BACKGROUND

SITUATION

26 APRIL 2014

RISK ASSESSMENTS

INFECTION CONTROL

MIDDLE EASTSAUDI ARABIA MINISTRY OF HEALTH FACEBOOK | TWITTER NOVEL CORONAVIRUS

JORDAN MINISTRY OF HEALTHQATAR SUPREME COUNCIL OF HEALT

HUAE MINISTRY OF HEALTHEGYPT MINSTRY OF HEALTH

EUROPEFRANCE MINISTRY OF HEALTHGREECE HELLENIC CENTRE FOR DISEA

SE CONTROL AND PREVENTION

GERMANY MINISTRY OF HEALTHENGLAND MINISTRY OF HEALTHITALY MINISTRY OF HEALTH

NORTH AFRICATUNISIA MINISTRY OF HEALTH

ASIAMALAYSIA MINISTRY OF HEALTHPHILIPIINES DEPARTMENT OF HEALTH

YALE- TULANE ESF-8 SPECIAL REPORT

MIDDLE EAST RESPIRATORY SYNDROME (MERS-CoV)

DEAD

345 107

LABORATORYCONFIRMED CASES*

WHAT MERS-CoV?

INTERNATIONAL ORGANIZATIONS WHO

WORLD HEALTH ORGANIZATION – EASTERN MEDITERRANEAN DISEASE OUTBREAK NEWSGLOBAL ALERT RESPONSE – CORONAVIRUS INFECTIONSWHO – MERS-COV

US GOVERNMENT CDC – MERSUS EMBASSY SAUDI ARABIA

EUROPEAN UNION ECDC _MERS

CANADA PUBLIC HEALTH AGENCY OF CANADA The World Health Organization (WHO) is

concerned about the rising number of cases of Middle East respiratory syndrome coronavirus (MERS-CoV) in recent weeks, especially in the Kingdom of Saudi Arabia and the United Arab Emirates (UAE) and in particular that two significant outbreaks occurred in health facilities.

HEALTHCARE WORKER INFECTED

72*Numbers reported by the European Centre for Disease Prevention and Control (ECDC) as of 23 APR 14

Graphic: Mallory Brangan

NEW SOURCES ALERTNET CNN Washington Post Wall Street Journal ARAB NEWS

PORTALS, BLOGS, AND RESOURCES CIDRAP HEALTH MAP PROMED MAIL VIROLOGY DOWN UNDER BLOG FLUTRACKERS

BACKGROUNDMiddle East Respiratory Syndrome (MERS) is viral respiratory illness first reported in Saudi Arabia in 2012. It is caused by a coronavirus called MERS-CoV. Most people who have been confirmed to have MERS-CoV infection developed severe acute respiratory illness. They had fever, cough, and shortness of breath.

Since MERS was discovered in 2012, there has been a steady stream of cases with the majority coming out of Saudi Arabia. In March 2014 the World Health Organization (WHO) had reported that there had been 199 cases worldwide, including 84 deaths and all of the cases had been linked to the Middle East.

In April 2014 the numbers out of Saudi Arabia (KSA) and the United Arab Emirates (UAE) had soared (47% in past month). Most of the new cases coming from two healthcare associated outbreaks, one in a hospital in Jeddah, KSA and ‐the second among paramedics in UAE.

The European Centre for Disease Prevention and Control now says the total is 345 cases, including 107 deaths. (AS OF 23 APR 14)

The cause of the rapid increase in cases is unknown. Possible scenarios that might explain this are • More sensitive case detection through more active case finding and contact

tracing or changes in testing algorithms, • Increased zoonotic transmission with subsequent transmission in healthcare

settings• Breakdown in infection control measures or otherwise increased transmission

in the local healthcare setting,• Change in the virus resulting in more effective human-to-human transmission,

resulting in both nosocomial clusters, and increased numbers of asymptomatic community acquired cases, or False positive lab results.

On Monday, 21 April 2014, the Saudi Arabia's Minister of Health was replaced. His replacement, the Acting Minister of Health Adel bin Mohammed Fakeih, promised ”transparency and to promptly provide the media and society with the information needed. “He has appointed Dr. Tarek Madani as a medical advisor for the Ministry of Health (MOH).

