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Prepared by: I man Nahle Raad

Head, I nfection Control Department


Infection Control Measures
to Prevent Hospital
Transmission MERS CoV
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ICD-RCMC
April 17, 2014
Coronaviridae
Epidemiology & Clinical
Management

Background
Chronology
Epidemiology
Case Definitions
Clinical Picture
Clinical Management
Case study (Al Hasa-KSA ) published by
Dr Memish & Dr.Asiri
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Background
In September 2012, the World Health
Organization announced the discovery of a
novel coronavirus.


This virus has been named the Middle East
Respiratory Syndrome Coronavirus (MERS-
CoV)


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Chronology
MERS-CoV, an atypical pneumonia of
unknown etiology
Causes severe acute respiratory
illness, was recognized Novel
coronavirus that emerged in
2012
First cluster of 2 cases occurred near
Amman, Jordan April 2012


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The first indication that MERS-CoV could be
transmitted in health care setting was observed
in J ordan in April 2012.

On 15 May 2013,the Ministry of Health in Saudi
Arabia announced that 2 patients are health care
workers who were exposed to patients with
confirmed MERS-CoV.
Approximately 132 laboratory Confirmed
cases including 58 deaths. Until September
2013. A significant number of cases have
been in health care workers
As of March 2014, MERS-CoV has been
identified in several countries in the Middle
East (Saudi Arabia, Qatar, the United Arab
Emirates, Jordan, Oman, and Kuwait),
Europe (the United Kingdom, France, and
Italy), and Tunisia.


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14 April 2014 -WHO has been informed of an
additional 16 laboratory-confirmed cases of
infection with Middle East respiratory syndrome
coronavirus (MERS-CoV) from Saudi Arabia and
the United Arab Emirates (UAE).

15 laboratory-confirmed cases, including two
deaths announced on the Ministry of Health of
Saudi Arabia website and provided to WHO
between 6 and 11 April

The World Health Organization (WHO) is
coordinating the international responses
to provide epidemiological, clinical and
logistical support as required

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Epidemiology
Cause : New Corona Virus
Recent evidence of new corona virus identified
with etiological co-factors ? involved
Highly infectious
Means of transmission
Evidence of person to person transmission
Close contact with body fluids (especially
respiratory droplets )
Contaminated hands, clothes, equipment; the
environment may also be important

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Incubation period
2 10 days and up to 13 days in exceptional
cases
Onset and duration of infectivity unknown

Organism survival in environment
Duration unknown
Other corona virus are known to survive for up
to 4 hours
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KSA and the WHO announced that, there are 3
main epidemiological patterns.
The first pattern is the occurrence of sporadic
cases in communities. The source or how these
people became infected is not known at the present
time.
The second pattern is intra-familial infection. This
is likely related to person to-person transmission
limited to close contacts with a sick family
member.
The third pattern contains clusters of healthcare
transmission.
A person presenting after 1 February 2003 with a history
of:
High fever >38
0
C
AND
One or more respiratory symptoms including
cough, shortness of breath or breathing difficulty
AND one or more of the following:
Close contact, within 10 days prior to onset of
symptoms with a person diagnosed with MERS
COV;
History of travel, within 10 days prior to onset of
symptoms to an affected area (see archive of
Affected Areas at
http//www.who.int./csr/mers/en/).
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Suspect Case
Case Definitions


Close contact : having cared for, lived with, or
had direct contact with the respiratory
secretions or body fluids of a suspect or
probable case of MERS CoV.

Affected area : an area in which local chain(s) of
transmission of MERS CoV is/are occurring as
reported by the national public health
authorities.

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Explanations:
Probable Case

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A suspect case with chest X-Ray findings
consistent with pneumonia or respiratory
distress syndrome (RDS)

OR

A suspect case with an unexplained illness
resulting in death, with autopsy
examination demonstrating the
pathology of RDS without an identifiable
cause.


