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Middle East Respiratory Syndrome Coronavirus (MERS-CoV): The Bottom Line for Clinicians
Susan Yox, RN, EdD
May 04, 2014
EDITORS' RECOMMENDATIONS
MERS-CoV Infection and Guidance for the Public, Clinicians
(UPDATED May 14, 2014) Middle East respiratory syndrome (MERS) is a respiratory illness caused by a coronavirus, usually referred to as the Middle East Respiratory Syndrome Coronavirus, or MERS-CoV. A coronavirus also caused the outbreak of severe acute respiratory syndrome (SARS), which led to almost 800 deaths in 2003.
MERS-CoV was first reported in Saudi Arabia in September 2012. In a press release issued May 2, 2014, the Centers for Disease Control and Prevention (CDC) identified 401 confirmed cases of MERS-CoV infection in 12 countries, with all reported cases originating in the Arabian Peninsula. Most patients developed severe acute respiratory illness, with fever, cough, and shortness of breath, and 93 patients have died. The case fatality rate in symptomatic patients is 30%.
On April 24, 2014, the World Health Organization (WHO) issued a statement indicating, "although camels are suspected to be the primary source of infection for humans, the exact routes of direct or indirect exposure remain unknown. Investigations to identify the source of infection and routes of exposure are still ongoing." (See also a recent article from Emerging Infectious Diseases, "Human Infection With MERS Coronavirus After Exposure to Infected Camels.")
On May 2, 2014, the first confirmed case of MERS-CoV was reported in the United States: A healthcare worker who was working in Saudi Arabia and who traveled back to the United States on April 24 fell ill on April 27, went to an unidentified hospital emergency department in Indiana on April 28, and was admitted to the hospital that same day. On May 2, CDC testing confirmed that the patient had MERS-CoV, and he/she remains in the hospital, in isolation and in stable condition. (See our news story, "First MERS Case Reported in United States.")
A second case was reported in the United States on May 12, 2014, at a Florida hospital, also in a healthcare worker who had traveled to Florida from Saudi Arabia. (See our news story, "Second MERS Case Reported in United States.")
For clinicians practicing in the United States who may have questions, here is the latest guidance, directly from the CDC and the WHO, on MERS-CoV. (Be sure to check the links provided for the most recent information, because this guidance may change rapidly.)
What are the characteristics of patients diagnosed with MERS-CoV and how communicable is the disease?
The average age of patients who have had confirmed MERS-CoV is 51 years, said Anne Schuchat, MD, assistant surgeon general with the US Public Health Service and director of the CDC's National Center for Immunization and Respiratory Diseases, at a CDC press conference held on May 2, 2014, although children as young as 2 years have reportedly had the disease.
The incubation period is from 2 to 14 days, and it is believed that patients are not contagious during the incubation period.
However, when a patient has had MERS-CoV, it has then spread to others who are in close physical contact with the patient. Transmission from infected patients to healthcare personnel has also been observed. Clusters of cases in several countries are currently being investigated.
The April 24, 2014, WHO statement pointed out that a full 75% of the recently reported cases appear to be secondary cases, meaning that the individuals acquired the infection from another infected person. "The majority of these secondary cases are mainly healthcare workers who have been infected within the healthcare setting, although several patients who were in the hospital for other reasons are also considered to have been infected with MERS-CoV in the hospital. The majority of the infected healthcare workers presented with no or minor symptoms. Only 4 instances of transmission within households have been reported, and no large family cluster has been identified. When human-to-human transmission occurred, transmission was not sustained, and to date only 2 possible tertiary cases have been reported."
Which patients in the United States should be evaluated for MERS?
Healthcare professionals should evaluate patients for MERS-CoV infection if they develop fever and symptoms of respiratory illness, such as cough or shortness of breath, within 14 days after traveling from countries in or near the Arabian Peninsula. (These countries and neighboring countries include Bahrain, Iran, Iraq, Israel, Jordan, Kuwait, Lebanon, the Palestinian territories, Oman, Qatar, Saudi Arabia, Syria, the United Arab Emirates, and Yemen.) In addition, evaluate patients with respiratory symptoms and fever who have been in contact with a symptomatic recent traveler from this area.
Here are all the details you need to consider: CDC: Patient Under Investigation.
If a patient presents who needs investigation for MERS-CoV, immediately contact your local/state health department. Health departments will find information from CDC on reporting here: Reporting Patients Under Investigation.
What lab specimens should I collect if I suspect MERS-CoV?
The CDC has developed molecular diagnostics that will accurately identify MERS cases as well as assays to detect MERS-CoV antibodies. MERS-CoV testing kits have been provided to state health departments so that they can test patients under investigation for MERS-CoV infection.
The CDC recommends "collecting multiple specimens from different sites at different times after symptom onset. Lower respiratory specimens are preferred, but collecting nasopharyngeal and oropharyngeal specimens, as well as stool and serum, are strongly recommended, depending upon the length of time between symptom onset and specimen collection. Respiratory specimens should be collected as soon as possible after symptoms begin." For more information, see the CDC's Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from PUIs for MERS-CoV.
If I suspect a patient may have MERS-CoV, what infection control precautions should be put into place?
