- What's new in this advice
- Key point
- What is MERS coronavirus and how does it spread
- Who should be tested for MERS
- Testing for MERS
- Infection prevention for a suspected MERs case in General Practice
- Pre-travel advice, travel restriction, periods of peak travel
- Further information
- Advice for contacts of cases
- State and Territory Communicable disease branch/centres
Cases and clusters continue to be reported from the Middle East, particularly Saudi Arabia. Rare cases continue to be diagnosed outside of the Middle East in people who are exposed in the Middle East.
- As of the end of August 2018, the World Health Organization (WHO) global case count for MERS was over 2220 laboratory-confirmed cases since the first cases were reported in September 2012.There have been 798 deaths (case fatality rate 36%). The latest situation updates can be found on the World Health Organization website.
- 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 and over 80% 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 Middle East. 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. This has predominantly occurred in adult males with 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.
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, 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 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.
GPs are encouraged to follow the recommended infection prevention measures as soon as MERS is suspected so as to minimise the risk of transmission.
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.
Approximately 36% of patients with MERS have died, but this may be an overestimate of the true mortality rate, as mild cases of MERS may be missed by existing surveillance systems and until more is known about the disease, the case fatality rates are counted only amongst the laboratory-confirmed cases.
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.
Testing and initial infection control and public health actions for MERS 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
- Refer to 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.
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 laboratory facilities. Patients should be referred to a hospital for investigation and management. Routine 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) and serological testing is not routinely available.
For GPs who work in hospital settings and for further information on testing for MERS and infection control, please refer to the information for clinicians, laboratories and public health personnel (http://health.gov.au/MERS-coronavirus).
Infection control recommendations 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 and transmission based precautions (contact, droplet and airborne) for infection control, to minimise the risk of spread of MERS. 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/).
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. Ensure the ambulance personnel are informed so appropriate PPE can be used.
Please also remember to inform your local public health unit / communicable disease control branch about the case urgently.
In patients who meet the definition for a suspected case of MERS (refer to 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 PCR testing. Appropriate PPE must be used when collecting specimens.
The WHO does not currently recommend any restrictions to travel due to the MERS outbreak.
Umrah and Hajj
GPs should be aware that many Muslims from Australia travel to Saudi Arabia to undertake the Umrah throughout the year but particularly during the period at the end of Ramadan in late June/July and for the Hajj, currently around August.
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. Travellers should be advised to seek medical attention as soon as possible if they feel unwell. They should also follow usual food and water precautions, 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 the immunocompromised) 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.
Refer to separate information for clinicians, laboratories and public health personnel available from the Department of Health website (health.gov.au/MERS-coronavirus).
WHO situation updates and the latest advice is available from the WHO website (www.who.int/csr/disease/coronavirus_infections/en/)
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
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).
Contacts of cases should be directed to your state/territory communicable disease branch/centre for advice.
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
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)