Download MERS-CoV

MERS-CoV
M.Talebi-Taher,MD.
IUMS
Cases and clusters:
• The index case was a patient in jaddah,
who was hospitalized with pneumonia in
June 2012.
• ARDS, acute kidney injury
• Died
• MERS-CoV was isolated from his sputum.
September 2012:
• A patient with acute kidney injury, ARDS I
Qatar.
• He had recently traveled to Saudi Arabia.
• An additional case was reported from
Qatar: severe pneumonia,kidney injury.
April 2012:
• Jordan
• 11 pneumonia cases( 8 HCWs)
• One patient: pneumonia and pericarditis
• Other: pneumonia and DIC
April 2013:
• 23 confirmed cases in Saudi Arabia.
• Person to person exposure( 9 cases in
hemodialysis ward, four cases in ICU, 2
HCWs,…).
May 2014:
• 697 lab-confirmed cases of infection with
MERS-CoV.
• 210 death
Possible sources:
• Camel:serves as intermediate hosts for
MERS-CoV?
• 100% of camels in Oman had MERS-CoVspecific antibody.
• Sera from European sheep, goats,cattle,
and other camelids had no specific
antibodies.
Continue:
• Various wild and domestic animal species
in the highest risk areas should be
sampled for coronaviruses by serology,
PCR, virus isolation,…in order to confirm
the possible role of camels and to identify
other potential reservoirs of MERS-CoV.
Human to human transmission:
• The case clusters in the UK, Tunisia, Italy,
and in HCWs in Saudia Arabia and France
strongly suggest that human to human
transmission occurs.
• MERS-CoV does not yet have pandemic
potential.
Case definitions:
• Limited data
• Fever, chills/rigors, headache, nonproductive cough, dyspnea, and myalgia.
• Sore throat, coryza, sputum production,
dizziness, nausea, and vomiting, diarrhea,
and abdominal pain.
Case definitions:
• Atypical presentations:
mild respiratory illness without fever
and diarrheal illness preceding
development of pneumonia.
Patient Under Investigation:
• PUI:
• A. Fever AND pneumonia or ARDS AND
EITHER:
• HX. of travel within 14d
• Close contact with a symptomatic traveler
within 14d
• A member of a cluster of patients with
severe acute respiratory illness? MERS
PUI:
• OR
• B. Fever AND symptoms of respiratory
illness AND being in a healthcare
facility(as a patient, worker, or visitor)
within 14 days before symptom onset.
Case definitions:
• Confirmed case: laboratory confirmation
• Probable case: a PUI with absent or
inconclusive laboratory results for MERSCoV infection who is a close contact of a
laboratory-confirmed MERS-CoV case.
Close contact:
• Includes anyone who provided care for the
patient, including a HCWs or family
member or another individual who had
other similarly close physical contact, and
anyone who lived with or visited a case
while the case was symptomatic.
Clinical manifestations:
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Incubation period: 5.2 days in S.Arabia
9-12 days: France
2-14 d
WHO, CDC: MERS-CoV be considered in
individuals with a syndrome of MERS who
returned from travel to the Arabian
countries within the past 14 days.
Clinical features:
• Most patients with MERS-CoV infection
have been severely ill with pneumonia and
ARDS, and some have had acute kidney
injury.
• Many patients required mechanical
ventilation.
• Gastrointestinal symptoms(anorexia,
nausea, vomiting, abdominal pain,
diarrhea).
Continue:
• Immunocompromised patients
• Comorbidities
• Study: in 47 patients with MERS 96 % had
underlying comorbidities(DM,
Hypertension, chronic cardiac disease,
chronic kidney disease, prednisolone)
• Old age
HCWs:
• Over 25% of recent Saudi MERS patients
were health worker.
• 402 MERS-CoV cases reported in Saudi
Arabia over the past 2 months.
• 13 Jun :an iranian patient is a nurse
assistant who had contact with Iran’s first
MERS patient.
Stable transmission pattern:
• WHO: Sustained community transmission
of MERS-CoV
• Household clusters has not increased.
Laboratory findings:
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Leukopenia
Lymphopenia
Thrombocytopenia
LDH
Virus can be detected with higher viral
load and longer duration in the lower
respiratory tract compared to URT(urine,
feces, serum).
