Middle East Respiratory Syndrome (MERS-CoV)

Update: 18th June, 2015

This document outlines current facts and IAED recommendations regarding the recent MERS outbreak in Korea and China for AMPDS users

Background on the current MERS outbreak

Middle East Respiratory Syndrome  coronavirus (MERS-CoV) is an illness caused by a virus (more specifically, a coronavirus which are a large family of viruses that can cause diseases ranging from the common cold to Severe Acute Respiratory Syndrome). MERS-CoV predominantly affects the respiratory system (lungs and breathing tubes).

As of 3 June 2015, 1179 laboratory-confirmed cases of human infection with Middle East respiratory syndrome coronavirus (MERS-CoV) have been reported to WHO since 2012. On the 20th of May, one case of MERS-CoV was reported from Republic of Korea. The cluster of (MERS-CoV) continues to evolve in South Korea, where 153 confirmed (one of these is the case confirmed in China) cases and 11 deaths have been reported as of 16 June 2015. This case had recently travelled to KSA, Qatar, UAE, and Bahrain. The WHO is in close contact with Republic of Korea, which has been actively providing information on the situation to WHO. This is the largest outbreak of MERS-CoV outside the Middle East.

The following countries have reported cases of MERS, in the Middle East*: Iran, Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia (KSA), United Arab Emirates (UAE) and Yemen; in Africa: Egypt, Algeria, and Tunisia; in Europe: Austria, France, Germany, Greece, Italy, the Netherlands, Turkey and the United Kingdom; in Asia: China, the Republic of Korea, Malaysia and Philippines; and in North America: the United States of America (USA). The majority of cases (>85%) have been reported from KSA. Since May 2015 two new countries have been affected (China and Republic of Korea).

Most MERS patients developed severe acute respiratory illness with symptoms of fever, cough and shortness of breath. About 3-4 out of every 10 patients reported with MERS have died. MERS-CoV has spread from ill people to others through close contact, such as caring for or living with an infected person.

Symptoms

The incubation period for MERS-CoV (from exposure to when signs or symptoms appear), ranges from 2 to 14 days (most commonly less than a week, 5-6 days).

Most people confirmed to have MERS-CoV infection have had severe acute respiratory illness with symptoms of:

  • Fever
  • Cough
  • Shortness of breath

Other symptoms can include chills/rigors, headache, myalgia, sore throat, coryza, sputum production, dizziness, nausea and vomiting, diarrhea, and abdominal pain.

Atypical presentations including mild respiratory illness without fever and diarrheal illness preceding development of pneumonia have been reported.

For many people with MERS-CoV, more severe complications followed, such as pneumonia and kidney failure. Most of the people who died had an underlying medical condition. Some infected people had mild symptoms (such as cold-like symptoms) or no symptoms at all; they recovered.

Patients with the following known pre-existing medical conditions (also called comorbidities) may be more likely to become infected with MERS-CoV, or have a severe case. Pre-existing conditions include diabetes, cancer, and chronic lung, heart, and kidney disease. Individuals with weakened immune systems are also at higher risk for getting MERS or having a severe case.

Prevention

CDC routinely advises that people help protect themselves from respiratory illnesses by taking everyday preventive actions:

  • Wash your hands often with soap and water for 20 seconds, and help young children do the same. If soap and water are not available, use an alcohol-based hand sanitizer.
  • Cover your nose and mouth with a tissue when you cough or sneeze, then throw the tissue in the trash.
  • Avoid touching your eyes, nose, and mouth with unwashed hands.
  • Avoid personal contact, such as kissing, or sharing cups or eating utensils, with sick people.
  • Clean and disinfect frequently touched surfaces and objects, such as doorknobs.

IMPORTANT: Alert the crew of any vehicle dispatched to a patient who is symptomatic of MERS-CoV to ensure that necessary infection control precautions and policies are followed.

All receiving health care facilities should be notified, in advance, when a suspected case of MERS-CoV is to be transported to the facility.

Healthcare providers should be alert for and evaluate suspected patients for MERS who have both consistent symptoms and risk factors as follows:

If you develop a 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*, you should call ahead to a healthcare provider and mention your recent travel.

