Information for clinical, laboratory and public health personnel on MERS coronavirus

Important information for clinical, laboratory and public health personnel.

Page last updated: 24 August 2017

What’s new in this advice?

  • There have been no cases outside the Middle East since 2015.
  • Cases and clusters continue to be reported from the Middle East, particularly Saudi Arabia

Key point

Clinicians should be alert to the possibility of MERS in unwell travellers returning from the Middle East, and obtain a full travel and exposure history. Contact public health urgently and Apply appropriate infection control measures as soon as MERS is suspected and contact public health immediately.

Summary

  • As of 24 July 2017, the World Health Organization (WHO) global case count for MERS was 2040 laboratory-confirmed cases since the first cases were reported in September 2012. There have been at least 710 deaths (case fatality rate 35%)
  • All cases have been linked with travel to or residence in the Middle Eastern countries of Saudi Arabia, the United Arab Emirates (UAE), Qatar, Oman, Jordan, Kuwait, Lebanon and Yemen, or with contact with travellers retuning from these areas. 82% of cases have been reported by Saudi Arabia.
  • MERS Coronavirus is a zoonotic virus that has repeatedly entered the human population via infected dromedary camels in the Arabian Peninsula. Person-to-person transmission is known to occur, particularly in healthcare settings, and particular attention to infection control is required.
  • Sporadic infections have typically presented with, or later developed, severe acute lower respiratory disease and this has predominantly occurred in adult males with certain underlying medical conditions.
  • Mild or asymptomatic secondary infections have occurred in people of all ages. These are usually people who have been tested because they were close contacts of a seriously ill case either in healthcare or household settings.
  • There is no evidence of ongoing community transmission in any country and only occasional instances of household transmission. Transmission in health care settings has been a feature of the outbreak.
  • People with underlying illnesses (such as diabetes, renal failure, chronic lung disease, and immunocompromise) are considered at high risk of severe disease from MERS and should consult their health care provider before travelling to discuss the risks. This group of people should avoid contact with dromedary camels.
  • All people travelling to the Middle East should take general precautions when visiting farms and markets where camels might be present. Travellers should wash their hands often, including before eating, and after touching animals and adhere to food safety and hygiene measures. Close contact with people or animals that are unwell should be avoided.
  • Anyone travelling to affected areas to work or volunteer in a healthcare setting should seek advice and ensure they are fully informed about infection control procedures and recommendations.
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What is MERS coronavirus and how does it spread?

MERS Coronavirus is a zoonotic virus that has repeatedly entered the human population via direct or indirect contact with infected dromedary camels in the Arabian Peninsula, although the mechanism of spread is unclear. MERS Coronavirus is genetically distinct from the SARS coronavirus, and appears to behave differently. Coronaviruses are a large and diverse family of viruses that include viruses that are known to cause illness in humans (including the common cold), and in animals.

Scientific evidence suggests that MERS Coronavirus is not present in Australian camels.

Many confirmed cases have occurred in healthcare-associated clusters, and there have been a large number of cases in healthcare workers, but mainly in hospital settings. Secondary infections have most frequently been associated with healthcare settings, but have also occurred amongst family and workplace contacts.

The virus appears to spread through close contact, but exactly how it spreads is not well understood. The virus does not seem to transmit easily, unless there is close contact, such as occurs when providing unprotected care to a patient. The particular conditions or procedures that lead to transmission in hospital are not well known. From observational studies, transmission in health-care settings is believed to have occurred before adequate infection prevention and control procedures were applied and cases were isolated. A joint mission to the Republic of Korea (where in 2015, the only large outbreak outside of the Middle East occurred) assessed that factors contributing to the outbreak in there were a lack of awareness about MERS, sub-optimal infection control, overcrowding in emergency departments, multi-bed rooms, the practice of doctor-shopping or seeking care at multiple hospitals and the practice of having many visitors including family members staying in the room as carers.

MERS has so far not been demonstrated to transmit from asymptomatic cases to their contacts.