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Sudden onset of high fever with
myalgia, chills, rigors and a non-
productive cough

Most cases have bilateral pneumonia

~ 90% begin to recover from day 6 or 7
Clinical Picture Onset / Presentation



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Rapid deterioration in 10% (+/-) of cases

Acute RDS

Require ICU admission & mechanical
ventilation

Case fatality rate: ~ 4%

No specific treatment available

Patients Who Should be Evaluated for MERS-
CoV Infection

A person with fever ( 38C , 100.4F)
and pneumonia or acute respiratory
distress syndrome (based on clinical or
radiological evidence);
AND
History of travel from countries in or near
the Arabian Peninsula within 14 days before
symptom onset;
OR



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Close contact with a symptomatic
traveler who developed fever and acute
respiratory illness (not necessarily
pneumonia) within 14 days after traveling
from countries in or near the Arabian
Peninsula;
OR
Is a member of a cluster of patients with
severe acute respiratory illness (e.g.,
fever and pneumonia requiring
hospitalization) of unknown etiology in
which MERS-CoV is being valuated.
Collection of Laboratory
Specimens
Determine if patient meets PUI criteria
Collect:
An upper respiratory specimen:
Nasopharyngeal AND oropharyngeal swab
A lower respiratory specimen:
Broncheoalveolar lavage, OR
Tracheal aspirate, OR
Pleural fluid, OR
Sputum
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The best specimen for testing is a lower
respiratory tract specimen as nasopharyngeal
swabs.
It is strongly advised that lower respiratory
specimens such as sputum, endotracheal aspirate, or
bronchoalveolar lavage should be used when
possible
Serum for eventual antibody testing (tiger
top tube)
Should be collected during acute phase
during first week after onset, and again
during convalescence 3 weeks later
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If patients do not have signs or symptoms of
lower respiratory tract infection and lower
tract specimens are not possible
or clinically indicated, both nasopharyngeal
and oropharyngeal specimens should be
collected
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The 2 can be combined in a single collection
container and tested together.

If initial testing of a nasopharyngeal swab is
negative in a patient who is strongly suspected
to have MERS-CoV infection, patients should be
retested using a lower respiratory specimen or
a repeat nasopharyngeal specimen with
additional oropharyngeal specimen if lower
respiratory specimens are not possible


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SUPPORTIVE TREATMENT

Antibiotic Therapy : to cover causative
organisms

Prophylactic Antibiotic Therapy : to
prevent secondary bacterial infection

Maintain oxygenation :

intubate and ventilate as necessary
Clinical Picture Management



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SUPPORTIVE TREATMENT

Avoid interventions which may cause
aerosolisation of
respiratory secretions:
Bronchoscopy
Nebulised bronchodilators
Chest physiotherapy
Gastroscopy
Any procedure / intervention that may
release respiratory secretions



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SUPPORTIVE TREATMENT


In severe cases corticosteriods and ribavirin
have been used, however there is no
evidence to support their general or
routine use at this stage.


MERS CoV Therapy
CDC suggestion
The suggested Ribavirin oral
dosage is 2000 mg loading dose then
1200mg q8h for 4 days, then 600mg po
q8h for 4-6 days with pegelated
interferon 1.5mcg/kg once per week.

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So far there is no treatment &
no Vaccine
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TO PREVENT
TRANSMISSION TO
HCWs AND OTHERS
Infection Control
Precautions MUST BE
PRACTICED AT ALL
TIMES
MERS CoV : Infection Control Goals
In addition to providing the best possible
clinical care:

Detect early any suspect cases
Implement appropriate isolation measures
Protect healthcare personnel
Protect other patients
Protect family and community members

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Triage for MERS CoV Admissions
Where possible have a specific area for triaging
patients who may have MERS CoV :
Establish separate reception area for patient
triage.
Staff must wear full personal protective
equipment (PPE).
Patients must be given a surgical mask
Screen patients by closely questioning them
about symptoms, close contacts and travel.
Admit if they meet the case definition.




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If possible, there should be separate
wards/areas for each of the following
categories :
Patients with colds, sniffles and runny noses
should be isolated in a single room / area
Suspect cases
Place in a single room
Probable cases
If cohort nursing : keep probable and suspect cases
apart
May share room with other probable cases : where
possible use a single room for all patients
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Components of MERS CoV Isolation
Facility
Administrative Controls
Clinical Surveillance of Staff
Organization of Isolation Area
Protective Equipment
Standard Precautions

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Administrative Controls
Limit, and control points, of entry to MERS
CoV ward(s)
One entrance
Guard to control entrance
Log of permitted visitors (staff & visitors)
Visitors must be restricted or preferably forbidden
with NO EXCEPTIONS
Limit patient travel/transport outside unit
Minimize the number of staff exposure to cases
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Clinical Surveillance of Staff
Maintain list of all staff who worked with MERS CoV
patients or on the MERS CoV ward
Systematically monitor for fever
Twice daily temperature for staff working in the
area (baseline Chest X-Ray may be needed )
Screen for symptoms of MERS CoV -like illness
among staff reporting for duty
List contact information for:
Persons visiting or caring for MERS-CoV patients
Contacts of HCWs in close contact with MERS CoV
patients
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Organization of Isolation Area
Signs: MERS CoV Isolation Area
Designated area for clean protective
equipment
Instructions for using protective equipment
Accessible to personnel
Sufficient inventory to meet daily needs
Separation of clean and dirty supplies
including an area for containment of waste
and soiled linen
Color-coded bags and containers for
contaminated waste and laundry
Containers for laundry and all waste should have
foot-operated lids
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Personal Protective Equipment
(PPE)
N-95 Respirator Mask must be worn

