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DR HANIHASELAH BINTI MOHD SALEH
PAKAR PERUBATAN KELUARGA
PEJABAT KESIHATAN KOTA TINGGI10/10/2013
PENGURUSAN KES JANGKITANMiddle East Respiratory syndrome
- CORONAVIRUS (MERS-CoV)
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Ackonowledgement
Dr Benedict Sim , Consultant Infetious Diseases , Hospital Sg Buloh
, Selangor
Dr Anilawati Jelani , Consultant Infectious Diseases, HRPZ11, KotaBharu , Kelantan
Dr. Wan Noraini ; Surveillance Section, Disease Control Division,
KKM
Dr. Shahanizan bt Mohd Zin; Medical Development Division, KKM
Dr . Masliza Bt Zaid, ID Physician, HAS JB
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OUTLINE
What will MERS Co-V infection look like ?
Who to test ?
How, what and when to test?
When to admit?
Where to admit?
What Infection control is needed ?
How to manage MERS CoV infection ?
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The epidemic so far cases and
mortality
**SO FAR WHO HAS NOT RELEASED ANY TRAVEL ADVISORY NOR
ANY TRAVEL RESTRICTIONS TO ANY COUNTRY **
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MIDDLE EAST RESPIRATORY
SYNDROME VIRUS( MERS CoV)
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Middle East Respiratory Syndrome Virus
(MERS CoV)
Genus -Coronavirus
Acronym : SARS-like virus, The Saudi virus
( novel Coronavirus , nCoV)
First reported in SEPTEMBER 2012 as a novel Coronavirus
Source of infection and mode of transmission is yet to be accuratelydetermined
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What will MERS CoVinfection look like ?
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MERS CoV :FACTS
Evidence of non-sustainedhuman-to-humantransmission Communities: sporadic cases with unknown exposure
Families: contact with infected family members
Health care facilities: patients & health care workers
Most people confirmedto have MERS CoV infectiondeveloped Severe Acute Respiratory illness
The virus has spread from ILL patientsto othersthrough CLOSE CONTACTS.
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MERS CoV
Has strong tropism fornonciliated bronchial epithelial
cells --> LOWER RESPIRATORY TRACT INFECTION
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Mas, July 22,2013, Hosp Permai
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MERS CoV
Based on Hospital outbreak of MERS-CoV published on
June 19, 2013 , NEJM
Incubation period
Where exposure is known or strongly suspected : generally < 1
week In a case : 9 to 12 days
Minority of cases : More than a week but < 2 weeks
More common among adults
Male to female ratio 2.6 : 1.0
Affect all ages . Median age 56 years (range: 294 years)
Case fatality rate = 31/55 = 56%
4~14d after onset, 2~10d after hospitalization
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Hospital outbreak of MERS-CoV published on June 19, 2013 , NEJM
23 confirmed cases April - May 2013
Fever
Cough
Shortness of breath
Gastrointestinal symptoms
Diarrhoea
Vomiting
Abnormal CXR
20/23 (87%)
20/23 (87%)
11/23 (48%)
8/23 (35%)
5/23 (22%)
4/23 (17%)
20/23 (87%)
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Hospital outbreak of MERS-CoV published on June 19, 2013 , NEJM
CLINICAL SYMPTOMS
Mostly - pneumonia. Some - GI symptoms, diarrhoea
1 immuno-compromised patient - fever and diarrhoea;
pneumonia only on CXR.
Case fatality rate = 31/55 = 56%
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Hospital outbreak of MERS-CoV published on June 19, 2013 , NEJM
CLINICAL SYMPTOMS
Mostly - pneumonia. Some - GI symptoms, diarrhoea
1 immuno-compromised patient - fever and diarrhoea;
pneumonia only on CXR.
Case fatality rate = 31/55 = 56%
Complications
Respiratory failure
ARDS with multi-organ failure
Renal failure requiring dialysis
Consumptive coagulopathy
Pericarditis.