Clinicians are encouraged to follow the recommended infection prevention measures as soon as MERS is suspected so as to minimise the risk of transmission.

Symptoms

Sporadic infections have typically presented with, or later developed, severe acute lower respiratory disease, with radiological, clinical or histopathological evidence of pneumonia and pneumonitis. Typical symptoms have included fever, cough, shortness of breath, and breathing difficulties. Sporadic cases have predominantly been adult males with underlying medical conditions that may have predisposed them to infection, or may have increased the severity of the disease, including diabetes, kidney disease, hypertension, asthma and lung diseases, cancer and cardiovascular disease. GPs should be aware of the possibility of atypical presentations including fever, diarrhoea, muscle pain, nausea and vomiting.

Secondary infections acquired through person-to-person spread have occurred in people of all ages, may frequently have mild influenza-like symptoms or be asymptomatic.

Who should be tested for MERS?

Testing and initial infection control and public health actions for MERS should be undertaken for persons with:

  1. Fever AND pneumonia or pneumonitis or acute respiratory distress syndrome (ARDS) AND
    • history of travel from or residence in affected countries in the Middle East1 within 14 days before symptom onset, OR
    • contact2 within the incubation period of 14 days) with a symptomatic traveller who developed fever and acute respiratory illness of unknown aetiology within 14 days after travelling from affected countries in the Middle East, OR
    • contact (within the incubation period of 14 days) with a symptomatic traveller who developed fever and acute respiratory illness of unknown aetiology within 14 days after travelling from a region with a known MERS outbreak at that time3

OR

  1. Fever AND symptoms of respiratory illness (e.g. cough, shortness of breath) AND
    • being in a healthcare facility (as a patient, worker, or visitor) in a country or territory in which recent healthcare-associated cases of MERS have been identified3 within 14 days before symptom onset, OR
    • being in contact with camels or raw camel products within affected countries in the Middle East within 14 days before symptom onset.

OR

  1. Fever OR acute symptoms compatible with MERS AND onset within 14 days after contact with a probable or confirmed MERS case while the case was ill.

OR

  1. Testing and initial infection control and public health actions for MERS should also be considered, in consultation with the public health unit, where there is a cluster of patients with severe acute respiratory illness of unknown aetiology following routine microbiological investigation, particularly where the cluster includes health care workers.
  1. Affected countries in the Middle East include Iran, Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia (KSA), United Arab Emirates (UAE) and Yemen
  2. A close contact is defined as requiring greater than 15 minutes face-to-face contact with a symptomatic probable or confirmed case in any setting, or the sharing of a closed space with a symptomatic probable or confirmed case for a prolonged period (e.g. more than 2 hours).
    A casual contact is defined as any person having less than 15 minutes face-to-face contact with a symptomatic probable or confirmed case in any setting, or sharing a closed space with a symptomatic probable or confirmed case for less than 2 hours. For more details, and for examples of people in these categories, see section 11 of the CDNA Series of national guidelines for MERS (http://www.health.gov.au/internet/main/publishing.nsf/Content/cdna-song-mers-cov.htm) Definition of contact
  3. See the Department of health website (http://www.health.gov.au/internet/main/publishing.nsf/Content/ohp-mers-cov-countries-lab-confirmed.htm) for list of countries currently experiencing a MERS outbreak.

    Note: Transiting through an international airport (<24 hours stay, remaining within the airport) in the Middle East is not considered to be risk factor for infection.
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Testing for MERS

Following isolation and reporting of a suspected MERS case, routine tests for acute pneumonia should be performed where indicated, including consideration of bacterial culture, serology, urinary antigen testing and tests for respiratory viruses.

Suitable respiratory samples for MERS coronavirus testing includes upper respiratory tract viral swabs, nasopharyngeal aspirates, sputum, bronchoalveolar lavage fluid, lung biopsies and post-mortem tissues. There is now increasing evidence that lower respiratory tract specimens such as bronchoalveolar lavage, sputum and tracheal aspirates contain the highest viral loads, therefore, lower respiratory tract specimens should be collected where possible.