Stars highlight difference in scale at left-hand side, (x-axis) numbers. Seasons based on info. Source: Ian Mackay, an epidemiologist at the Australian Infectious Diseases Research Centre at the University of Queensland

On 24 April 2014, WHO encourages all Member States to continue their surveillance for severe acute respiratory infections (SARI) and to carefully review any unusual patterns

BACKGROUND

Geographic distribution of confirmed MERS-CoV cases, worldwide, as of 23 April 2014 (n=345) SOURCE: ECDC RISK ASSESSMENT

• Common symptoms are acute, serious respiratory illness with fever, cough, shortness of breath and breathing difficulties.

• Most patients have had pneumonia. Many have also had gastrointestinal symptoms, including diarrhoea.

• Some patients have had kidney failure.

• About half of people infected with MERS-CoV have died.

• In people with immune deficiencies, the disease may have an atypical presentation.

WHAT IS MERS CoV?

HOW IS IT TRANSMITTED

SIGNS AND SYMPTOMS

WHAT IS MERS-CoV?

• According to the limited available information it is likely to be transmitted in a similar way to the other viruses from the corona virus family. There are several theories including:

Possible transmission through animal sources Direct spread through droplets from patients during cough or

sneezing. Indirect spread through contaminated surfaces and

instruments and then touching the mouth, nose or eyes. Direct close contact with affected individuals.

• MERS-CoV is a beta coronavirus. • It was first reported in 2012 in Saudi Arabia. MERS-CoV used to be

called “novel coronavirus,” or “nCoV”. • It is different from other coronaviruses that have been found in

people before.

WHERE ARE MERS-CoV INFECTIONS OCCURRING?

• Twelve countries have now reported cases of human infection with MERS-CoV.

• Cases have been reported in France, Germany, Greece, Italy Jordan, Malaysia , the Philippines, Qatar, Saudi Arabia, Tunisia, the United Arab Emirates, and the United Kingdom.

• All cases have had some connection (whether direct or indirect) with the Middle East.

• In France, Italy, Tunisia and the United Kingdom, limited local transmission has occurred in people who had not been to the Middle East but who had been in close contact with laboratory-confirmed or probable cases.

SOURCE: CDC WHO

Distribution of confirmed cases of MERS-CoV by gender and age group, March 2012–23 April 2014 ECDC

DIAGNOSIS

TREATMENT

WHAT IS MERS-CoV?

Laboratory tests can be done to confirm whether the illness may be caused by human coronaviruses. However, these tests are not used very often because people usually have mild illness. Also, testing may be limited to a few specialized laboratories.

Specific laboratory tests may include:• Virus isolation in cell culture,• Polymerase chain reaction (PCR) assays that are more practical

and available commercially, and • Serological testing for antibodies to human coronaviruses.

Nose and throat swabs are the best specimens for detecting common human coronaviruses. Serological testing requires collection of blood specimens.

• No vaccine is currently available. • Treatment is largely supportive and should be based on the patient’s clinical

condition.

SOURCE: CDC WHO ECDC

INDIVIDUAL PROTECTION• 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 close contact, such as kissing, sharing cups, or sharing eating utensils, with sick people.

• Clean and disinfect frequently touched surfaces, such as toys and doorknobs.

VISITORS TO THE ARABIAN PENINSULA Follow general travel health precautions that lower the risk of infection in general, including illnesses such as influenza and traveller’s diarrhoea. This includes:

• Wash hands often with soap and water. When hands are not visibly dirty, a hand rub can be used.

• Adhere to good food-safety practices, such as avoiding undercooked meat and unpasteurized milk (especially from camels) or food prepared under unsanitary conditions, and properly washing fruits and vegetables before eating them.

• Maintain good personal hygiene. • Avoid unnecessary contact with farm, domestic, and wild animals,

especially camels. • Use appropriate precautions when in close contact with case-persons

presenting with acute respiratory illness, diarrhoea or other potentially infectious diseases.

