Overview on Middle East Respiratory Syndrome - Coronavirus - Comment
Information covered in this presentation slides:
1. OVERVIEW ON MIDDLE EAST RESPIRATORY SYNDROME- CORONAVIRUS (MERS-COV) Abdullatif Sami Al Rashed Medical Intern (King Faisal University) Microbiology Rotation King Fahd Hospital of The University Al-Khobar, Saudi Arabia
2. LEARNING OBJECTIVES Definition. Epidemiology. Clinical Manifestations. Investigations. Case Definition (MOH & WHO Guidelines). Management. Infection Control and Prevention Precaution. References.
3. WHAT IS MERS-COV? - Middle East Respiratory Syndrome-Coronavirus (MERS-CoV) is a novel coronavirus discovered in 2012 and is responsible for acute respiratory syndrome in humans. - This novel coronavirus has been identified in several countries across the Middle East and Europe and Asia, with primary infections found in Saudi Arabia, Qatar, Jordan, and The United Arab Emirates (UAE).
4. WHAT IS MERS-COV? -The members of Coronaviridae are large, enveloped, positive- sense, single-stranded RNA viruses with distinctive arrangement of spikes (Peplomers) projecting from their surface. -These projections have the appearance of a solar corona, which gives the virus its name. -CoVs cause a variety of diseases in mammals, including respiratory, hepatic, enteric, and neurologic pathologies of differing severity in species ranging from humans to domesticated and companion animals.
5. MERS-CoV particles as seen by negative stain electron microscopy. Virions contain characteristic club-like projections emanating from the viral membrane. Image source: Cynthia Goldsmith/Maureen Metcalfe/Azaibi Tamin https://www.cdc.gov/coronavirus/mers/photos.html
6. WHAT IS MERS-COV? - MERS-CoV is a member of the family Coronaviridae, which is divided into four genera based on phylogenetic clustering: •HCoV-229E •HCoV- NL63Alphacoronavirus genus •lineages A, B, C, and D Betacoronavirus genus •predominantly comprise avian CoV species, with some CoVs found in mammalian species, but none thus far in humanGammacoronavirus genus •Pedominantly comprise avian CoV species, with some CoVs found in mammalian species, but none thus far in humanDeltacoronavirus genus
7. WHAT IS MERS-COV? -Both MERS and SARS are caused by β-CoVs, -But MERS-CoV belongs to lineage C whereas SARS-CoV belongs to lineage B. -The origin of MERS-CoV is still obscure but is likely to be zoonotic. It is believed that camels and bats are the probable zoonotic origin of the virus.
8. Main differences between SARS-CoV and MERS-CoV 2014
9. EPIDEMIOLOGY -The First case discovered was In June of 2012 in a man at the Dr. Soliman Fakeeh Hospital in Jeddah, Saudi Arabia. He was admitted to the hospital with severe pneumonia and acute kidney injury and he was getting worse and no one knew why. The sample showed no positive results of any of the virus assays routinely used. - The hospital contacted Dr. Ron Fouchier, at Erasmus Medical College in Rotterdam, Netherlands. At his lab, A novel coronavirus (CoV) related to the severe acute respiratory syndrome (SARS) CoV was isolated from this patient and shown to be the etiological agent. Dr.Soliman Fakeeh Hospital (DSFH), Jeddah
10. EPIDEMIOLOGY - Shortly thereafter, a report appeared of an almost identical virus detected in a patient in Qatar with acute respiratory syndrome and acute kidney injury; the patient had traveled recently to Saudi Arabia. - After that, subsequent cases and clusters of infections have been reported. - Since April 2012, more than 2060 cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection have been reported.
11. Confirmed cases of Middle East respiratory syndrome coronavirus 2012 to 2017, as of 10 February 2017
12. KSA (2017 GIDEON INFORMATICS, INC.) 1,537 cases (640 fatal) of infection by Middle East Respiratory Syndrome Coronavirus (MERS-CoV) were reported by Saudi Arabia during 2012 to January 14, 2017. The male/female ratio among cases was 1.6/1, and both incidence and case-fatality rates are highest in patients above age 44 years (2014).