Co-infections : influenza, herpes simplex, and pneumococcus
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Important findings
Limited person-to-person
transmission
Settings: Hospital, Household
Most family members and
HCWs closely exposed did not
develop disease
No evidence at present of
sustained person-to-person
transmission
Coinfection with influenza &
parainfluenza - ? Roles in
transmissibility and/or the
severity of the illness.
Transmissibility pattern ?
SARS
Reported case of milder nCoVillnessspectrum of clinical
disease maybe wider
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Who has MERS CoV?
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Case definitionMOH June 14, 2013/ WHO Ju ly 3 , 2013
1. Confirmed case
2. Probable case
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MOH / WHO Case definition
June 14, 2013
Confirmed case
A person with laboratory confirmationofMERS-CoV infection.
molecular diagnostics including either positive PCR
on at least two specific genomic targets or a single
positive target with sequencing on a second.
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MOH Case definition
June 14, 2013
Probable Case: SARI* with clinical, radiological, or HPE evidence of pulm parenchymal dz
(PPD) [e.g. pneumonia or ARDS];
AND
No possibility of lab confirmationAND
Close contact** with lab-confirmed case.
SARI = Syndrome of acute respiratory illness
PPD = Pulmonary Parenchymal diseases
*Include history of fever or measured fever** Close contactanyone who
- Provided care for the pt, including HCW or family member;- Stayed at the same place (e.g., lived with, visited) while pt ill
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WHO Interim Case definition July 3,2013
Clinical + Epidemiolgical + Laboratory
Probable Case:
1. Febrile ARI with clinical, radiological, or HPE evidence of pulm
parenchymal dz (PPD) e.g. pneumonia or ARDSANDTesting for MERS-CoV isunavailable / negative on a singleinadequate specimen*
ANDDirect epid-link with a confirmed MERS-CoV case.
*Inadequate specimen
Nasopharyngeal swab without lower resp specimen, specimen with
improper handling, judged to be poor quality by lab, taken too late.
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WHO Interim Case definition
July 3, 2013
Probable Case:
2. Febrile ARI with clinical, radiological, or HPE evidence of pulm
parenchymal disease (PPD)ANDInconclusive MERS-CoV#(positive screening test withoutconfirmation)AND
A resident of or traveler to Middle East 14 days before onset of illness.
#Inconclusive testsmay include: A positive screening test without further confirmation eg positive on a
single PCR target A serological assay positive.
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WHO Interim Case definition July 3,2013
Clinical + Epidemiolgical + Laboratory
Probable Case:
3. Febrile Acute Respiratory Illness of any severityANDInconclusive MERS-CoV (positive screening test withoutconfirmation)ANDDirect epid-linkwith a confirmed MERS-CoV case.
Direct epid link may include: Close physical contact
Working together in close proximity or sharing the same classroom environment
Traveling together in any kind of conveyance
Living in the same household
14/7 period before or after the onset of illnessin the case under consideration.
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Who to test for MERS CoV?
MOH June 14, 2013
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Screening for MERS CoV
OBJECTIVES:
1. To detect early, sustained human-to-human transmission.
2. To determine the geographic risk areafor infection with the virus.
Clinical and epidemiological investigation to:1. Determine clinical characteristics - incubation period, spectrum of disease
and natural history.