Imaging findings:
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Increased bronchoalveolar marking
Airspace opacities
Patchy infiltrates
Interstitial changes
Patchy to confluent airspace consolidation
Nodular, reticular opacities
Reticulonodular shadowing
Pleural effusion
Diagnosis:
• Preferred tests and specimen types:
• rRT-PCR testing of lower respiratory
specimens appears to be more sensitive
for detection of MERS-CoV than testing of
upper respiratory tract specimens.
Continue:
• Multiple specimens be collected from
different sites and at different times to
increase the likelihood of detecting MERSCoV.
• Serology: acute phase, ≥3weeks
WHO,CDC:
• Lower respiratory tract specimens such as
sputum, endotracheal aspirate, or BAL
should be obtained from all cases of
severe dis. And from milder cases when
possible.
• Nasopharyngeal and oropharyngeal swab
specimen.
• Serology, rRT-PCR from blood, urine,
stool?
Whom to test:
• A person with an acute respiratory
infection, which may include history of
fever and cough and evidence of
pulmonary parenchymal
disease(pneumonia, ARDS) based upon
clinical or radiographic evidence of
consolidation, who requires admission to
hospital.
And any of the following:
• 1)The disease is in a cluster that occurs
within a 14-day period, without regard to
place of residence or history of travel.
• Cluster: workplace, household,…
Continue:
• 2)the disease occurs in a HCW who has
been working in an environment where
patients with severe acute respiratory
infections are being cared.
Continue:
• 3)the person has HX. Of travel to the
Middle East within 14 days before onset of
illness.
Continue:
• 4)unusual clinical course, especially
sudden deterioration despite appropriate
treatment.
Continue:
• 5)a person with acute respiratory illness of
any severity who, within 14 days before
onset of illness, was in close physical
contact with a confirmed or probable case
of MERS-CoV infection while that patient
was ill.
Treatment:
• No antiviral agents are recommended for
the treatment of MERS-CoV infection.
• Ribavirin, interferon alpha-2b?
Prevention:
• There is no licensed vaccine for MERSCoV.
• Infection control:standard, contact, and
airborne precautions for the management
of hospitalized patients.
May 14 2014:
• High rate of morbidity and mortality.
• Evidence of limited human to human
transmission
• Poorly characterized clinical signs and
symptoms
• Unknown modes of transmission of
MERS-CoV.
• Lack of vaccine or chemoprophylaxis.
Continue:
• Patient placement: airborne infection
isolation room(AIIR).
• The patient should not be placed in any
room where room exhaust is recirculated
without high-efficiency particulated
air(HEPA)filtration.
Continue:
• In AIIR room facemask may be removed.
• Outside of the AIIR, patient should wear a
facemask to contain secretions.
• Limit transport of patient.
• Minimize the number of personnel
Aerosol generating procedure:
• Bronchoscopy, sputum induction,
intubation and extubation, CPR, open
suctioning of airways.
• Conduct the procedures in a private room
and ideally in an AIIR when feasible.
• Rooms doors should be kept closed
except when entering or leaving the room.
Continue:
• Entry and exit should be minimized during
and shortly after the procedure.
• PPE(gloves, gown, goggles, N95 mask).
• PPE should be removed and either
-discard
-reused: cleaned and disinfected
Hand hygiene:
• Hand hygiene should be performed after
removal of PPE.
• Before and after all patient contact,
infectious material.
• Water and soap
• Alcohol based hand rubs.
Environmental infection control:
• Follow standard procedures, per hospital
policy, and manufactures’ instruction, for
cleaning and or disinfection of:
• Environmental surfaces and equipment.
• Textiles and laundry
• Food utensils and dishware.
Duration of infection control
precautions:
• ?
• Symptoms resolved
Monitoring and management of
potentially exposed personnel:
• HCWs: close contact 14 days
• HCW who developed respiratory
symptoms or fever after an unprotected
exposure:
-stop working
-comply with work exclusion until they
are deemed no longer infectious to others.
Continue:
• Asyptomatic HCW who had unprotected
exposure:
• 1)exclusion from work for 14 days.
• 2) or wear a facemask for 14 days
Visitors:
• Limit visitors
Treatment:
• There is no specific antiviral treatment
recommended for MERS-CoV infection.
• Rest, Fluid, pain relievers, O2 therapy.
Travel recommendations:
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>65yr
<12yr
Pregnant women
Immuncompromised patients
Chronic disease(heart dis., kidney dis.,
respiratory dis., diabetes)
• Patients with a terminal illness