MERS-COV

Merry Joy Casuncad/Cherry Lou Serafino

-- A Case Study--
Introduction
Middle East respiratory syndrome (MERS) is an
acute viral respiratory tract infection caused by
the novel beta coronavirus Middle East
respiratory syndrome coronavirus (MERS-CoV).
It was first identified in Saudi Arabia in 2012.
Cases have been limited to the Arabian
Peninsula and its surrounding countries, and to
travelers from the Middle East or their contacts.
Introduction
Introduction
Introduction
Introduction
Introduction

The virus is a positive-sense, ssRNA of genus

betacoronavirus. It was also termed as novel
coronavirus 2012 or simply novel coronavirus,
first reported 2012 after genome sequencing of
virus isolated from sputum samples from
patients who fell ill during flu outbreak in 2012
Epidemiology
Epidemiology
Epidemiology
 Prevalence
The global prevalence of MERS-CoV infection from June 2012 to
April 2018 is 2206 people. The number of cases reported from
Saudi Arabia is 1831 (83%) with mortality rate of 787 (35.67%).
The main clinical manifestations are fever, chills, generalized
myalgia, cough, shortness of breath, nausea, vomiting and
diarrhea. The age-allied prevalence of MERS-CoV was highest
amongst elderly people with chronic debilitating diseases such as
pulmonary diseases, end-stage renal illness, diabetes mellitus and
malignancy.
AGENT

Found in
bats in Saudi
Arabia
is a zoonotic
virus infected
dromedary
camels.
PORTAL OF ENTRY

Droplet and Human to human

Direct Contact transmission has
probably Large been occurred in
droplet health care
transmission is settings, among
suspected as the family contacts
most likely route and in the work
place.
Critical features: Risk of Infection- dromedary to human
Ample evidence that dromedary camels play an
important role in transmission in the region
Virus has been detected in dromedary camels in:
Qatar, Saudi Arabia, UAE, Oman and Egypt
Antibodies have been found in Human and camel viruses closely related camels
in:
Jordan, Tunisia, Ethiopia, Nigeria, Egypt, Oman, Kenya, Saudi Arabia,
Canary Islands, UAE…

Occupationally exposed = higher risk of infection

Risk factors for infection are unclear

Several studies are being planned/ are ongoing
INCUBATION PERIOD

 The median incubation period for secondary cases

associated with limited human-to-human
transmission is approximately 5 days (range 2-14
days).

CONTAGIOUS PERIOD
 The contagious period (the time that a sick animal or
human is infectious) for MERS-CoV is not known but
may last as long as virus is being shed.
https://www.cdc.gov/coronavirus/mers/clinical-
features.html
Case Scenario
A 50 year old diabetic female OFW who
worked in Saudi Arabia as a caregiver
came home to the Philippines for a
vacation.
1
5 days after arrival
She developed flulike symptoms, associated with
low – moderate grade fever & chills &
accompanied by rhinorrhea, fatigue, and
myalgias.
Anorexia, nausea, diarrhea, and abdominal pain
were also noted.
She subsequently developed shortness of breath
and dyspnea which increased in severity, thus she
was immediately rushed to the emergency room.
Approach To Diagnosis
Patient under investigation (PUI)
 Specimen
The following specimens should be collected in all patients
for diagnostic testing:

• Blood cultures: for potential bacterial pathogens that can

also cause pneumonia or sepsis
Lower respiratory tract specimens (e.g., sputum, tracheal
aspirates, bronchoalveolar lavage): for bacterial and viral
testing
• Upper respiratory tract specimens (e.g., nasopharyngeal
and throat swabs): for molecular viral testing • Serum: for
molecular and serological testing.
Serology
 DIFFERENTIAL Rule in Rule out Differentiating Signs/Symptoms Differentiating
DIAGNOSIS Tests

Influenza-like illness Frontal or Lack of travel history to or from

Influenza the Middle East (or country where
RT-PCR:
infection retro-orbital there is an ongoing outbreak) in positive
 low mod grade
headache the preceding 14 days.
fever for
IP. 2 days or 1-4days length  Chills Sore throat No close contact with a
Aerosol transmission may
 Cough Tachycardia symptomatic traveler from the influenza
occur 1 day before the onset of Middle East or a suspected or
symptoms  Fatigue Red, watery confirmed case of MERS in the
A or B
 myalgia eyes preceding 14 days. viral RNA.
 Nausea
 abdominal pain
sore throat Seasonal outbreak during winter.