2. Determine epidemiological characteristics
- exposures that result in infection, risk factors, secondary attack
rates, and Mode of transmission
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Patient Under Investigation (PUI)
SARI, (include history of fever and cough) andindications of PPD (e.g., pneumonia or ARDS), based onclinical or radiological evidence of consolidation,(possibility of atypical presentations in immunocompromised)
AND
Travel to the Middle East 10 days before
AND
Not explained by other aetiology
SARI = Syndrome of acute respiratory illness
PPD = Pulmonary Parenchymal diseases Mas, July 22,2013, Hosp Permai
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Contacts
ARI of any severity, 10 days before onset of illness,
close physical contact* with a confirmed or probable case ofMERS-CoV infection
Health care worker (HCW) working where pt with SARI cared for, (esp ICU)
without regard to history of travel (WRTHOT)
Not explained by other aetiology
ARI = Acute respiratory illnessSARI = Syndrome of acute respiratory illness
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Who should be investigated?-
summarized
1. SARI + PPD+ either
In a cluster (within 14 days)
HCW exposed to patient with severe LRTI
Traveled to middle east (within 14 days)
unexpected clinical course unexplained by current aetiology2. ARI of any severity
close contact with confirmed/probable MERS-CoV within 14days
3. Travel to Middle East within 14 days - any ventilated patientCLUSTER (>1 persons in a specific setting -classroom, workplace, household, extended family, hospital,
other residential institution, military barracks or recreational camp) that occurs within 14-days, without
regard to history of travel(WRTHOT)
unless another aetiology identified (UAAI).
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What test to do ?
What specimen to send?
How to send specimens ?
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WHO 27 June 2013 update
A longer period of observation for contacts of cases ( 14 days) .
Stronger recommendations for LOWER RESPIRATORY TRACT
SPECIMENS (BAL, tracheal aspirate, sputum), rather than
Nasopharyngeal swabs, to be used to diagnose MERS-CoV
infection.
- If patients do not have LRTI or specimens not possible both
nasopharyngeal swab and Oropharyngeal swabs should be
collected
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BAL = BROCHOSCOPIC ASPIRATION & LAVAGE
TRACHEAL ASPIRATE
NASOPHARYNGEAL SWAB SPECIMENS ( LESS SENSITIVE)Mas, July 22,2013, Hosp Permai
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Laboratory Testing Methods (IMR)
1. Real time RT-PCR
2. Cell Culture
3. RT-PCR & Sequencing
4.Serology (paired sera 4 weeks apart)
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How to send specimen?
Send specimen to laboratory in ice AS SOON AS POSSIBLE .(Temp = 4c)DO NOT FREEZE SPECIMENS
Triple packing
Specimens will be sent to Virology Unit IMR until *1/8/2013 ( then HSAJB )
* tentative date
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When to admit ?
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Mas, July 22,2013, Hosp Permai
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Mas, July 22,2013, Hosp Permai
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Mas, July 22,2013, Hosp Permai
HOME ASSESSMENT TOOL
(HAT)
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TATACARA PENILAIAN
KESIHATAN KENDIRI
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Amalkan langkah mudah:
TATACARA PENILAIAN KESIHATAN
KENDIRI
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When to admit?
Hospital admissions :
1. Clinical assessment tool ( CAT)
2. Co-morbidities & risk factors
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CLINICAL ASSESSMENT TOOLS ( CAT)
Respiratory impairment: Any of the following
Tachypnoea, respiratory rate > 24/minInability to complete sentence in one breath
Use of accessory muscles of respiration, supraclavicular recession
Oxygen saturation < 92% on pulse oximetry
Decreased effort tolerance since onset of ILI ( Influenza-like illness)
Respiratory exhaustionChest pains
Evidence of clinical dehydration or clinical shockSystolic BP < 90mmHg and/or diastolic BP < 60mmHgCapillary refill time > 2 seconds, reduced skin turgorAltered Conscious level (esp. in extremes of age)New confusion, striking agitation or seizuresOther clinical concerns:Rapidly progressive (esp. high fever > 3 days) or serious atypical illness
Severe & persistent vomitingMas, July 22,2013, Hosp Permai
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Where to admit ?
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Hospital admissions : refer Criteria for Hospital Admission
Clinical assessment tool
Co-morbidities & risk factors
Admission to any nearest MOH hospital
non-specialist hosp MO to inform & consult specialists opinion for further
Mx
Urgent referral and transfer to the respective hospital to be done if the nearest
hospital doesnt have any of the facilities needed (ICU, isolation rooms)
Non-MOH Hospitals to admit & manage patients
Admission policies will be updated from time to time
HOSPIT L DMISSION
Medical Development DivisionMinistry of Health Malaysia
MERS-CoV
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WHAT INFECTION CONTROL
IS NEEDED ?