Goggles (protective glasses)

Disposable Gowns

Disposable Gloves

Cap
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Infection Control Practices

Standard Precautions
(Respiratory
Precautions)
Exposure Risks

Hand Washing

PPE

Patient transport
Patient and family
education

Laboratories /
Specimens
Mortuary Care

Waste and Linen
Handling
Cleaning &
Disinfection
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Infection Control Practice
You can minimize YOUR risk of
catching

MERS CoV

by following

infection control procedures.
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A,C Precautions


Designed to reduce the risk for
occupational exposure to
MERS CoV infection from both
recognized and
unrecognized sources of
infection
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Exposure Risks
Patient:
Respiratory
secretions
Blood
Body fluids
including excreta
Skin lesions
Staff
Visitors
Health Care Staff:
Respiratory
secretions
Blood
Body fluids
including excreta
Mucous membranes
Skin lesions
Sharps
Visitors
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Principles of Hand Washing
Hand Washing :
Is the single most important and effective
component for preventing the transmission of
infection.
Is designed to remove transient
microorganisms that may have been picked up
from the environment.
Prevents the transfer of these microorganisms
to other patients, staff and equipment.
Is best performed using soap (preferably
liquid) and warm running water
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After removing gloves
Before and after patient
contact
After contact with blood
or body fluids from any
patient
After taking blood
pressure or vital signs
from any patient
Other times:
After using bathroom
After blowing or wiping
nose
Before eating
Before preparing food
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Handwashing When?

Drying Your Hands
It is important to dry your hands thoroughly after
washing them because :

Damp hands collect microorganisms
Damp hands spread potentially infectious
microorganisms
Damp hands may become colonised with
potentially infectious microorganisms

Therefore it is important to pat dry your hands
thoroughly.

Pat drying also helps to prevent damage to skin.

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Handwashing Tips
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Remember:

Wash hands for a minimum of 15 to 20
seconds.

Ensure you have washed all areas
properly.

Dry hands thoroughly.
Personal Protective Equipment for
MERS CoV

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Personal Protective Equipment (PPE)
Cap
Gown

N-95 Respirator
Mask
Gloves

Goggles
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Principles for Using PPE
PPE reduces but does not completely
eliminate the possibility of infection

PPE is only effective if used correctly

The use of PPE does not replace basic
hygiene measures such as hand washing
hand washing is still essential to prevent
transmission of infection.
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N-95 Respirator Masks


N-95
Respirator
Mask

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Principles for Using the
N-95 Respirator Mask

The N-95 respirator mask is used to protect
health care workers, other patients, staff
or visitors by preventing potentially
infectious microorganisms such as
respiratory secretions from :
Contaminating their face including the
nose and mouth.
Being inhaled or ingested.
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N-95 Respirator Mask
For respiratory
protection wear
an N-95
respirator mask
during all
patient contact
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Proper use of N-95 Respirator Mask
DO NOT touch the front of the mask

Wear only one N-95 mask no need for
additional respiratory protection

REMOVE the N-95 respirator mask before
leaving the isolation unit / area
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WHY an N-95 Respirator Mask?
N-95 respirator masks offer
a higher level of filtration
for respiratory secretions
than a surgical mask

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HOW to use an N-95
Respirator Mask
Use for single shift unless excess moisture
necessitates replacement during each shift
Label with the wearers name

Dispose of with medical waste

NB: You must fit the mask securely
over both your nose and mouth
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HOW to use an N-95 Respirator
Mask

Always use the correct sized mask.

The incorrect size will not fit properly and
will fail the fit test.

