Close contact is defined as a) any person who provided care for the patient,
including a healthcare worker or family member, or had similarly close physical
contact; or b) any person who stayed at the same place (e.g. lived with, visited) as
the patient while the patient was ill.
MERS-CoV
• Treatment is largely supportive and should be
based on the patient’s clinical condition
• Medical care is supportive and to help relieve
symptoms
• Currently, there is no available vaccine against
MERSCoV
MERS-CoV
• Infection Control
– Healthcare settings
• Contact, droplet & airborne isolation
– Fit-tested N95 or higher level respirators
– Gowns, gloves & eye protection
– Negative – pressure airborne infection isolation
• Surgical mask when out of room
– Home
• Precautions for ill persons, care givers & close contacts
• Self-monitor if asymptomatic
MERS-CoV
• Critical to prevent the possible spread of MERSCoV in health care facilities
• Health-care facilities that provide for patients
suspected or confirmed to be infected with
MERS-CoV infection should take appropriate
measures to decrease the risk of transmission of
the virus from an infected patient to other
patients, health-care workers and visitors
• Health-care workers should be educated, trained
and refreshed with skills on infection prevention
and control
MERS-CoV
• It is not always possible to identify patients
with MERS-CoV early because some have mild
or no symptoms at all!!!
– It is important that health-care workers apply
standard precautions consistently with all patients
– regardless of their diagnosis – in all work
practices all the time
MERS-CoV
• Droplet precautions should be added to the
standard precautions when providing care to
all patients with symptoms of acute
respiratory infection
• Contact precautions and eye protection
should be added when caring for probable or
confirmed cases of MERS-CoV infection
• Airborne precautions should be applied when
performing aerosol generating procedures
“Updates on Emerging &
Re-emerging Infectious Diseases”
WELCOME BACK..
EMERGING AND RE-EMERGING INFECTION
• Emerging Infections
– Newly identified or previously unknown infections
– New or drug-resistant infections whose incidence in
humans has increased within the past two decades
or whose incidence threatens to increase in the
near future
• Re-emerging Infections
– Secondary to the reappearance of a previously
eliminated infection or an unexpected increase in
the number of a previously known infectious
disease
Disease Prevention & Control Bureau, DOH
The Global Threat of Infectious Diseases
Emerging and re-emerging diseases
Adapted from Morens, Folkers, Fauci 2004 Nature 430; 242-9
Disease Prevention & Control Bureau, DOH
EBOLA VIRUS
Updates on the Ebola Virus
Disease Outbreak in West Africa
What is Ebola Virus Disease?
• A severe, infectious, often fatal disease in humans
and non-human primates (monkeys, gorillas and
chimpanzees) caused by infection with Ebola virus.
• EVD is very infectious, kills in a short time but can
be prevented.
• The Ebola virus can cause severe viral hemorrhagic
fever outbreaks in humans with a case fatality rate
of up to 90% (25-90%).
What is Ebola Virus Disease?
• Belongs to family of RNA viruses - Filoviridae
• Five identified subtypes of Ebola virus:
– Ebola – Zaire
– Ebola – Sudan
– Ebola – Ivory Coast
– Ebola – Bundibugyo
– Ebola - Reston
What is Ebola Virus Disease?
• Incubation period ranges from 2 to 21 days
• Onset of illness is abrupt
• Ebola Hemorrhagic Fever (EHF) is a severe acute viral illness
often characterized by the sudden onset of fever, headache,
intense weakness, joint and muscle pain, headache and sore
throat.
• This is followed by vomiting, diarrhea, stomach pain, rash,
impaired kidney and liver function, and in some cases, both
internal and external bleeding.
• A rash, red eyes, hiccups and bleeding from body openings
may be seen in some patients.
BUSHMEAT
Transmission
• Infections with Ebola virus are acute
• Transmitted in several ways
– Direct contact with the blood and/or secretions of
an infected person
– Through contact with objects, such as needles,
that have been contaminated with infected
secretions
Risk of Transmission
Risk Level
Type of Contact
Very low or No
recognized risk
Casual contact with a feverish, ambulant, self-caring patient
Eg. Sharing a sitting area or public transportation; receptionist
tasks
Low risk
Close face to face contact with with a feverish, ambulant
patient.
Eg. Physical examination, measuring temperature & blood
pressure
Moderate risk
Close face to face contact without appropriate personal
protective equipment (including eye protection) with a
patient who is coughing or vomiting, has nosebleeds or who
has diarrhea
High risk
Percutaneous, needle stick or mucosal exposure to viruscontaminated blood, bodily fluids, tissues or laboratory
specimens in severely ill or known positive patients
What is Ebola Virus Disease?
