What’s new in this advice?
- Previous outbreak in Republic of Korea (South Korea, RoK) under control
- Updated case definition
- 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.
- 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:
- 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).
- 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 GPs 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 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 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 and diarrhoea.< /p>
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 and workplace contacts.
If transferring a patient to the emergency department, 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. Please also remember to inform your local public health unit / communicable disease control branch about the case urgently.
Notes: 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. Affected countries in the Middle East include Iran, Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia (KSA), United Arab Emirates (UAE) and Yemen.
Who do I consider MERS-CoV infection in?
The possibility of MERS-CoV infection, and initial infection control and public health actions should be considered for:
Testing and initial infection control and public health actions for MERS-CoV should be undertaken for persons with:
- 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
- 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.
- 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.
- 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.
- Affected countries in the Middle East include Iran, Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia (KSA), United Arab Emirates (UAE) and Yemen
- 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
- 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.
Testing for MERS-CoV
It should not be necessary to collect diagnostic specimens in a general practice setting as this is best done as part of a comprehensive follow up plan and with ready access to appropriate PPE and reference lab facilities. Patients be referred to a hospital for investigation and management. 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) and serological testing is not routinely available.
For GPs who work in hospital settings and for further information on testing for MERS-CoV and infection control, please refer to the information for clinicians, laboratories and public health personnel (http://health.gov.au/MERS-coronavirus).
Are GPs at risk from MERS-CoV?
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.
The particular conditions or procedures that lead to transmission in hospital are not well known. However, 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.
What are the recommended isolation and personal protective equipment recommendations for patients in general practice?
Infection control recommendations in this document for suspected cases aim to provide the highest level of protection for health care workers, given the current state of knowledge. In patients with compatible symptoms and exposure history, GPs should follow standard precautions for infection control, and to minimise the risk of spread of MERS-CoV, contact, droplet and airborne precautions (transmission based precautions) are used in addition to standard precautions. The recommendations include:
- Keep patient in a single room with the door closed
- Contact precautions, including careful attention to hand hygiene
- Encourage patient to use respiratory etiquette
- Ask patient to wear a mask
- Use personal protective equipment, including a P2 mask/respirator, gloves and eye protection
- Single use equipment wherever possible
- Clean areas where the patient has been after they have left.
The Royal Australasian College of General practitioners (RACGP) provides infection control standards for office-based practice, available from the RACGP website (http://www.racgp.org.au/your-practice/standards/infectioncontrol/).
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.
Umrah and Hajj
GPs 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.
There is no immunisation for MERS-CoV. 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 avoid 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/)
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. MERS-CoV has never previously been detected in humans or animals but appears most closely related to coronaviruses previously found in bats. It is genetically distinct from the SARS coronavirus, and appears to behave differently.
Refer to separate information for clinicians, laboratories and public health personnel available from the Department of Health website (health.gov.au/MERS-coronavirus).
Refer to the WHO website for the latest information (www.who.int/csr/disease/coronavirus_infections/en/).
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)