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Updates in MOH Guidelines for Middle East Respiratory Syndrome Corona virus(MERS-CoV)

Dr Mostafa Mahmoud, MD, Ph D,Consultant MicrobiologistLabs & Blood Banks Admin, Riyadh.Head of IPC Dept. Iman HospitalAssist. Prof. of Medical Microbiology & Immunology

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Coronaviruses are common viruses that most people get some time in their life. Human coronaviruses usually cause mild to moderate upper-respiratory tract illnesses in 25% of Common cold.

Q: What are coronaviruses?Why it is called Coronavirus?Because of the surface glycoprotein spikes seen by EM and surrounding the whole virus like a crown.

2All personnel should be aware of:Hazards of using any material, device or equipment.Proper technique in handling of material, devices or equipment, including procedures to follow if something should go wrong.Emergency telephone numbers.Location and use of eyewash fountains and emergency showers.Location and use of spill kits. Location and use of fire extinguishers.Emergency codes, exits and evacuation routes.

Coronavirus EM and Diagrammatic

EM Picture.Diagrammatic

Virology of Coronavirus: Single-stranded RNA virus 30 000 nucleotide, positive-sense, enveloped. Enveloped virus i.e. not affecting GIT die out due to gastric secretions. 3 groups of the virus affecting human and animals. Coronavirus can undergo dramatic change in virulence and tissue tropism e.g. change in spike gives SARS-CoV or MERS-CoV.

Changes or fusion of S protein may be the responsible one for changing pathogencity???

Coronavirus groups:Group Representative Virus Group 1Human coronavirus 229E (HCoV-229E)Human coronavirus NL63 (HCoV-NL63)Canine enteric coronavirus (CCoV)Feline coronavirus (FCoV)Porcine transmissible gastroenteritis coronavirus (TGEV)Porcine epidemic diarrhoea coronavirus (PEDV)Bat coronaviruses (BtCoVs)Group 2Human coronavirus HKU1 (HCoV-HKU1)Bovine coronavirus (BCoV)Canine respiratory coronavirus (CRCoV)Porcine hemagglutinating encephalomyelitis coronavirus (HEV)Murine hepatitis coronavirus (MHV)Feline infectious peritonitis virus (FIPV)SARS coronaviruses (SARS-CoVs)Bat coronaviruses (BtCoVs)Group 3Infectious bronchitis coronavirus (IBV)Turkey coronavirus (TCoV)Pheasant coronavirus (PhCoV)

Is Coronavirus a new virus? No; it affects human allover the world and was known since 1960s.Affecting all people but mostly children.Causing 25% of Colds.The only severe form of it was SARS-CoV who disappeared since 2004.

What is the mode of transmission of Coronavirus? Direct and Indirect contact.

Droplet infections.

But still needs to be more determined.

What is the clinical picture of coronavirus infection? It is mild to moderate upper respiratory tract infection cold.

Re-infection of the individual with the same serotype can occur within months i.e. short lived immunity.

Newly emerged CoronavirusesThe first new one was called SARS-CoV.

The running one nowadays is the Middle East Respiratory Syndrome corona virus MERS-CoV.

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Newly emerged Coronaviruses1- SARS-CoVAppeared in 2002 in China.Emerged from animal reservoir. IP 2-14 days, droplet infection.Affected 8000 patients in 29 countries of the world .Had 9.6% Mortality rate (744 cases).Disappeared in 2004.Low pathogenicity, not transmitted from human to human, no vaccine.

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2- MERS-CoV Appeared in 2012.Human to-human transmission confirmed.Mode of transmission not yet confirmed. (respiratory secretion, direct & Indirect contact)Reservoir of infection not yet determined. (from Bats to Camels to Humans?)Incubation period (2-14 days) not yet confirmed.

Based on DNA sequencing, researcher speculate that MERS coronavirus started in infected bats in Egypt or the horn of Africa (left panel). They suspect that the winged mammals transmitted the microbe to one-humped camels, where the virus circulated possibly for decades, before hopping into humans. Since camels are an accessible intermediate host, some groups have proposed vaccines for the hooved animals to prevent future spread to humans. Source: Papaneri, AB et al. Expert Rev. Vaccines. 2015.

Are we the reservoir of MERS CoV my dear??

Calm down my dear we love you anyway

Current situation worldwide

KSA, Korea, & China situationTotal cases Total deaths Last case Korea &18536 (19.4%)4-7-2015China1KSA1225521 (42.5%)9-9-2015Still running

Whom to be investigated for MERS CoV?1* Suspected cases: A- ADULTS (> 14 years):I. Acute respiratory illness with clinical and/or radiological, evidence of pulmonary parenchymal disease (pneumonia or Acute Respiratory Distress Syndrome (ARDS).

II. A hospitalized patient with healthcare associated pneumonia based on clinical and radiological evidence.

III. Upper or lower respiratory illness within 2 weeks after exposure to a confirmed or probable case of MERS-CoV infection

IV- Unexplained acute febrile (38C) illness, AND body aches, headache, diarrhea, or nausea/vomiting, with or without respiratory symptoms, AND leucopenia (WBC < 3.5 x 109/L) and thrombocytopenia (platelets 24 H.5- Serum for serology or virus detection and EDTA whole blood for PCR.

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N.B.The diagnostic test approved and applied by the MOH is the PCR one.

Serology by finding seroconversion in double samples is applied by some other countries.

Algorithm for managing patients with suspected MERS-CoV, MOH, KSA, June 2015.