• Consult their physician if suffering major medical conditions (e.g. chronic diseases such as diabetes, chronic lung or renal disease, immunodeficiency) that can increase the likelihood of illness including MERS-CoV infection, or contact with healthcare facilities during travel.

CURRENT SITUATIONDuring April 2014 there has been an unprecedented increase in cases and community transmission as well as transmission in hospital settings.

SAUDI ARABIA• On 26 April the new action Health Minister, Adel Fakeih, announced the

country was reserving three medical centers to treat MERS. The main referral center will be King Abdullah Medical Center In Jeddah. Prince Mohammed bin Abdul Aziz in Riyadh, and Dammam Medical Center in the eastern region. The plan is to equip these facilities with 146 ICU beds, and the latest medical and laboratory equipment necessary.

• On Friday, 25 April 2014, Saudi Arabia discovered 14 more cases of the potentially deadly Middle East Respiratory Syndrome (MERS) in the kingdom. According to the Ministry of Health 94 people have died and 323 have contracted the virus in Saudi since September 2012.

• Approximately 75% of the recently reported cases are secondary cases, meaning that they are considered to have acquired the infection from another case through human-to-human transmission. There have not been any tertiary cases.

• To date, more than half of all laboratory-confirmed secondary cases have been associated with health care settings. These include health care workers treating MERS-CoV patients, other patients receiving treatment for conditions unrelated to MERS-CoV, and people visiting MERS-CoV patients.

• The specific types of exposure resulting in transmission in the health care setting are currently unknown. (For additional information on infection prevention and control measures, please refer to the infection control page of this brief)

• Contact investigations in the Middle East around confirmed cases have identified a number of asymptomatic and mild cases, younger cases, and an increasing proportion of female cases.

DISTRIBUTION OF CONFIRMED CASES OF MERS-CoV REPORTED BETWEEN 1 - 23 APRIL 2014 BY DAY AND PLACE OF REPORTING (N=151)

SOURC: ECDC

SOURCE: CDC WHO ECDC PHAC

• The mild and asymptomatic cases indicate a broader spectrum of disease and raise concerns about the possibility of large numbers of milder cases going undetected.

• Public concern over the spread of MERS mounted last week after the resignation of at least four doctors at Jeddah’s King Fahd Hospital who refused to treat patients for fear of infection.

• Several recent cases of people becoming infected in either Saudi Arabia or United Arab Emirates and travelling to a third country have also been reported. Greece, Jordan, Malaysia, and Philippines each reported one such case. So far no further spread of the virus in those countries has been detected. Imported cases already occurred in the past that resulted in limited further human-to-human transmission in France and United Kingdom.

CURRENT SITUATION

VIROLOGY DOWN UNDER BLOG

UNITED ARAB EMIRATES On 11 APRIL the United Arab Emirates (UAE) announced a cluster of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) cases in six Filipino paramedics, killing one of them (16 APR).

The paramedics worked for the same ambulance section in the city of Al Ain, according to UAE’s interior ministry. It said the infections were detected during periodic medical exams.

Subsequently there has been a total of 23 patients associated with this cluster (17 APR)(23 APR)(APR 26) .

JORDANJordan's health ministry notified the WHO of its latest case on 9 APR which involves a 52-year-old man with underlying medical conditions who visited Saudi Arabia between Mar 20 and Mar 29. He got sick on Mar 25 and visited a hospital in Jeddah, then returned to Jordan on Mar 29, where he visited a hospital in Amman the same day and returned on Apr 2. He is listed in stable condition. The patient is Jordan's fifth MERS case-patient (11 APR).

GREECEOn 18 April 2014, the Hellenic Centre for Disease Control and Prevention (KEELPNO)announced a laboratory confirmed case of MERS-CoV infection in a 69 year old male patient. The individual is a Greek citizen, permanently residing in Jeddah, Saudi Arabia, who arrived in Athens on 17 April on a flight via Amman, Jordan. Close contact tracing is ongoing; there are no suspected or confirmed cases of MERS-CoV infection associated with this individual to date.