Standard, contact, and airborne precautions are recommended for management of hospitalized patients with known or suspected MERS-CoV infection. The complete CDC guidance can be found on the CDC Web site (Interim Infection Prevention and Control Recommendations for Hospitalized Patients with Middle East Respiratory Syndrome Coronavirus (MERS-CoV), but a key recommendation includes placing the patient in an airborne infection isolation room as soon as possible. In addition, provide personal protective equipment for healthcare personnel, including gloves, gowns, eye protection (goggles or face shield), and respiratory protection that is at least as protective as a fit-tested NIOSH-certified disposable N95 filtering facepiece respirator.
Additional, detailed guidance is offered at the following 2 links:
Healthcare Provider Preparedness Checklist for MERS-CoV
Healthcare Facility Preparedness Checklist
Are antiviral drugs or other specific therapies recommended for the treatment of MERS-CoV?
At this time, all treatment is supportive, and antiviral drug therapy is not recommended. No vaccine is currently available.
What should I tell patients who ask whether they may safely travel to countries in the Arabian Peninsula?
At this time, the CDC does not recommend that anyone change their travel plans because of MERS-CoV. You can remind patients that most instances of person-to-person spread have occurred in healthcare workers and other close contacts (such as family members and caregivers) of people sick with MERS. Details on travel can be found here: Travelers Health: MERS in the Arabian Peninsula.
Related Information
Middle East Respiratory Syndrome (MERS): Information for Healthcare Providers
PLUS:
As MERS hits U.S., scientists search for causes, treatments
Camels in Saudi Arabia
A worker wears a protective mask as he feeds camels on a farm outside Riyadh, Saudi Arabia. Scientists believe camels are involved in the transmission of the deadly MERS virus. (Fayez Nureldine / AFP/Getty Images)
ERYN BROWN contact the reporter Diseases and IllnessesSaudi ArabiaArabian PeninsulaU.S. Centers for Disease Control and Prevention
Scientists studying MERS remain optimistic that the deadly disease will come under control
A majority of camels in Saudi Arabia either are or have been infected with MERS, researcher estimates
There's still no treatment for MERS, but that could change soon
As two cases of Middle East respiratory syndrome, or MERS, emerged in the United States, scientists said they remained concerned about the deadly virus — but that they were getting closer to understanding how it spreads, and how doctors might someday treat patients who are infected with it.
“I’m optimistic that we’ll get this under control,” said Columbia University epidemiologist W. Ian Lipkin. “I think we’ll be able to stop this outbreak.”
Related story: CDC confirms second case of MERS in United States
Related story: CDC confirms second case of MERS in United States
Monte Morin
Characterized by fever, respiratory problems and kidney disease, MERS was first detected in a Saudi patient in 2012. In the two years since, 145 people have died from the ailment — nearly 30% of 538 confirmed to have had it, according to the U.S. Centers for Disease Control and Prevention.
lRelated As MERS virus reaches U.S., public health system springs into action
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As MERS virus reaches U.S., public health system springs into action
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In early May, the CDC reported the first case of MERS in the U.S. On Monday, a second case emerged. But just as MERS is arriving in the West, said Lipkin and Johns Hopkins University epidemiologist Trish Perl, scientists are beginning to understand more about its origins.
Some of what they are studying:
I think we'll be able to stop this outbreak.
- W. Ian Lipkin, Columbia University epidemiologist
How MERS spreads. Scientists know that MERS can spread in respiratory secretions, said Perl, who was part of a team that defined the incubation period for the illness (around five days from the time a patient is exposed to when he or she develops symptoms). But now, she added, researchers are exploring what types of secretions spread MERS most readily.
Evidence is emerging that the virus can survive on surfaces, which means MERS might spread by touch. Researchers are also noticing that many people have been infected with the disease who haven’t fallen seriously ill.
“We’re recognizing there’s a wider spectrum of illness,” Perl said – though she added that once patients develop severe disease, mortality still remains “in the 60% range.”
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The camel connection. Lipkin, who has worked to understand what animals harbor MERS, said that many cases of the illness might be traced back to camels -- a “major reservoir” of infection on the Arabian Peninsula. He estimates that a majority of camels in Saudi Arabia either are, or have been, infected with MERS.
The upside: if people can be convinced to change the way they interact with camels, fewer will get sick. But the widespread prevalence of MERS in camels is also worrisome, Lipkin said, because it could give the virus more opportunity to mutate and become more contagious or more deadly.
Related story: Plans in place in Calif. as 1st MERS case emerges in U.S.
Related story: Plans in place in Calif. as 1st MERS case emerges in U.S.
Eryn Brown
“We don’t have evidence that the virus is evolving, but we know there’s a risk, and the more people and animals are infected, the greater the risk becomes,” he said.
Hope for a cure? Currently, physicians treat MERS by controlling its symptoms, but researchers are beginning to hit on ways to combat the virus directly, Perl said.
Doctors may soon be able to dose people with antibodies to help their own immune systems fight MERS, she said; researchers are also working on a vaccine for camels that might be able to prevent the spread of MERS in people.
"It's not a human treatment but it's a prevention strategy," she said. "It's kind of like rabies, where we vaccinate the animals and not the humans."
Scientists are also finding that common drugs already in use may have antiviral potential, Perl added.
For more information about MERS in the U.S., visit this CDC MERS website.