13. KSA (2017 GIDEON INFORMATICS, INC.) Year Number of Cases Reported (# Fatal) 2012 Five cases (2 fatal). 2013 139 cases (58 fatal) were reported, including foreign travelers who were infected while in Saudi Arabia 2014 683 cases (296 fatal) were reported during January to December 30. 2015 461 cases (195 fatal) were reported to December 31. 2016 141 cases (83 fatal) were reported during January to December 31. 2017 15 cases (8 fatal) were reported during January 1 to 10.
14. CLINICAL MANIFESTATIONS
15. INCUBATION PERIOD -Studies of human-to-human MERS-CoV transmission from clusters of MERS patients revealed a median incubation period of 5–7 days, with a range of 2–14 days.
16. SIGNS AND SYMPTOMS -The clinical presentation of the disease is wide: 1. Most reported cases with MERS-CoV infection have been adults with severe pneumonia and acute respiratory distress syndrome, and some have had acute kidney injury. 2. Many patients have required mechanical ventilation, and some have required extracorporeal membrane oxygenation. Other clinical manifestations that have been reported are gastrointestinal symptoms (anorexia, nausea, vomiting, abdominal pain, diarrhea), pericarditis, and disseminated intravascular coagulation.
17. SIGNS AND SYMPTOMS 3. Among 12 critically ill patients, 11 had extrapulmonary manifestations including shock (in 11) and acute kidney injury (in 7). 4. One immunocompromised patient presented with fever, diarrhea, and abdominal pain but without early respiratory symptoms; pneumonia was identified incidentally on a chest radiograph. 5. Three adults with pneumonia and MERS-CoV infection also developed neurologic symptoms and showed widespread intracranial white matter lesions by magnetic resonance imaging.
18. SIGNS AND SYMPTOMS The following clinical findings were observed among 47 patients with MERS-CoV infection in Saudi Arabia: Fever (>38°C) (98 % of patients) Fever with chills or rigors (87% of patients) Cough (83% of patients) Shortness of breath (72% of patients) Myalgias (32% of patients) Hemoptysis (17% of patients) Assiri A, Al-Tawfiq JA, Al-Rabeeah AA, et al. 2013. Epidemiological, demographic, and clinical characteristics of 47 cases of Middle East respiratory syndrome coronavirus disease from Saudi Arabia: a descriptive study. Lancet Infect. Dis. 13:752–61
19. SIGNS AND SYMPTOMS The following clinical findings were observed among 47 patients with MERS-CoV infection in Saudi Arabia: Assiri A, Al-Tawfiq JA, Al-Rabeeah AA, et al. 2013. Epidemiological, demographic, and clinical characteristics of 47 cases of Middle East respiratory syndrome coronavirus disease from Saudi Arabia: a descriptive study. Lancet Infect. Dis. 13:752–61 Sore throat (21 % of patients) Diarrhea (26 % of patients) Vomiting (21 % of patients) Abdominal pain (17% of patients) Abnormal chest radiograph (100% of patients)
20. INVESTIGATIONS (LABORATORY TESTS) 1. CBC: - Leukopenia (lymphopenia). - Thrombocytopenia. - Anemia. 2. LFT: - Elevated AST. - Elevated ALT. 3. Lactate Dehydrogenase. (elevated) 4. Blood Urea Nitrogen and Creatinine. (Elevated in some reported cases)
21. INVESTIGATIONS (IMAGING) Chest Xray and CT Chest findings demonstrated minor to extensive unilateral and bilateral abnormalities including: Enhanced bronchovascular markings airspace opacities patchy infiltrates airspace consolidations
22. INVESTIGATIONS Imaging findings at presentation in Saudi patients with Middle East respiratory syndrome cororavirus infection Assiri A, Al-Tawfiq JA, Al-Rabeeah AA, et al. Lancet Infect Dis 2013; 13:752.