REPORTING COUNTRY CASES DEATHS

Saudi Arabia 272 81

United Arab Emirates 42 9

Qatar 7 4

Jordan 4 3

Oman 2 2

Kuwait 3 1

United Kingdom 4 3

Germany 2 1

France 2 1

Italy 1 0

Tunisia 3 1

Malaysia 1 1

Philippines 1 0

Greece 1 0

TOTALS 335 107

CURRENT SITUATIONMALAYSIAThe patient is a 54 year-old man with underlying health conditions. He travelled to Jeddah, Saudi Arabia with a pilgrimage group of 18 people from 15 to 28 March 2014 and became ill on 4 April. He sought treatment in a private clinic in Johor, Malaysia on 7 April and went to a hospital on 9 April. The patient died on 13 April. The patient visited a camel farm on 26 March, during which he consumed camel milk.

PHILIPINESA male nurse was tested MERS, by authorities in the United Arab Emirates after he came into close contact with a Filipino paramedic who died of the virus. The results of his test were only released after he had departed for Manila on an aircraft. Philippine health officials immediately quarantined the nurse as well as several family members who came into close contact with him following his arrival. A second test on the nurse came back negative.

EGYPTA 27-year-old civil engineer was diagnosed Saturday, 26 April 14 after returning from Saudi Arabia, where the Middle East respiratory syndrome, or MERS, has been centered. The man was quarantined upon his arrival at Cairo airport Friday and transported to a nearby hospital. This would be Egypt first case.

SOUCE : ECDC AS OF 23 APRIL 2014Eng. Faqih during his visit to King Fahad Hospital in Jeddah SOURCE: MOH

RISK OF INTERNATIONAL SPREAD• Countries should be on the lookout for cases of MERS in

people returning from Middle Eastern countries affected by the virus.

• It is very likely that cases will continue to be exported to other countries, through tourists, travelers, guest workers or pilgrims, who might have acquired the infection following an exposure to the animal or environmental source, or to other cases, in a hospital for instance.

RISK ASSESSMENT

ECDC RISK ASSESSMENT

GENERAL INFORMATIONA marked and sudden increase in the number of Middle East respiratory syndrome coronavirus (MERS-CoV) cases have been reported in April 2014. The majority of cases continue to be in Saudi Arabia and the Arabian Peninsula but earlier this month a confirmed case in Greece brought the total number of EU affected countries to five (France, Germany, Italy and the UK the other four). Given the current epidemiology, it is likely that more cases will be imported to the EU.

RISK OF FURTHER CASES

• It is very likely that more primary cases will occur, and consequently further transmission will occur.

• Diagnosing cases rapidly may be a challenge because some have mild or atypical symptoms.

• Given the potential to initially miss MERS cases, health-care workers should apply infection control precautions consistently with all patients, all the time, regardless of their diagnosis.

Distribution of confirmed cases of MERS-CoV by month of onset and symptom status, March 2012–23 April 2014 (n=345*) ECDC

WHO RISK ASSESSMENT

INFECTION CONTROL• Enhancing infection prevention and control awareness and measures is

critical to prevent the possible spread of MERS CoV in health care facilities.

• Health care facilities that provide care for patients suspected or confirmed to be infected with MERS CoV infection should take appropriate measures to decrease the risk of transmission of the virus from an infected patient to other patients, health care workers and visitors.

• It is not always possible to identify patients with MERS CoV early because some have mild or unusual symptoms.

• For this reason, it is important that health care workers apply standard precautions consistently with all patients – regardless of their diagnosis – in all work practices all the time.

• Droplet precautions should be added to the standard precautions when providing care to all patients with symptoms of acute respiratory infection.

• Contact precautions and eye protection should be added when caring for probable or confirmed cases of MERS-CoV infection. Airborne precautions should be applied when performing aerosol generating procedures.

SOURCE: OUTFOX PREVENTION

FOR DETAILED INFORMATION VISIT THE FOLLOWING SITES:• Interim Infection Prevention and Control Recommendations for Hospita

lized Patients with Middle East Respiratory Syndrome Coronavirus (MERS-CoV) (CDC)

• 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (CDC)

• 2013 Infection prevention and control during health care for probable or confirmed cases of novel coronavirus (nCoV) infection (WHO)