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MERS-CoV: A New Viral Threat?

Andrew Delgado, PharmD Intern and Jennifer K. Seltzer, PharmD

July, 2013

Coronaviruses, characterized by crown-like spikes that mimic the solar corona, are common viruses that typically cause mild-to-moderate respiratory tract illnesses.1 Five coronaviruses with respiratory effects have been described in humans, including the SARS and HKU1 viruses, which cause pneumonia, and 229E and OC43, which are responsible for the common cold.2 The viruses typically infect only one animal species or a small number of related species, but may use animals as a reservoir, adapting to perform inter-human transmission.1,2 Although humans normally contract a coronavirus within their lifetime, a new, unique virus has been reported to cause severe illness and death. Initially called novel coronavirus (nCoV), the Middle East Respiratory Syndrome Coronavirus (MERS-CoV) was identified in 2012 in Saudi Arabia.1 No animal reservoir has been identified for MERS-CoV, and it is noted that unlike SARS, few healthcare workers have contracted infections.1-3

In October 2012, the Centers for Disease Control (CDC) published its first warning about the virus, reporting two cases of a novel severe respiratory illness from June and September 2012.4 Analysis of documented cases from April 2012 to May 29, 2013 revealed that infections were linked to Saudi Arabia, Qatar, Jordan, and the United Arab Emirates. Except for two children, all patients were aged ≥ 24 years with a median age of 56 years. As of June 7, 2013, the case fatality rate is 56%. Although all patients have experienced respiratory symptoms during illness, abdominal pain and diarrhea have also been reported.5 As of July 11, 2013, no occurrences have been reported in the United States (see Table 1).1

 

Table 1. MERS Cases (and deaths), April 2012 – July 11, 2013*

Country

Cases (deaths)

France

2 (1)

Italy

3 (0)

Jordan

2 (2)

Qatar

2 (0)

Saudi Arabia

66 (38)

Tunisia

2 (1)

United Kingdom

3 (2)

United Arab Emirates

1 (1)

Total

81 (45)

                  *Updated July 11, 2013, 9:00 AM EDT

 

The CDC has released case definitions for patients under investigation (PUIs), also urging clinicians to report suspicious cases to state or local health departments immediately. PUIs are defined by: an acute respiratory infection, suspicion of pulmonary parenchymal disease, and history of travel from the Arabian Peninsula or neighboring countries in the past 14 days. Tests should rule out any other infection, including community-acquired pneumonia. Those with recent travel who develop severe acute lower respiratory illness within 14 days and do not respond to appropriate therapy, or who have close contacts with a symptomatic traveler in the past 14 days, should also be considered PUIs.6

Based on the high mortality rate from MERS-CoV, unknown origins of transmission, poorly characterized symptoms, lack of a vaccine or chemoprophylaxis, and absence of cases in the United States, the World Health Organization (WHO) has released interim guidance for healthcare workers, healthcare managers, and infection prevention and control teams regarding infection prevention strategies and precautions.7,8 When caring for patients with probable or confirmed MERS-CoV infections, contact should be limited to as few individuals as possible, with utilization of a medical mask, eye protection, a clean gown, and gloves. Disposable medical equipment should be employed when possible, as well as adequately ventilated rooms or airborne precaution rooms. Rooms occupied by MERS-CoV patients should be isolated, if possible, and movement of patients should be minimized. These additional precautions should be used for the duration of illness and continued for 24 hours after symptoms resolve.8 Utilizing lower respiratory tract specimens in addition to nasopharyngeal swabs to diagnose MERS-CoV has also been proposed, as recent evidence indicates these samples possess higher viral loads and may be more sensitive than nasal and throat swabs.2,9,10

Guery et al.2 published a case report whereby a patient without respiratory illness contracted MERS-CoV after sharing a room with a MERS-positive patient for 3 days. Memish et al.11 described a cluster of family members who contracted MERS-CoV after contact with an elderly relative. Death occurred in 2 out of 4 cases, with presenting signs and symptoms varying between the cases. Since the index patient reportedly came into contact with 27 family members, this report supports person-to-person transmission, but indicates that the risk of infection is actually relatively low. There have been reports of asymptomatic and mild cases, raising concern that cases are going undetected. Epidemiological information indicating sustained transmission at the community level is currently unavailable.12