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Administrative controls
Most important ( From door to door) Infrastructures and equipment
Adequate ventilation
Regular environmental cleaning
Spatial separation of at least 1 m
Education of HCWs
Prevent overcrowdingin waiting areas
Surgical 3-ply mask ( droplet precaustion ) & Hand hygiene
Standard Precaution
Placement of hospitalized patients
Occupational health; seeking medical care
Monitoring of compliance.
Rapid identificationof patients.
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Infection control
Limit number of visitors & family members to those essentialfor patient's support should be trained on risk of transmission
use same infection control as HCWs
PPE ( medical mask, eye shield or goggles, clean non sterile gowns andgloves )
Perform HAND HYGIENEbefore and after contact with patient and thesurroundings AND immediately on removal of PPE
Limit number of HCWs Assign care to exclusive group of skilled HCWs if possible
refrain from touching eyes , nose , mouth with contaminated gloves or
ungloved hands
PPE = personal protective equipment
HCW = Health care workersMas, July 22,2013, Hosp Permai
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Infection control
Use disposable equipments or dedicated equipments ( X-rayequipments , Blood pressure , thermometer, stethoscopes )
Adequately ventilatedrooms or airborne precautions rooms
Cohort patients with same diagnosis together , beds placed ATLEAST 1 metre apart
Avoid movement and transport of patients out of isolation roomsunless necessary . If required , use routes of transport with minimal
contacts with other patients , staffs and visitors.
Notify receiving area to prepare precautions before arrival of thepatients
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Isolation precautions
Standard precautions ( Including Hand Hygiene)
+
Droplet precautions
WHEN IN CLOSE CONTACT (WITHIN 1 METRE)
OR UPON ENTERING THE ROOM OR CUBICLE
OF THE PATIENTS
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Isolation precautions
Airborne for aerosol generating proceedures
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How to treat MERS CoV
infection?
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Early recognition and management
RECOGNIZE SARIand NOTIFICATION
SARI = Syndrome of acute respiratory illness
Early recognition and management
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Early recognition and management
of MERS CoV RecognizeSARI and NOTIFICATION
Initiate infection control measures
Give supplemental O2 therapy
Collect respiratory and other specimens for lab testing - including other possiblerespiratory pathogens
Empiric antimicrobials for suspected pathogens
Conservative fluids when not in shock
No high-dose steroids or other adjunctive therapies outside the context of clinical
trials
Watch for clinical deterioration, eg severe resp distress/resp failure; tissue
hypoperfusion/shockMas, July 22,2013, Hosp Permai
E l iti d t
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Managing severe respiratory distress,hyoxemia and ARDS Mechanical ventilation or NIV (non
invasiveventilation) depending on level of
consciousness and severityof pneumonia
Manging septic shock
Early recognition and management
of MERS CoV
SUPPORTIVE TREATMENT
NO ANTIVIRALS AVAILABLE
Mas, July 22,2013, Hosp Permai
TAKE HOME MESSAGES
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TAKE HOME MESSAGES
MERS CoV As virulent as SARS-CoV but is distinguished by relative abscence of severe
disease among close contacts of patients except among those withimmunosuppression
Natural host and reservoir remains unknown
Evidence of nonsustained human to human transmission
Settings : Household , Hospital Close contacts
Incubation period 14 days
Most people confirmedto have MERS CoV infection developed SevereAcute Respiratory illness
Standard and droplet precaution when managing PUI. Airborne precaution inaerosol generating procedures
SUPPORTIVE TREATMENT Mas, July 22,2013, Hosp Permai
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Thank you and Good Luck!
AIDIL ADHA