23. INVESTIGATIONS (LABORATORY DIAGNOSIS) - Lower respiratory tract specimens should be the first priority for collection and real-time reverse-transcriptase polymerase chain reaction (rRT-PCR) testing. - Studies shows that rRT-PCR testing of lower respiratory specimens appears to be more sensitive for detection of Middle East respiratory syndrome coronavirus (MERS-CoV) than testing of upper respiratory tract specimens. - A serum sample (at least 0.2 mL of serum) should be obtained in the first 10 to 12 days after onset of illness for rRT-PCR, and a second serum sample (also at least 0.2 mL of serum) should be collected at least 14 days after onset of illness for antibody detection
24. INVESTIGATIONS (LABORATORY DIAGNOSIS) Lower respiratory tract specimens such as: Should be obtained for rRT-PCR testing from all cases of severe disease and from milder cases Sputum Endotracheal Aspirate Bronchoalveolar Lavage (BAL) fluid
25. INVESTIGATIONS (LABORATORY DIAGNOSIS) ●Upper respiratory tract specimens should be obtained for rRT-PCR testing and should be either: 1. A combined nasopharyngeal and oropharyngeal swab specimen (two synthetic fiber swabs with plastic shafts, combined in a single collection container) or 2. A 2 to 3 mL nasopharyngeal aspirate. Obtaining upper respiratory tract specimens is especially important if the patient does not have signs or symptoms of lower respiratory tract disease or if the collection of lower respiratory tract
26. INVESTIGATIONS The CDC recommends the collection of multiple specimens from different sites, including upper respiratory tract, lower respiratory tract and serum, at different times after symptom onset. If initial testing of respiratory specimens is negative in a patient who is strongly suspected of having MERS-CoV infection, additional respiratory specimens should be obtained from multiple respiratory sites. Possible reasons for false-negative results include that the specimen was of poor quality, was collected late or very early in the illness, was not handled and shipped appropriately, or there were technical problems with the test.
27. INVESTIGATIONS (SEROLOGY) Several serology assays have been developed for the detection of MERS-CoV antibodies, including immunofluorescence assays and a protein microarray assay. The CDC has developed a two-stage approach which uses: Any positive test by a single serologic assay should be confirmed with a neutralization assay. followed by an indirect immunofluorescence test or microneutralization test for confirmation. An enzyme-linked immunosorbent assay (ELISA) for screening
28. INVESTIGATIONS (SEROLOGY) THERE ARE LIMITED DATA ON THE SENSITIVITY AND SPECIFICITY OF ANTIBODY TESTS FOR MERS-COV.
29. CASE DEFINITION (MOH GUIDELINES)
30. CASE DEFINITION (WHO GUIDELINES)
31. PROBABLE CASE – A PROBABLE CASE IS DEFINED BY THE FOLLOWING CRITERIA: 1. A febrile acute respiratory illness with clinical, radiographic, or histopathologic evidence of pulmonary parenchymal disease (eg, pneumonia or acute respiratory distress syndrome) and 2. A direct epidemiologic link with a confirmed MERS-CoV case and 3. Testing for MERS-CoV is unavailable, negative on a single inadequate specimen, or inconclusive OR 1. A febrile acute respiratory illness with clinical, radiographic, or histopathologic evidence of pulmonary parenchymal disease (eg, pneumonia or acute respiratory distress syndrome) and 2. The person resides in or traveled to the Middle East or countries where MERS-CoV is known to be circulating in dromedary camels or where human infections have recently occurred and 3. Testing for MERS-CoV is inconclusive
32. PROBABLE CASE – A PROBABLE CASE IS DEFINED BY THE FOLLOWING CRITERIA: OR 1. An acute febrile respiratory illness of any severity and 2. Direct epidemiologic link with a confirmed MERS-CoV case and 3. Testing for MERS-CoV is inconclusive
33. CONFIRMED CASE A person with laboratory confirmation of infection with MERS-CoV irrespective of clinical signs and symptoms
35. MANAGEMENT Currently there is no specific approved therapeutic agent available to treat MERS. Supportive care is the mainstay of treatment. In cell culture and animal experiments, combination therapy with interferon (IFN)-alpha-2b and ribavirin appears promising.