In addition,

Patients who present with severe acute respiratory disease and have recently been in contact with healthcare services in South Korea should be considered for MERS-CoV assessment, similar to patients who have been in contact with healthcare services in the Arabian Peninsula.

WHO recommends that probable and confirmed cases should be admitted to adequately ventilated single rooms or airborne precaution rooms. Healthcare workers caring for probable or confirmed cases of MERS-CoV infection should use contact and droplet precautions (medical mask, eye protection such as goggles or face shield, gown, and gloves) in addition to standard precautions. Airborne precautions should be applied when performing aerosol-generating procedures.

Close contact is defined as:

a) being within approximately 6 feet (2 meters) or within the room or care area for a prolonged period of time (e.g., healthcare personnel, household members) while not wearing recommended personal protective equipment (i.e., gowns, gloves, respirator, eye protection); or

b) having direct contact with infectious secretions (e.g., being coughed on) while not wearing recommended personal protective equipment (i.e., gowns, gloves, respirator, eye protection).

Data to inform the definition of close contact are limited. At this time, brief interactions, such as walking by a person, are considered low risk and do not constitute close contact.

The Emerging Infectious Disease Surveillance Tool (SRI/MERS/Ebola)

In October 2015, the latest update of the MPDS infectious diseases surveillance tool, previously known as the Severe Respiratory Infection (SRI) tool was released for use in the ProQA software.

All ProQA users have access to the Emerging Infectious Disease Surveillance Tool (EIDS Tool)—developed and approved by the International Academies of Emergency Dispatch (IAED) Chemical, Biological, Radiological, & Nuclear (CBRN) Committee—which has had an update applied to version 12.1 and 12.2 of the MPDS Protocol. The EIDS tool can be accessed at any time, in any active ProQA case.

As with our past position, the EIDS Tool can be utilized by any agency that has approval from their Medical Director. Typically, we recommend the call be processed through Case Entry and Key Questions and a Final Code be generated as per standard practice. At that point, if the patient has symptoms consistent with MERS (as approved by local medical control), and the caller has mentioned epidemiologic/travel risk factors (as approved by local medical control), the EMD should select the EIDS Tool to complete the interrogation. For MERS, the Chief Complaints we recommend for use of the EIDS tool are those that represent typical flu-like symptoms: Protocol 26:  Sick Person, Protocol 6:  Breathing Problems, Protocol 18:  Headache, Protocol 10:  Chest Pain, and Protocol 1:  Abdominal Pain. The EIDS tool is highly recommended for use on Protocol 26:  Sick Person, Protocol 6:  Breathing Problems, and Protocol 18:  Headache with the balance of the protocols selected left to medical directorate discretion.

The use of Protocol 36 is not yet recommended at this early stage of the disease.

This additional interrogation may extend the total calltaking time for those patients presenting initially with related symptoms and risk factors, but will not impact the time it takes to post a call for dispatch, or notify responders, as long as the EIDS Tool is launched after Final Coding is complete. This additional questioning may identify potential MERS patients and allow for appropriate notification to responders and receiving hospitals, etc., and for the modification of local response assignment and/or referral policies and procedures. The use of the EIDS Tool also enables the notification of governmental healthcare organizations on a local, national, and/or international level.

The IAED website link is: www.emergencydispatch.org 

References: 

  1. European Centre for Disease Prevention and Control. ECDC updates its rapid risk assessment as MERS-CoV cluster evolves in South Korea ” 2015; June, 11. http://ecdc.europa.eu/en/healthtopics/coronavirus-infections/Pages/index.aspx (accessed June 11, 2015).
  2. Center for Disease Control (CDC). “Middle East Respiratory Syndrome (MERS).” http://www.cdc.gov/coronavirus/mers/index.html (accessed June 11, 2015).
  3. European Centre for Disease Prevention and Control. Rapid risk assessment Middle East respiratory syndrome coronavirus (MERS-CoV) 17th update, 11 June 2015
  4. World Health Organization. Middle East respiratory syndrome coronavirus (MERS-CoV) – Republic of Korea [Internet]. 2015 [updated 24 May 2015]. Available from: http://www.who.int/csr/don/24-may-2015-merskorea/en/