Due to limited information about MERS-CoV, including source, transmission, and prophylaxis methods, the WHO has opted to convene an International Health Regulations Emergency Committee (IHREC). The committee's charge is to evaluate current information, determine whether the virus constitutes a Public Health Emergency of International Concern, and discern whether the WHO should offer any additional temporary recommendations.3 The first meeting of the Committee was held on July 9, 2013 via teleconference. After assessing the current data, the Committee decided that more information was needed to make any conclusions, setting a second meeting for July 17, 2013.13 At present, no travel or trade restrictions are advised. Persons travelling to the Middle East should consider evaluation for MERS-CoV if they develop severe acute respiratory illness within 14 days.5  

For more information and continued travel advisories, see:
                  http://wwwnc.cdc.gov/travel/notices/watch/coronavirus-saudi-arabia-qatar
                  http://www.cdc.gov/coronavirus/mers/faq.html

For more information on the continuing deliberations and conclusions of the IHREC, see:
                  http://www.who.int/ihr/ihr_ec_2013/en/index.html

REFERENCES

  1. Centers for Disease Control and Prevention. Middle East Respiratory Syndrome (MERS). 2013, June 14. Available at: http://www.cdc.gov/features/novelcoronavirus/. Accessed: July 12, 2013.
  2. Guery, B, Poissy J, el Mansouf L. et al. Clinical features and viral diagnosis of two cases of infection with Middle East Respiratory Syndrome coronavirus: a report of nosocomial transmission. Lancet 2013;381:2265–72.
  3. World Health Organization. Press conference with Dr. Keiji Fukuda, Assistant Director General for Health Security and the Environment on MERS-Coronavirus [Press release]. Available at: www.who.int/entity/ihr/procedures/MERS_Fukuda_PC_20130705.pdf. Accessed July 11, 2013.
  4. Centers for Disease Control and Prevention. Severe Respiratory Illness Associated with a Novel Coronavirus — Saudi Arabia and Qatar, 2012. MMWR. 2012;61(40):820. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6140a5.htm. Accessed July 11, 2013.
  5. Centers for Disease Control and Prevention. Update: Severe Respiratory Illness Associated with Middle East Respiratory Syndrome Coronavirus (MERS-CoV) — Worldwide, 2012–2013. MMWR. 2013;62(23):480-83. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6223a6.htm?s_cid=mm6223a6_w. Accessed July 11, 2013.
  6. Centers for Disease Control and Prevention. Middle East Respiratory Syndrome (MERS) – Case Definitions. 2013, July 2. Available at: http://www.cdc.gov/coronavirus/mers/case-def.html. Accessed: July 10, 2013.
  7. World Health Organization. Interim Infection Prevention and Control Recommendations for Hospitalized Patients with Middle East Respiratory Syndrome Coronavirus (MERS-CoV). 2013, July 10. Available at: http://www.cdc.gov/coronavirus/mers/infection-prevention-control.html. Accessed July 12, 2013.
  8. World Health Organization. Infection prevention and control during health care for probable or confirmed cases of novel coronavirus (nCoV) infection. 2013, May 6. Available at: www.who.int/csr/disease/coronavirus_infections/IPCnCoVguidance_06May13.pdf. Accessed: July 11, 2013.
  9. World Health Organization. Infection prevention and control during health care for probable or confirmed cases of novel coronavirus (nCoV) infection. 2013, June 27. Available at: www.who.int/csr/disease/coronavirus_infections/InterimRevisedSurveillanceRecommendations_nCoVinfection_27Jun13.pdf. Accessed: July 11, 2013.
  10. Drosten C, Seilmaier M, Carman VM, et al. Clinical features and virological analysis of a case of Middle East respiratory syndrome coronavirus infection. The Lancet. 2013, June 17. Available at: http://www.thelancet.com/journals/laninf/article/PIIS1473-3099%2813%2970154-3. Accessed: July 11, 2013.
  11. Memish ZA, Zumla AI, Al-Hakeem, RF, et al. Family Cluster of Middle East Respiratory Syndrome Coronavirus Infections. N Engl J Med. 2013;368(26):2487-94.
  12. World Health Organization. Global Alert and Response (GAR): MERS-CoV summary and literature update – as of 09 July 2013. Geneva, Switzerland: World Health Organization; 2013. Available at: http://www.who.int/csr/disease/coronavirus_infections/update_20130709/en/index.html. Accessed July 11, 2013.
  13. Chan, M. Alert, response, and capacity building under the International Health Regulations (IHR): Middle East respiratory syndrome coronavirus (MERS-CoV). World Health Organization. 2013, July 9. Available at: http://www.who.int/ihr/procedures/statements_20130709/en/index.html. Accessed: July 11, 2013.

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