 Diarrhea vomiting Differentiating MERS from

community-acquired respiratory
 Severe respiratory
tract infections is not possible
illness (e.g., from signs and symptoms.
shortness of
breath, difficulty
breathing)
 DIFFERENTIAL Rule in Rule out Differentiating Signs/Symptoms Differentiating
DIAGNOSIS Tests

Community- Dyspnea Productive cough, Lack of travel history to Blood or sputum

culture, or multiplex
often with pleuritic
acquired Fatigue chest pain.
or from the Middle East RT-PCR testing:
positive for
pneumonia Fever, sweating (or country where there causative organism
and shaking Confusion or is an ongoing outbreak) (e.g., Streptoco
chills
changes in mental in the preceding 14 days. ccus
awareness (in pneumoniae,
Nausea adults age 65 and No close contact with a Haemophilus
diarrhea older) symptomatic traveler influenzae, My
Shortness of from the Middle East or a coplasma
vomitting
breath suspected or confirmed pneumoniae, C
case of MERS in the hlamydophila
preceding 14 days. pneumoniae,
Moraxella
Differentiating MERS catarrhalis).
from community-
acquired respiratory tract
infections is not possible
 DIFFERENTIAL Rule in Rule out Differentiating Signs/Symptoms Differentiating
DIAGNOSIS Tests

Fever (typically low- Tachypnea Lack of travel history to or RT-PCR:

Respiratory
grade) Cyanosis from the Middle East (or positive for RSV
syncytial virus Cough Retractions RNA.
country where there is an
(RSV) infection Fever Wheezing
ongoing outbreak) in the
Difficulty breathing Rales
Sepsis like
preceding 14 days.
presentation or No close contact with a
apneic episodes (in symptomatic traveler from the
very young infants) Middle East or a suspected or
cyanosis confirmed case of MERS in
the preceding 14 days.
Common cause of lower
respiratory tract infection in
children <1 year of age.
Seasonal outbreak during
winter.
Differentiating MERS from
community-acquired
respiratory tract infections is
 DIFFERENTIAL Rule in Rule out Differentiating Signs/Symptoms Differentiating
DIAGNOSIS Tests

Avian influenza A Influenza-like illness Barking cough Lack of travel history to or from
Coryza the Middle East (or country where
RT-PCR:
(H5N1) virus there is an ongoing outbreak) in positive
 low mod grade Stridor
infection the preceding 14 days.
fever Retractions
No close contact with a
for H5N1
 Chills Tachypnea
 Cough Irritability symptomatic traveler from the viral RNA
Middle East or a suspected or
 Fatigue Wheezing
confirmed case of MERS in the
 myalgia altered mental preceding 14 days.
 Nausea status, seizures),
Close contact with infected birds
 abdominal pain and the
(e.g., farmer or visitor to a live
 Diarrhea involvement of market in endemic areas) or
 Severe respiratory other organ living in an area where avian
illness (e.g., systems. influenza is endemic.
shortness of Differentiating MERS from
breath, difficulty community-acquired respiratory
breathing) tract infections is not possible
from signs and symptoms.
 DIFFERENTIAL Rule in Rule out Differentiating Signs/Symptoms Differentiating
DIAGNOSIS Tests