36. INFECTION CONTROL AND PREVENTION PRECAUTION
37. INFECTION CONTROL AND PREVENTION PRECAUTION A. Standard Precautions: Hand hygiene: 1. HCWs should apply “My 5 moments for hand hygiene”: before touching a patient, before any clean or aseptic procedure, after body fluid exposure, after touching a patient, and after touching a patient’s surroundings, including contaminated items or surfaces. 2. Hand hygiene includes either washing hands with antiseptic soap and water or the use of an alcohol-based waterless hand sanitizer (waterless hands rub). 3. Wash hands with antiseptic soap and water when they are visibly soiled. 4. The use of gloves does not eliminate the need for hand hygiene. Hand hygiene is necessary after taking off gloves and other personal
38. INFECTION CONTROL AND PREVENTION PRECAUTION B. Respiratory precautions: 1. Visual Alerts. 2. Masking and Separation of Persons with Respiratory Symptoms. - a) Offer regular (surgical) masks to persons who are coughing. Regular (surgical) masks may be used to contain respiratory secretions (N-95 masks are not necessary for this purpose). - b) When space and chair availability permit, encourage coughing persons to sit at least 1 meter away from others in common waiting areas. - c) Healthcare facilities should ensure the availability of materials for adhering to Respiratory Hygiene/Cough Etiquette in waiting areas for patients and visitors. - d) Provide tissues and no-touch receptacles for used tissue disposal. - e) Provide conveniently located dispensers of alcohol-based hand sanitizer. - f) Where sinks are available, ensure that supplies for hand washing (i.e., antiseptic soap and disposable towels) are consistently available.
39. INFECTION CONTROL AND PREVENTION PRECAUTION C. Prevention of overcrowding: oIn clinical areas is essential to prevent cross infection. oMany of the outbreaks of MERS has been linked to overcrowding in clinical units especially emergency room and dialysis units
40. REFERENCES • Manual of Clinical Microbiology 11th Edition. • Infectious Diseases of Saudi Arabia - 2017 edition Stephen Berger, MD by GIDEON Informatics. • Infection Prevention and Control Guidelines for the Middle East Respiratory Syndrome Coronavirus (MERS-CoV) Infection 4th Edition January 2017. MOH • ProMed Mail: Novel coronavirus - Saudi Arabia: human isolate; Archive Number: 20120920.1302733 http://www.promedmail.org/direct.php?id=20120920.1302733 (Accessed on April 22, 2013). • https://www.uptodate.com • http://www.who.int • https://www.cdc.gov/ • Coleman CM, Frieman MB (2013) Emergence of the Middle East Respiratory Syndrome Coronavirus. PLoS Pathog 9(9): e1003595. https://doi.org/10.1371/journal.ppat.1003595 • Fehr, A. R., Channappanavar, R., & Perlman, S. (2017). Middle East respiratory syndrome: emergence of a pathogenic human coronavirus. Annual review of medicine, 68, 387-399. • Reusken, C. B., Haagmans, B. L., Müller, M. A., Gutierrez, C., Godeke, G. J., Meyer, B., ... & Drexler, J. F. (2013). Middle East respiratory syndrome coronavirus neutralising serum antibodies in dromedary camels: a comparative serological study. The Lancet infectious diseases, 13(10), 859-866. • Assiri A, Al-Tawfiq JA, Al-Rabeeah AA, et al. (2013). Epidemiological, demographic, and clinical characteristics of 47 cases of Middle East respiratory syndrome coronavirus disease from Saudi Arabia: a descriptive study. Lancet Infect. Dis. 13:752–61
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