NB: You must fit the mask securely over both
your nose and mouth so size is important.
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N-95 Respirator Masks
- Fitting Instructions
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N-95 Respirator Masks
- Fitting Instructions
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Inhale deeply. If there is
no leakage, the negative
pressure will make the
mask cling to your face.
A poor seal will result in
prompt loss of negative
pressure in the mask due to
air entering through gaps in
the seal.
Negative Fit Test
Principles for Using Goggles,
Gowns, Gloves and Caps

Goggles, gowns, gloves, caps and
overshoes are used to protect health care
workers, by preventing potentially
infectious microorganisms from :
Contaminating their eyes, clothing, hands
and hair
Being transmitted to other patients and
staff.
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Goggles
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Assign one pair to each worker at the beginning of
a shift


Wear goggles in room with MERS CoV patients


Leave in the container in the anteroom at the end
of the shift to be cleaned and disinfected


Gowns
Long sleeved gowns must be
worn when in direct contact
with the patient
Wear gown at all times in the
patients room
Gowns must be removed
before leaving the patients
room or dedicated anteroom
Remove used gowns as soon
as possible particularly when
grossly contaminated

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Gloves
Before all patient
contact

Before all
cleaning

Before handling
soiled linen &
waste

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Gloves
Remove after contact
with patients or lab
specimens

Do not wear gloves
outside of the
patients room /
anteroom

Do not re-use gloves

Wash hands after
removing your gloves
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Caps
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Caps are worn to protect
the hair from aerosols
that may otherwise lodge
on the hair and be
transferred to other
parts of the health care
worker such as the face
or clothing by the hands
or onto inanimate
objects.
Key Points
Wear N-95 respirator mask, goggles,
disposable gowns, hats and gloves for all
patient contact & aprons when necessary

Wash hands using soap (preferably liquid)
and water when leaving the anteroom

Use an 70% alcohol-based hand rub solution
after hand washing

Wash hands when leaving the unit
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Patient Transport
It is essential to avoid all unnecessary
transport of isolated patients to control
and prevent the potential spread of
infection.
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Patient Transport
If the patient needs to be out of their room for an
essential procedure, e.g. X-Ray

Transport route must avoid populated areas.

Patient must and an isolation gown.

Accompanying staff must wear :
N-95 respirator mask
Gloves
Gown
Goggles
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Patient Transport
Transport Ambulance
No dedicated ambulance needed
Mask patient (N-95 respirator mask)
Transporters wear personal protective equipment
N-95 respirator mask, disposable gown, goggles, gloves
Disinfect ambulance after transport
Standard cleaning and disinfecting or
1:100 dilution of bleach; after 10 minute contact time,
clean and disinfect using standard procedures.
DO NOT use spray cleaners
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Patient, Family & Community
Education
Education for the patient, their family and
the community is essential in the control
and prevention of the MERS Cov.

It is particularly essential for those
persons requiring hospital or home
isolation to understand the necessary
restrictions.
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Patient, Family & Community
Education
Explain:
What MERS Cov. is (to date)

Why isolation is required.

Precautions required including PPE

Hand washing procedures
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Patient and Family Education
Teach the patient and family members :
about the MERS Cov. illness and
the reason for the precautions being used

Teach the patient and visiting family members :
how to perform hand hygiene
how to wear an N-95 respirator mask, gown,
gloves and goggles (if available)
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Patient and Family Education
Explain to the patient and family why
disposable equipment is being used such as
:

Eating utensils
Medical equipment
Patient gowns

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Laboratories
Laboratory staff must ensure that their
practices are meticulous.

Advance planning in each designated
laboratory is essential to ensure that
specimen handling, transportation and
storage is managed according to the
guidelines.
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Specimen Collection
Wear full PPE

Write clinical details on the request form

Samples should be collected by clinical staff

Label the clinical samples clearly

Change PPE between patients

Discard all disposable materials in a biohazard bag
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Storage of Specimens
Respiratory samples and frozen tissues :
store at 70
o
C

Serum :
store at 4 - 8
o
C for 24-48 hours or
at -20
o
C for longer periods
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Patient Specimens
Treat all
patient
specimens
as highly
infectious

Use leak
proof
containers
for collection
Do not
contaminate
outside of
container

Transport
specimens in
leak-proof
outer
containers
e.g. a sealed
plastic bag
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Linen Management
All contaminated or
soiled linen is potentially
highly infectious therefore:

Wear full PPE when handling
linen.

Separate grossly contaminated
linen from non- contaminated
linen in the patients room for
ease of handling in the laundry
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Waste
Wear full PPE when handling waste.
Clinical waste: all items from treatment
areas
Soiled surgical dressings
Swabs
Masks
Gowns
Other contaminated waste
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Cleaning & Disinfecting the Hospital
Environment and Equipment
Cleaning is usually sufficient for prevention
and control of infection, but for MERS Cov
infection the use of a disinfectant following
cleaning is essential.
It is essential to clean thoroughly before
disinfecting the environment or equipment.
Cleaning and disinfection must be carried out
at least daily and particularly when gross
contamination occurs.
In some instances it may be necessary to
disinfect to render the item safe to handle.
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Cleaning and disinfecting patient
rooms and equipment is the best way
to reduce transmission of infection


Wear full PPE when cleaning and
disinfecting
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Cleaning & Disinfecting the
Hospital Environment and
Equipment
To communicate infection
risk, use signs.
MERS CoV I solation

Protect patients & staff by:

- Cleaning and disinfecting
equipment.