Severe acute 100.4°F [>38.0°C]). Pneumonia. Lack of travel history to or from the Real-time
Chills Middle East (or country where there is reverse
respiratory an ongoing outbreak) in the preceding transcription
syndrome SARS headache 14 days. polymerase
Fatigue No close contact with a symptomatic chain reaction
traveler from the Middle East or a (RT-PCR):
Myalgias suspected or confirmed case of positive for
MERS in the preceding 14 days.
After 2 to 7 days, SARS
coronavirus
SARS patients may Patients have lower incidence of
(SARS-CoV)
comorbidities compared with MERS.
develop a dry, RNA.
Clinical features are similar; however,
nonproductive patients are less likely to present with
cough or feel short hemoptysis (1% of patients with
of breath. SARS) or dyspnea (42% of patients
with SARS).
hypoxia Usually less aggressive than MERS
as reflected by the lower mortality
rate.
 DIFFERENTIAL Rule in Rule out Differentiating Signs/Symptoms Differentiating
DIAGNOSIS Tests

MERS COV fever Travel history to or from the Middle Real-time

cough East (or country where there is an reverse
shortness of breath ongoing outbreak) in the preceding 14 transcription
IP: 5 days (range 2-14
days. polymerase
days) dyspnea
gastrointestinal Close contact with a symptomatic chain reaction
symptoms including traveler from the Middle East or a (RT-PCR):
suspected or confirmed case of positive for
diarrhea and
MERS in the preceding 14 days. MERS COV
nausea/vomiting.
Working Diagnosis

“Acute Respiratory Distress syndrome probably due to Mers-Cov

infection”
PATHOPHYSIOLOGY
 The pathogenesis is not completely understood.

 The virus is transmitted primarily via respiratory droplets from an infected

person which enter the human body via the respiratory tract mucosa.

 The virus binds to the functional receptor dipeptidyl peptidase-4 (DPP4;

also called CD26) on the surface of host cells (e.g., type I and II alveolar
cells, ciliated and non-ciliated bronchial epithelium, endothelium, alveolar
macrophages, leukocytes).

 Binding is mediated by a receptor binding domain on the S1 subunit of the

virus’ surface spike (S) proteins.
https://www.ncbi.nlm.nih.gov/pubmed/26597880
PATHOPHYSIOLOGY
 Membrane fusion and cell entry is facilitated by the S2 unit through the
actions of 2 heptad repeat domains (HR1 and HR2) and a fusion protein.

 The virus can also bind to DPP4 receptors in several species (e.g., camels,
rabbits, sheep, goats, non-human primates).

 DPP4 is expressed on the epithelial and endothelial cells of most human

organs (e.g., kidney, liver, intestines). T

 This may explain the multisystem clinical spectrum of the infection which
includes severe (and sometimes fatal) pneumonia, acute respiratory
distress syndrome, and multi-organ failure.
https://www.ncbi.nlm.nih.gov/pubmed/26597880
COMPLICATIONS
Acute Respiratory Failure
Reported 25-95% of confirmed cases
Median time to invasive mechanical ventilation was 7 days in a
cohort of 47 patients
Risk factors include age ≥50 years, diabetes mellitus, end-stage renal
disease, and obesity.
Acute respiratory distress syndrome
New or worsening respiratory symptoms within one week of
presentation. Chest x-ray shows bilateral opacities.
High-flow oxygen (up to 50 mL/minute) is recommended in some
patients, although mechanical ventilation and intubation is usually
required.
COMPLICATIONS
Acute renal failure
Initially reported in a few case reports. Has since been reported in
58% of critically ill patients.
Possibly due to the presence of dipeptidyl peptidase-4 (DPP4)
receptors in renal epithelial cells.
Detection of the virus in urine samples has been previously
documented.
Multi-organ failure
Occurs in a minority of patients late in the course of illness.
Underlying mechanism of action is unknown.
Usually presents with thrombocytopenia, prolonged coagulation
profile, and circulatory collapse
Patients may require vasopressor and inotrope support.
PHARMACOLOGIC TREATMENT
• There is no vaccine available to prevent MERS-CoV infection as of the
moment however there are many researches being conducted such as The U.S.
National Institutes of Health being one of these organisations trying to develop
one.

