Pr. R. S. Tobgiسالم. . رجب د أ

الطبجي

األوسط الشرق متالزمةالتنفسية

Middle East Respiratory SyndromeMERSCoVالتاجية الفيروسات

Corona viruses

•Coronaviruses are :

•The virions appear as 'crown' or 'halo‘ named after Corona (Latin) •Enveloped RNA Viruses•Family:  Coronaviridae  •Subfamily: Coronavirinae

Common cold•Common cold ,البرد الشائع, الزكام, انفلونزا بردة

•The common cold has been associated with over 100 different viruses, including Human

Coronavirus and Rhinovirus.

•Human CoVs  may cause of up to 15% of all respiratory problems.

•The early symptoms of MERS-CoV are non-specific, therefore, it is not always possible to identify pt’s. with MERS-CoV early.

MERS-CoV

•MERS-CoV

was first identified in 2012 in Saudi Arabia.

•Incubation period: 2 ‐ 14 days

•Period of infectivity: duration of infectivity is

unknown.

•Asymptomatic cases as well as patients during

the incubation period might not be contagious.

• http://www.who.int/csr/disease/coronavirus_infections/case_definition/en/

Symptoms & Complications•Most people confirmed to have: Travel: to KSA within 10 days before onset of illness Fever (over 38°C) Cough Shortness of breathSome people also had symptoms including

pneumonia and gastrointestinal Diarrhea, nausea/vomiting and kidney failure.•Suspicion of pulmonary parenchymal disease (e.g. pneumonia or ARDS),•Some infected people had mild symptoms or no symptoms at all; they recovered.

• http://www.who.int/csr/disease/coronavirus_infections/en/index.• WHO:Clinical management of severe acute respiratory infections when novel

coronavirus is suspected

Epidemiological summary

•Summary: •Since April 2012 and as of 22 May 2014,

•815 laboratory-confirmed cases , including 313 deaths of MERS-CoV

•WHO does not advise special screening at points of entry nor does it recommend the application of any travel or trade restrictions.

Deaths Cases

283 689 Saudi Arabia :

9 70 UAE

4 7 Qatar

5 18 Jordan

2 2 Oman

1 3 Kuwait

0 1 Egypt

1 1 Yemen

0 1 Lebanon

1 2 Iran

3 4 UK

1 2 Germany

1 2 France

0 1 Italy

0 1 Greece

0 2 Netherlands

1 3 Tunisia

1 2 Algeria

1 1 Malaysia

0 1 Philippines

0 2 USA

313 815 38.4%

13 June 2014

www.ecdc.europa.eu

Transmission Human

•Several of the recent cases acquired the infection in

KSA or UAE and then travelled to another country,

including Greece (1 case), Malaysia (1 case), and

the Philippines (1 case). No further transmission has

been documented so far.

•On other hand, exported cases occurred in the past

that resulted in limited further human‐to‐human

transmission (France and UK).

Transmission

•The current medical consensus confirms that the corona virus that causes MERS is to be found in animals hosts which are camels and bats.

•There are still many unknowns about the spread of the MERS coronavirus. 

•It seems that the virus is not easily transmitted from person to person, but it's happened a few times that people were infected after contact with a sick person.

Secondary Transmission HCW

•As much as 75% of the recently reported cases appear to be secondary cases, thus they acquired the infection from another infected person.

•The majority of these secondary cases, presented with no or minor symptoms, are mainly healthcare workers who have been infected within the healthcare setting,

•Although several patients who were in the hospital for other reasons are also considered to have been infected with MERS‐CoV in the hospital.

Health Care Workers

109/402 (27%)

63 (57.8%) Asymptomatic

35 (32.1%) Hospitalization

7 (6.4%) ICU

4 (3.7%) Died

Tertiary Transmission HCW

•Only four cases of transmission within households have been reported, and no large family cluster has been identified.

•To date only two possible tertiary cases have been reported.

Transmission

Source

PrimarySecondary

PrimarySecondary Tertiary

Primary

Primary

Secondary

75%100%

Seasonal transmission•The number of cases sharply increased follow a seasonal pattern since mid‐March 2014, essentially in KSA and UAE, where two important healthcare‐associated outbreaks are occurring.