Notes:History of contact with camels or its products in the last 14 days.All suspected cases nasopharyngeal swab + orophryngeal swab & LRT secretions when intubated.Swabbing for asymptomatic contacts only for exposed unprotected HCWs or in outbreaks.Positive lab test for other causes of pneumonia does not exclude MRES CoV.

I- General IPC precautions:

A- Standard precautions;1- Hand hygiene (5 moments- washing or rubbing- water when soiled- gloves not eliminate washing).2- Respiratory precautions: -Visual alerts:- (coughing- HH- tissues)- Separation of respiratory patients: (Triage- mask- cough etiquette- no overcrowding and distances in waiting).

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MOH recommended distances between beds:Units Recommended distances General ward A minimum of 1.2 meters between bedsCritical care unit (ICUs)A minimum of 2.4 meters between bedsHemodialysis Units A minimum of 1.2 meters between bedsEmergency UnitsA minimum of 1.2 meters between beds

3 Environmental ventilation in all areas within a health-care facility.4 Environmental cleaning and/or disinfection.5 Prevention of needle-stick or sharps injury.6 Safe waste management (Medical waste).

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Standard precuations

II- IPC precautions when caring for suspected, probable, or confirmed MERS-CoV infection1- Isolation: -Non-critically ill: (standard, contact and droplet isolation precautions).-Critically ill: Airborne precautions.

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Negative pressure airborne isolation room.

Pressure Monitor Private BathroomAnteroomHEPA filterAir Pumping & suction separated from hospital

Airborne infection isolation sign

2- Patient Placement: Non-critically ill: segregated single room + HEPA, AGP in negative pressure room.

Critically-ill: airborne negative pressure isolation room.If not available : well ventilated single roomIf not available: cohorting If not available: put patients in beds with 1.2 meters distances.

Transport of patient limited and prepared if necessary and patient must wear surgical mask on transport.

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4-Personal Protective Equipment (PPE) for Healthcare Workers (HCWs)A must when caring isolated patients.Donning order: 1- HH2- Gown 3- Mask (surgical for rooms & N95 for airborne) 4- Eye protection 5- GlovesDoffing order in anteroom: 1- Gloves, 2- Eye protection, 3- Gown 4- Mask (removed outside negative pressure room). 5- HH

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III-Fit test.Fit test is a must for HCWs entering negative pressure and performed annually.

IV- IPC precautions for aerosol generating procedures (AGP)Aerosol are particles < 5 m in diameter.Infectious aerosol particles travel in air more than 1 meter. These procedures include: bronchoscopy, sputum induction, elective intubation and extubation, also emergency procedures such as CPR, emergency intubation, open suctioning of airways, manual ventilation via umbo bagging through a mask.Bilevel Positive Airway Pressure BiPAP is not recommended in MERS patients.PPE for AGP include N95 mask, gown, eye protection in a negative pressure room.

V- Admission criteria Hypoxemia, and/or clinical or radiological evidence of pneumonia should be admitted.

VI-Home isolationFor mild cases of MER-CoV infections.Home should be suitable for isolation.Instructions for the patient in home isolations to be clear and followed.Instructions for the care givers to the patient at home.Instructions for the other house-hold contacts.Close contacts to be followed for 14 days for any symptoms or signs of MERS.

VII- Management of HCWs who had contacts with patients with MERS-CoV infectionHigh-risk unprotected exposure (Contact with confirmed MERS-CoV case within 1.5 meters for > 10 minutes): single swabbing, off work till negative results.Low-risk unprotected exposure (Contact with confirmed MERS-CoV case more than 1.5 meters and/or for < 10 minutes): continue work and not testing.Protected exposure (Contact with confirmed MERS-CoV case and having appropriate isolation precautions including the PPE): continue work and no testing.

VIII. Duration of isolation precautions for MERS-CoV infectionDefinitely unknownHowever it is guided by clinical picture and 2 negative lower respiratory samples for MERS-CoV.Negative samples to be repeated after 1 week for improving patient.No need for repeated sampling for non-improving patient.Home-isolated patients to be tested after 1 week isolation and then every 3 days, stop isolation when patient is asymptomatic or negative single PCR test.

IX. Managing bodies in the mortuary.Deceased bodies should be washed by regional secretariats and municipalities of the ministry of municipality and rural affairs.If family member wishes to do washing, this must be under supervision and wearing all PPE.

References: Malik Peiris JS and LLM Poon 2009. Coronaviruses and Toroviruses, pp 511-531. In, Principle and Practice of Clinical Virology, 6th edition. Edited by A. J. Zuckerman, J. E. Banatvala, B. D. Schoub, P. D. Griffiths and P. Mortimer 2009 John Wiley & Sons Ltd. ISBN: 978-0-470-51799-4.

Command and Control Center, Ministry of Health, Kingdom of Saudi Arabia, Scientific Advisory Board, Infection Prevention and Control Guidelines for Middle East, Respiratory Syndrome Coronavirus (MERS-CoV) Infection, 3rd Edition. June 2015.

MOH CCC website: http://www.moh.gov.sa/en/ccc/Pages/default.aspx.

http://www.cdc.gov/coronavirus/about/index.html.

http://www.who.int/csr/disease/coronavirus_infections/LaboratoryTestingNovelCoronavirus_21Dec12.pdf.

http://www.who.int/csr/disease/coronavirus_infections/InterimRevisedSurveillanceRecommendations_nCoVinfection_18May13.pdf.

Prof. Ali Zaki

Thank You