• Laboratory findings of low counts of white blood
cells and platelets as well as elevated liver
enzymes
• EVD can only be diagnosed definitively in the
laboratory by a number of different tests:
 Enzyme-linked immunosorbent assay (ELISA)
 Antigen detection tests
 Serum neutralization test
 Reverse transcriptase polymerase chain
reaction (RT-PCR) assay
 Virus isolation by cell culture
WHO Update on the Situation of
Ebola Virus Disease in West Africa
(as of July 31, 2104)
According to WHO, the outbreak of
Ebola in West Africa is the largest in
history in terms of the number of cases,
deaths and geographic spread.
Since March 2014, when Guinea reported
its first cases of EVD to the WHO, the
cases have spread to its capital city and
to its neighboring countries of Liberia and
Sierra Leone, after being initially confined
to a rural area Guinea. On July 25,
Nigeria reported its first probable case
and death.
As of July 31, 2014, the number of cases
in the four affected West African countries
has so far reached 1323, which includes
729 deaths. The over-all case fatality rate
is at 55%.
Actions taken by the Philippine Government
The Philippines has many OFWs in the three
affected countries, including a Filipino
contingent of UN Peacekeepers
Inter-Agency Task Force has convened to
share information & discuss preparations &
response to potential arrival of OFWs & foreign
nationals from West Africa:
• DFA, DOLE, DOH, DILG, PNP, DOTC, Bureau of
Immigration
Inter-Agency Coordination
DFA raised Alert Level 2 for the
three initially affected countries:
• a deployment ban on newly
hired OFWs to these countries
is now in effect
DOLE provided info that
recruitment agencies have been
notified by employers in West
Africa of repatriation of 20 OFWs
from Sierra Leone.
DOH is monitoring these OFWs
for 30 days after their departure
from their points of origin.
Recommendations to Prevent Spread of
EVD
The following recommendations were jointly developed by the DOH,
DFA and DOLE:
1. Careful coordination of the repatriation of OFWs from EVD-affected
countries should be done:
a. OFWs should coordinate with their recruitment agencies in
assessing the risk of the spread of the epidemic in their places of
deployment.
b. Proper coordination of Philippine labor officials (DOLE, POEA,
OWWA) should be undertaken in the possible repatriation with the
DFA and the Bureau of Immigration.
c. Any returning symptomatic Filipino (those who have fever,
headache, intense weakness, joint and muscle pains and sore
throat) should seek clearance with the local health authorities from
the country of employment before being allowed to embark.
Recommendations (cont)
2. The Bureau of Immigration (BI) will also forward data on
recent travel history to the affected countries of non-repatriated
OFWs and foreigners to the DOH Bureau of Quarantine (BOQ).
3. The repatriation of Filipino U.N. Peacekeepers will be
coordinated by DND & PNP to monitor arrival of any enlisted
personnel:
 Coordination with DFA & BI on info on travel & health status
while in EVD affected country, including possible exposure to
cases while in place of assignment & any initial management
provided to them
Recommendations (cont)
4. Upon the arrival of repatriated OFWs or foreign nationals who had
recent travel to the three affected countries of Guinea, Liberia, Sierra
Leone and possibly Nigeria, the BOQ will undertake the following:
a. Health checklist should be distributed to passengers from all
incoming flights to the Philippines.
b. Determine the status of returning Filipinos upon arrival and refer
symptomatic cases to the appropriate health facilities for clinical
care (Research Institute for Tropical Medicine, San Lazaro Hospital
or Lung Center of the Philippines)
c. Passengers from affected areas will be provided a notification card
to facilitate consultation and laboratory testing should they manifest
any symptom.
d. Coordinate with DOLE on other possible repatriation activities from
other manpower agencies in the affected countries.
Recommendations (cont)
5. Once asymptomatic individuals are cleared by BOQ, they will be closely
monitored daily by Heath Emergency Management Staff (HEMS) up to 30
days from potential exposure (i.e. date of departure from point of origin).
6. Once an individual is found to be symptomatic after their arrival, HEMS
will coordinate with National Epidemiology Center (NEC) & health officials
of CHDs & local government units to facilitate pick-up of patients by the
DOH and brought to the appropriate hospital and managed accordingly.
 The NEC will organize possible contact tracing for possible exposed
individuals and conduct the necessary epidemiologic investigation in
coordination with HEMS.
7. National Center for Disease Prevention and Control (NCDPC) will
provide policy and program support as well as technical assistance to the
other DOH agencies involved.
The single biggest threat to man’s
continued dominance on the planet is
the virus.
• Joshua Lederburg, Ph D
Nobel laureate
DR. JOANRI T. RIVERAL, FPLS
DEPARTMENT OF HEALTH RO7