The WHO emphasises repeat testing (especially of lower respiratory tract specimens) in compatible cases as initial results may be negative.

Transmission-based contact and airborne precautions must be used when taking respiratory specimens. These are described in NHMRC: Australian Guidelines for the Prevention and Control of Infection in Healthcare – 2010 (particularly section B2.4), and include:

  • Contact precautions, including close attention to hand hygiene
  • Airborne transmission precautions, including routine use of a P2 respirator, disposable gown, gloves, and eye protection when entering a patient care area
  • A requirement for negative pressure air-handling

Laboratory staff should handle specimens under PC2 conditions in accordance with AS/NZS 2243.3:2010 Safety in Laboratories Part 3: Microbiological Safety and Containment.

Specimens should be transported in accordance with current regulatory requirements.

Testing for suspected cases of MERS will be based on detection of target sequences of viral RNA by real-time reverse-transcriptase polymerase chain reaction (rRT-PCR). A confirmed case requires a positive rRT-PCR for two target viral sequences and sequencing where necessary, as per the WHO testing algorithm. Serological testing for MERS may be of use in certain circumstances, but it is not routinely available in Australia.

Infection prevention for a suspected MERS case in a hospital

Isolate

These recommendations on isolation and PPE for probable and confirmed cases take a deliberately cautious approach by recommending measures that aim to control the transmission of pathogens that can be spread by the airborne route.

If history and/or symptoms are consistent with MERS, the patient, whilst awaiting medical assessment and results of diagnostic tests, should be placed (in order of preference) either:

  1. in a negative pressure room, if available;
  2. in a single well ventilated room in an area away from other patients. The patient should be asked to wear a mask, if practicable, and observe cough etiquette and hand hygiene; or
  3. spatial separation from other patients, with respiratory precautions as above.

The room should have its own toilet and bathroom facilities (if en suite facilities are not available in a suitable location, a commode can be used for short term patient care).

An adjacent clean area for storage of, and putting on, clean PPE and a separate area of adequate size for the safe removal of PPE and the disposal of clinical waste are required.

Movement within a healthcare facility of a suspected/confirmed case of MERS should be kept to a minimum and aerosol generating procedures avoided where possible. The patient should wear a surgical mask during any movement from isolation to any other area of the facility.

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Infection prevention: standard, contact and airborne precautions

These include:

  • Hand hygiene according to “5 Moments of Hand Hygiene”.
  • Use of appropriate PPE to be put on when entering patient room:
    • Gloves (nonsterile, disposable)
    • Gown (fluid resistant, disposable)
    • Mucous membrane (respiratory/ eye) protection: fit-checked P2/N95 respirator/mask and goggles/face shield should be worn; staff performing aerosol-generating procedures, such as suctioning or endotracheal intubation, should wear a fit-tested P2/N95 respirator or equivalent protection, such as a powered air purifying respirator (PAPR).
  • PPE should be removed in the following order: gloves, gown (before leaving room); mask/goggles (after leaving room; avoid touching front surfaces); perform hand hygiene before and after mask removal.
  • Safe handling and disposal of waste (as infectious waste) and sharps
  • Environmental controls: routine care, cleaning, and disinfection of environmental surfaces, especially frequently touched surfaces in patient-care areas.

Where possible all equipment required for patient care should be dedicated for the use of an individual patient.

Further information is available in the Interim infection prevention and control advice for acute care hospitals relating to suspected Middle Eastern respiratory syndrome MERS coronavirus, available from the Department of Health website (http://www.health.gov.au/mers-coronavirus).

Inform

Please remember to inform your local public health unit/communicable disease control branch about the case urgently.

If transferring a patient to a different hospital, please ensure your phone call and letter of referral includes details of relevant travel history, or known exposure to confirmed or probable cases and include details of any relevant treatments or investigations undertaken for the patient. Ensure the ambulance personnel are informed so appropriate PPE can be used.