•The number of cases who acquired the infection in the community has also increased since mid‐March. These cases have no reported contacts with other laboratory confirmed cases, and some have reported contacts with animals.

Seasonal transmission

Seasonal pattern

Close contact

•**Close contact is defined as:

•a) any person who provided care for the

patient, including a healthcare worker or

family member, or had similarly close

physical contact; or

•b) any person who stayed at the same place

(e.g. lived with, visited) as the patient while

the patient was ill.

Personal Protective Equipment (PPE)

• Gloves • Gown • Eye protection • Surgical mask • Acceptable respiratory protection devices

(N-95 respirator or higher level)• Biological Safety Cabinet (BSC) Class II .

http://www.osha.gov/SLTC/etools/respiratory/

• ALWAYS wash hands before and after entering a patient room. Not only does this protect the patients, it also protects YOU!

Always wash your hands

Viral Transport System•PROCEDURES•Materials Provided: BD Universal Viral Transport System includes a capture-cap vial containing 3 mL of transport medium plus three glass beads. Universal Viral Transport System supplied with the following specimen collection swab:

•Two regular size plastic scored shaft swabs with polyester fiber tips.

• Highest viral titers are present during the acute illness.

• www.bd.com/ds

Viral Transport System

•Universal transporting medium that is room temperature stable.

•This system is supplied as a sample collection kit that comprises a package containing:

•one capture-cap vial of medium and

•two specimen collection swabs.

Viral Transport System

•Do not incubate or freeze.•Once a swab specimen is collected it should be placed immediately into the transport vial

•Transport the specimen to the laboratory as soon as possible.

•Specimens are refrigerated at 2 – 8°C. storage at 4°C or -70°C.

EVERY ONE is responsible

for quality and safety

Respiratory Specimens•A. Lower respiratory tract•Sputum•Deep cough sputum directly into a sterile, leak-proof, sterile dry container. Refrigerate specimen at 2-8°C.

•Broncheoalveolar lavage, tracheal aspirate, pleural fluid

•Collect 2-3 mL into a sterile, leak-proof, screw-cap sputum collection cup or sterile dry container. Refrigerate specimen at 2-8°C.

Respiratory Specimens•B. Upper respiratory tract•Nasopharyngeal AND oropharyngeal swabs (NP/OP swabs)

•Use only the synthetic fiber provided swabs. Place swabs immediately into the viral transport media.  NP/OP specimens can be combined, placing both swabs in the same vial. 

Respiratory Specimens•B. Upper respiratory tract

•Nasopharyngeal swabs - Insert a swab into the nostril parallel to the palate. Leave the swab in place for a few seconds to absorb secretions. Swab both nasopharyngeal areas.

•Oropharyngeal swabs - Swab the posterior pharynx, avoiding the tongue.

Blood•II. Blood Components•Serum (for rRT-PCR testing)•For rRT-PCR testing, a single serum specimen. •Children and adults:•Collect 1 tube (5-10 mL) of whole blood in a serum separator tube. Refrigerate the specimen at 2-8°C and ship on ice- pack;•Infants :•A minimum of 1 mL of whole blood is needed for testing of pediatric patients. If possible, collect 1 mL a serum separator tube. Do not freeze.

References•WHO Coronavirus website: http://www.who.int/csr/disease/coronavirus_infections/en/. http://www.who.int/csr/disease/coronavirus_infections/NamingCoV_28May13.pdf

•http://www.who.int/csr/disease/coronavirus_infections/case_definition/en/

•http://www.lematin.ma/express/transmission-du-coronavirus_les-dromadaires-probablement-impliques/186277.html#sthash.wmk3a19f.dpuf

•http://www.who.int/csr/disease/coronavirus_infections/en/•Reusken CB et.al http://www.ncbi.nlm.nih.gov/pubmed/23933067

•http://www.who.int/csr/disease/coronavirus_infections/MERS_CoV_investigation_guideline_Jul13.pdf?

Thankyou