- Cleaning and disinfecting
the room and
anteroom.

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Cleaning & Disinfecting the Hospital
Environment and Equipment
The immediate area around patients
must be considered heavily
contaminated.

Bedside table, bed stand, and accessible
areas of bed and floors must be cleaned
with detergent and twice a day.

In addition, disinfect all surfaces after
cleaning.

Use disinfectant first if surfaces are
grossly contaminated before cleaning to
reduce the viral load.
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Cleaning & Disinfecting the Hospital
Environment and Equipment
Contain and dispose of infectious materials
in waste containers :
Put waste containers near entrance / exit to
patient room.

Provide dedicated patient equipment when
possible.

Clean and disinfect patient care equipment
immediately after use depending on the
type of equipment.
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When areas and inanimate objects are grossly
contaminated use :
1:100 sodium hypochlorite (bleach) solution
to disinfect (before cleaning)
it will reduce the viral load and the potential
for infection to spread.

Then use the standard cleaning and
disinfecting procedures mentioned previously.
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Cleaning & Disinfecting the Hospital
Environment and Equipment
All reusable patient items should be:

Cleaned and disinfected before being used
on another patient
Taken to the dirty utility room for cleaning
Send to CSSD for sterilization



Staff should wear full PPE when handling
contaminated equipment.
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Cleaning & Disinfecting the
Hospital Environment and
Equipment
DO NOT spray clean the room / area.

Why?

Because it :
Spreads droplets

Spreads aerosols

Is not effective as a surface disinfectant
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Case SUDTY
MERS-CoV
EPIDEMIOLOGY & OUTCOME UPDATE
www.smj.org.sa
Saudi Med J 2013: vol.34
Case Study
In April to May 2013, there were 27 cases
and the majority of those cases were
linked to different healthcare facilities in
Al-Hasa, the eastern province of the
Kingdom of Saudi Arabia (KSA).The
majority of these cases occurred in
patients with underlying comorbidities
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Clinical presentation and
laboratory data.
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The majority of patients presented
with fever (98%),
fever with chills/rigors (87%),
Cough (83%),
shortness of breath (72%),
and dry cough (56%).
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Note that 21% of patients had diarrhea
and 21% had vomiting.
Radiographic manifestations range from
unilateral infiltrate (43%), to increased
bronchovascular markings (17%),
bilateral infiltrate (22%),
and diffuse reticulonodular pattern(4%)
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Symptoms n (%)
Fever 46 (98.0)
Fever with chills/rigors 41 (87.0)
Respiratory symptoms
Cough 39 (83.0)
Dry 22 (56.0)
Productive (sputum) 17 (44.0)
Hemoptysis 8 (17.0)
Shortness of breath 34 (72.0)
Chest pain 7 (15.0)
Sore throat 10 (21.0)
Runny nose 2 (4.0)
Gastro-intestinal symptoms
Abdominal pain 8 (17.0)
Nausea 10 (21.0)
Vomiting 10 (21.0)
Diarrhea 12 (26.0)
Other symptoms
Myalgia 15 (32.0)
Headache 6 (13.0)
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Middle East Respiratory Syndrome
coronavirus infection is associated with a high
case fatality rate with more than 50% death
among diagnosed patients.
Case-fatality rates seem to be higher with
increasing age, 39% in patients <50 years, to
75% in cases >60 years
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The current case-fatality rate is 58%.
The median age of affected individuals is 56
years (range:2-94 years),
with a male-to-female ratio of 2.6-1
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Dr. Al-Assiri: Coronavirus Does
not Spread Easily among
Humans, and Needs Direct
Contact
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MERS Resources
MERS overview:
http://www.cdc.gov/coronavirus/mers/ind
ex.html
Case definitions and guidance:
http://www.cdc.gov/coronavirus/mers/cas
e-def.html
Additional MERS resources:
http://www.cdc.gov/coronavirus/mers/rel
ated-materials.html
Infection Control Measures to
Prevent Hospital Transmission
We hope YOU have learnt
something about MERS CoV
and YOUR role in :

preventing transmission
and
infection control

Thank you for listening.
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