Figure 1:Epidemic curve of confirmed and probable MERS cases by confirmation status; as of 8 September 2015. An additional 132 confirmed cases in Saudi Arabia with onset dates between 1 May 2013 and 15 May 2014 are not The Department of Health issues regular situation updates, available from the Department of Health website (http://www.health.gov.au/mers-coronavirus).

Pre-travel advice, travel restrictions, periods of peak travel

The WHO does not currently recommend any restrictions to travel due to MERS.

Peak periods of travel - Umrah and Hajj

Clinicians, laboratories and public health practitioners should be aware that many Muslims from Australia will travelled to Saudi Arabia to undertake the Umrah, particularly during the period at the end of Ramadan in late June/July and for the Hajj in September.

Pre-travel advice

There is no vaccine available for MERS. Travellers should be aware of relevant immunisation requirements and the importance of personal hygiene including frequent hand washing, avoiding unprotected close contact with animals and with people who are suffering from acute respiratory infection, and should be advised to seek medical attention as soon as possible if they feel unwell. They should also follow usual food hygiene practices for travellers, including avoiding drinking raw milk or meat or eating food that may be contaminated with animal secretions or products unless they are properly washed, peeled or cooked.

All people travelling to the Middle East should take general precautions when visiting farms and markets where camels might be present. Travellers should wash their hands often, including before eating, and after touching animals and adhere to food safety and hygiene measures. Hand sanitiser may be used when soap and water is not available. Close contact with people or animals that are unwell should be avoided. Travellers should avoid consuming raw or unpasteurised camel products, including milk and meat.

People with underlying illnesses (such as diabetes, renal failure, chronic lung disease, and immunocompromise) are considered at high risk of severe disease from MERS and should consult their health care provider before travelling to discuss the risks. This group of people should avoid contact with dromedary camels.

Anyone travelling to affected areas to work or volunteer in a healthcare setting should seek advice and ensure they are fully informed about infection control procedures and recommendations.

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Further information

WHO situation updates and the latest advice is available from the WHO website (www.who.int/csr/disease/coronavirus_infections/en/)

For further information, refer to DFAT’s Smartraveller website information for travellers (www.smartraveller.gov.au/).

United States Centers for Disease Control and Prevention MERS-CoV pages (www.cdc.gov/CORONAVIRUS/MERS/INDEX.HTML).

European Centre for Disease Prevention and Control - MERS
(https://ecdc.europa.eu/en/middle-east-respiratory-syndrome-coronavirus).

Reporting

The relevant state/territory public health unit/communicable diseases branch must be notified urgently of any suspected (and probable or confirmed) cases in order to discuss patient testing and/or referral and coordinate management of contacts.

Confirmed and probable cases must be reported to state/territory public health authorities immediately on being classified as such. State and territory authorities should notify the Commonwealth Department of Health which is responsible for reporting to WHO (under IHR 2005).

Advice for contacts of cases

Contacts of cases should be directed to your state/territory communicable disease branch/centre for advice.

State and Territory Communicable disease branch/centres

ACT - 02 6205 2155

NSW - 1300 066 055 Contact details for the public health offices in the NSW Local Health Districts (http://www.health.nsw.gov.au/Infectious/Pages/phus.aspx)

NT - 08 8922 8044 Monday-to Friday daytime and 08 8922 8888 ask for CDC doctor on call – for after hours

Qld - 13 432 584 Contact details for the public health offices in the Qld Area (www.health.qld.gov.au/cdcg/contacts.asp)

SA - 1300 232 272

Tas. - 1800 671 738 (from within Tasmania), 03 6166 0712 (from mainland states) After hours, follow the prompt “to report an infectious disease”

Vic. - 1300 651160

WA - 08 9388 4801 After hours 08 9328 0553 Contact details for the public health offices in WA (www.public.health.wa.gov.au/3/280/2/contact_details_for_regional_population__public_he.pm)

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