• Antimicrobials: empirical antimicrobial therapy (including antibiotics and

antivirals) should be started in inpatients with suspected MERS pneumonia
(within one hour if sepsis is suspected) to cover all likely community-acquired
or hospital-acquired (if patient has been admitted for >48 hours) pathogens.
Antimicrobial selection should be based on local epidemiology, susceptibility
data, and guidelines until diagnosis is confirmed, and empirical therapy
adjusted based on results

• Antipyretics/analgesics: recommended for the control of fever and pain.

PHARMACOLOGIC
TREATMENT
Non-PHARMACOLOGIC TREATMENT

• Oxygen: patients with signs of severe respiratory distress,

shock, or hypoxemia should be started on oxygen therapy
immediately

• Fluids: cautious fluid management is recommended in patients

if necessary, provided that there is no evidence of shock (more
aggressive resuscitation may be required in patients with shock)

https://www.who.int/emergenc
ies/what-we-do/prevention-
readiness/disease-commodity-
packages/dcp-mers.pdf?ua=1
 Good Hygiene practices

Avoidance of travel to high risk areas

Control and
Prevention In case of contact with camel, wash hands
and avoid touching eyes, nose and mouth.

Avoid consumption of meat and unpasteurized milk

Proper cooking and pasteurization prevents

infection
Persons who are immunocompromised or with DM or chronic
lung dse are at high risk and must avoid contact with sick
animals
 Cover your nose and mouth with a tissue when you
cough or sneeze, then throw the tissue in the trash.
Control and
Prevention 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.
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.
 SLIDE TITLE
Control and
Prevention
One must remember that
infected animals with
MERS-COV may shed the
virus from nasal, eye
discharge, feces, urine
and milk

It may also be found in

organs and meat of
infected animal.
 SLIDE TITLE
Contact Tracing :
Why is it
important?

 Contact identification
 Contact listing
 Contact follow-up
 SUMMARY OF CARE
• History and PE • Diagnostic evaluation, screening
• Triage and confirmatory diff dx
• Mode of acquisition and transmission • Voluntary Home isolation
monitoring • Telephone contact if:
• Travel history • Confirmed + for PCR for SARS in
• Identify case definition category whether atleast 2 clinical specimens
suspected or probable • Nasopharyngeal or stool on
• SARS contact exposure 2 or more days during the
Patient-Centered
• Plan of management course of illness
• Education • Serconversion on ELISA or IFA
• Biomedical: RITM/ • Neg AB test on acute serum
San Lazaro (DOH) then + AB test on
hospital admission convalescent serum
foe medical mngt • Virus isolation
• Psychosocial: medical • Isolation of virus plus PCR
counseling confirmation
 SUMMARY OF CARE
• History and PE
• Diagnostic evaluation, screening
• Family history and determinants
and confirmatory diff dx
• Confidentiality and disclosure • Tools for family assessment
issues • Impact of illness
• Financial issues • Isolation issues
• Family financial stability

Family - Focused
• Plan of management
• Medical conseling
• Proper Hygiene among family members
• Family education (hand-washing, regular bathing, waste
• Reassurance management)
• Undergo initial screening for • Healthy family lifestyle, eating the right
MERS-CoV if exposed to a patient food and exercise to avoid
with the illness immunosuppression
 SUMMARY OF CARE
• Diagnostic evaluation, screening
• History and PE
and confirmatory diff dx
• Place of Origin and work
• Availability f testing for
(abroad)
suspects
• Possible mode of acquisition
• Identification of SARS referral
(foreign place/person)
hospital
Community-oriented
• Plan of management to community based
• Contact tracing Plan of management
• Support group
• Preventive isolation • Availability of treatment hub
• Medical gear for • In the nearest area
protection from • Community and national
exposure impact