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

Important information for clinical, laboratory and public health personnel.

Page last updated: 30 September 2015

PDF printable version of Information for clinical, laboratory and public health personnel on Middle East Respiratory Syndrome coronavirus (MERS-CoV) (PDF 257 KB)

What’s new in this advice?

  • Previous outbreak in Republic of Korea (South Korea, RoK) under control
  • Updated case definition

Summary

  • The WHO has reported that the outbreak of MERS in the Republic of Korea (South Korea, RoK) is under control. The most recent confirmed case was isolated on 3 July 2015. The RoK has put in place a range of measures to control the outbreak and to detect any further importations from the Middle East.
  • The WHO has reported 186 cases including 36 deaths (case-fatality rate 19%) in the outbreak in the Republic of Korea (RoK). The most recent confirmed case was isolated on 3 July 2015. The outbreak began with a case who travelled to multiple countries in the Middle East during the 14 days prior to onset. The remaining cases can be linked directly or indirectly to the index case through transmission in in healthcare settings.
  • As of 8 September 2015, the World Health Organization (WHO) global case count for MERS was 1,542 laboratory-confirmed cases, including at least 544 deaths (case fatality rate 35%) since the first cases were reported in September 2012. 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.
  • Dromedary camels are the suspected source of sporadic human infections, though the exact routes of direct or indirect exposure remain unknown. 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, and have most frequently been associated with healthcare settings.
  • People with underlying medical conditions are advised to take appropriate precautions when visiting farms or barns or market environments where camels may be present in affected countries, including avoiding contact with camels.

In patients who meet the definition for a suspected case of MERS (see section – Who should be tested for MERS?), the following is recommended in hospital settings:

  1. The patient should be placed in a single room with negative pressure air-handling, and implement transmission-based precautions (contact and airborne), including the use of personal protective equipment (PPE).
  2. Investigations and management should be performed as for community acquired pneumonia. Appropriate specimens should also be collected for MERS-CoV PCR testing.

What are the symptoms and how do I manage a suspected case?

The likelihood of a case of pneumonia or pneumonitis in Australia being due to MERS is very low, and clinicians should investigate as usual, but be aware of the possibility of MERS in patients with a compatible exposure history.

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

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. Secondary infections have most frequently been associated with healthcare settings, but have also occurred amongst family contacts.

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Who should be tested for MERS?

Testing and initial infection control and public health actions for MERS-CoV 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 or RoK  is not considered to be risk factor for infection.
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How is testing for MERS-CoV performed?

Routine tests for acute pneumonia should be performed where indicated, including consideration of bacterial culture, serology, urinary antigen testing and tests for respiratory viruses.

Respiratory samples including upper respiratory tract viral swabs, nasopharyngeal aspirates, sputum, bronchoalveolar lavage fluid, lung biopsies and post-mortem tissues are suitable for testing for MERS-CoV. 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.

Routine testing for suspected cases of MERS-CoV infection 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.

Are health workers at risk from the MERS-CoV?

Many confirmed cases have occurred in healthcare-associated clusters. A large number of these cases have been healthcare workers.

The particular conditions or procedures that lead to transmission in hospital are not well known. However, in the only published study, lapses in infection control were known to have occurred for seven healthcare workers who acquired the infection from cases in Saudi Arabia. A joint mission to the RoK 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, and 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.

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What are the recommended isolation and PPE recommendations for patients in hospital?

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.

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 coronavirus (MERS-CoV) infections, available from the Department of Health website (http://www.health.gov.au/mers-coronavirus).

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What is the MERS-CoV?

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. Dromedary camels are the suspected source of sporadic human infections, though the exact routes of direct or indirect exposure remain unknown. MERS-CoV is genetically distinct from the SARS coronavirus, and appears to behave differently.

What is the current situation?

  • As of 8 September 2015, the World Health Organization (WHO) global case count for MERS was 1,542 laboratory-confirmed cases, including at least 544 deaths (case fatality rate 35%) since the first cases were reported in September 2012. There has been an increase in reported incidence during the past two weeks, with 68 cases reported, most of them part of ongoing outbreaks in Saudi Arabia and Jordan.
  • While the current outbreaks in Saudi Arabia are concentrated in hospitals in Riyadh City, travellers to the annual Hajj Pilgrimage should follow the recommended precautions to prevent infection. Healthcare workers should remain vigilant, and be aware of the possibility of infection in returning Hajj Pilgrims.
  • A current hospital outbreak in Jordan began when a resident of Saudi Arabia travelled to Jordan and sought healthcare there after developing a fever.
  • The WHO has reported 186 cases including 36 deaths (case-fatality rate 19%) in the outbreak in the Republic of Korea (RoK). The most recent confirmed case was isolated on 3 July 2015.
  • The WHO has issued a new recommendation that asymptomatic contacts of a case should be screened for MERS Coronavirus in the context of a hospital outbreak.
  • All cases of MERS world-wide have had a history of residence in or travel to the Middle East (mainly Saudi Arabia), or contact with travellers returning from these areas, or can be linked to an initial imported case. There have been no cases in Australia.
  • Camels are suspected to be the primary source of infection for humans, but the exact routes of direct or indirect exposure are not fully understood, and further studies (particularly case control studies) are needed. 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.

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)



graph. text description follows.

Figure text description

The Department of Health issues regular situation updates, available from the Department of Health website (http://www.health.gov.au/mers-coronavirus).

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

The WHO does not currently recommend any restrictions to travel due to the MERS-CoV outbreak.

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

Travellers should be aware of relevant immunisation requirements and the importance of personal hygiene including frequent hand washing, avoiding 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 eating food that may be contaminated with animal secretions or products unless they are properly washed, peeled or cooked.

The WHO advises that people at potentially higher risk of severe disease due to MERS-CoV should in addition consider avoiding contact with camels. For further information, refer to: DFAT’s Smartraveller website information for travellers (www.smartraveller.gov.au/).

The latest WHO updates, available from the WHO website (www.who.int/csr/disease/coronavirus_infections/en/).

Further advice

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

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

European Centre for Disease Prevention and Control - risk assessments (www.ecdc.europa.eu/en/healthtopics/coronavirus-infections/Pages/publications.aspx).

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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.

Who do I contact if I have a suspected case?

Contact your state/territory communicable disease branch/centre.

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)