MIDDLE EAST

RESPIRATORY
SYNDROME -
CORONAVIRUS
DR.T.V.RAO MD
WHAT IS MIDDLE EAST
RESPIRATORY SYNDROME
(MERS)
MIDDLE EAST RESPIRATORY SYNDROME (MERS) IS
VIRAL RESPIRATORY ILLNESS FIRST REPORTED IN
SAUDI ARABIA IN 2012. IT IS CAUSED BY A CORONAVIRUS
CALLED MERS-COV. MOST PEOPLE WHO HAVE BEEN
CONFIRMED TO HAVE MERS-COV INFECTION
DEVELOPED SEVERE ACUTE RESPIRATORY ILLNESS.
THEY HAD FEVER, COUGH, AND SHORTNESS OF
BREATH. ABOUT 30% OF PEOPLE CONFIRMED TO HAVE
MERS-COV INFECTION HAVE DIED.
MIDDLE EAST RESPIRATORY
SYNDROME (MERS) BELONGS TO
CORONAVIRUS INFECTIONS

CORONAVIRUSES ARE A
LARGE FAMILY OF VIRUSES
THAT CAUSE A RANGE OF
ILLNESSES IN HUMANS,
FROM THE COMMON COLD
TO THE SEVERE ACUTE
RESPIRATORY SYNDROME
(SARS). VIRUSES IN THIS
FAMILY ALSO CAUSE A
NUMBER OF ANIMAL
DISEASES
MIDDLE EAST RESPIRATORY
SYNDROME CORONAVIRUS (MERS-COV)
THIS STRAIN OF
CORONAVIRUS THAT
CAUSES MERS WAS FIRST
IDENTIFIED IN 2012 IN
SAUDI ARABIA. OUR
UNDERSTANDING OF THE
VIRUS AND THE DISEASE
IT CAUSES IS CONTINUING
TO EVOLVE.
STRUCTURE OF MERS
VIRUS

THE INFECTION IS LINKED TO
ALL THE CASES HAVE BEEN
LINKED TO COUNTRIES IN THE
ARABIAN PENINSULA. THIS
VIRUS HAS SPREAD FROM ILL
PEOPLE TO OTHERS
THROUGH CLOSE CONTACT,
SUCH AS CARING FOR OR
LIVING WITH AN INFECTED
PERSON. HOWEVER, THERE
IS NO EVIDENCE OF
SUSTAINED SPREADING IN
COMMUNITY SETTINGS.
WHY PALM TRESS IN THE MERS-COV
ACQUISITION MODEL...? A
HYPOTHESIS?
THE MIDDLE EAST RESPIRATORY
SYNDROME CORONAVIRUS
THE MIDDLE EAST
RESPIRATORY SYNDROME
CORONAVIRUS (MERS-
COV),[1] ALSO TERMED
EMC/2012 (HCOV-
EMC/2012), IS POSITIVE-
SENSE, SINGLE-
STRANDED RNA NOVEL
SPECIES OF THE GENUS
BETA CORONAVIRUS.
MERS-COV REPORTED AT SEVERAL
PLACES
AS OF 14 MAY 2014, MERS-COV
CASES HAVE BEEN REPORTED
IN SEVERAL COUNTRIES,
INCLUDING SAUDI ARABIA,
MALAYSIA, JORDAN, QATAR,
EGYPT, THE UNITED ARAB
EMIRATES, TUNISIA, KUWAIT,
OMAN, THE PHILIPPINES,
INDONESIA (NONE WAS
CONFIRMED), THE UNITED
KINGDOM, AND THE UNITED
STATES.
VIRUS AND CLADES
THE VIRUS MERS-COV IS A NEW
MEMBER OF THE BETA GROUP OF
CORONAVIRUS, BETA
CORONAVIRUS, LINEAGE C. MERS-
COV GENOMES ARE
PHYLOGENETIC ALLY CLASSIFIED
INTO TWO CLADES, CLADE A AND B.
THE EARLIEST CASES OF MERS
WERE OF CLADE A CLUSTERS
(EMC/2012 AND JORDAN-N3/2012),
AND NEW CASES ARE GENETICALLY
DISTINCT (CLADE B).
FIRST CASE OF MERS-COV
THE FIRST CONFIRMED CASE WAS REPORTED IN
SAUDI ARABIA 2012. EGYPTIAN VIROLOGIST DR.
ALI MOHAMED ZAKI ISOLATED AND IDENTIFIED A
PREVIOUSLY UNKNOWN CORONAVIRUS FROM
THE MAN'S LUNGS. DR. ZAKI THEN POSTED HIS
FINDINGS ON 24 SEPTEMBER 2012 ON PROMED-
MAIL. THE ISOLATED CELLS SHOWED
CYTOPATHIC EFFECTS (CPE), IN THE FORM OF
ROUNDING AND SYNCYTIA FORMATION.
SECOND CASE OF MERS-COV
A SECOND CASE WAS FOUND IN SEPTEMBER 2012. A 49-
YEAR-OLD MALE LIVING IN QATAR PRESENTED SIMILAR
FLU SYMPTOMS, AND A SEQUENCE OF THE VIRUS WAS
NEARLY IDENTICAL TO THAT OF THE FIRST CASE.[4] IN
NOVEMBER 2012, SIMILAR CASES APPEARED IN QATAR
AND SAUDI ARABIA. ADDITIONAL CASES WERE NOTED,
WITH DEATHS ASSOCIATED, AND RAPID RESEARCH AND
MONITORING OF THIS NOVEL CORONAVIRUS BEGAN.

TROPISM IN MERS
IN HUMANS, THE VIRUS HAS A STRONG TROPISM FOR
NONCILIATED BRONCHIAL EPITHELIAL CELLS, AND IT HAS BEEN
SHOWN TO EFFECTIVELY EVADE THE INNATE IMMUNE
RESPONSES AND ANTAGONIZE INTERFERON (IFN) PRODUCTION
IN THESE CELLS. THIS TROPISM IS UNIQUE IN THAT MOST
RESPIRATORY VIRUSES TARGET CILIATED CELLS
DUE TO THE CLINICAL SIMILARITY BETWEEN MERS-COV AND
SARS-COV, IT WAS PROPOSED THAT THEY MAY USE THE SAME
CELLULAR RECEPTOR; THE EXOPEPTIDASE, ANGIOTENSIN
CONVERTING ENZYME 2 (ACE2).[14] HOWEVER, IT WAS LATER
DISCOVERED THAT NEUTRALIZATION OF ACE2 BY RECOMBINANT
ANTIBODIES DOES NOT PREVENT MERS-COV INFECTION.
INCUBATION PERIOD
THE MEDIAN INCUBATION PERIOD
FOR SECONDARY CASES
ASSOCIATED WITH LIMITED
HUMAN-TO-HUMAN
TRANSMISSION IS
APPROXIMATELY 5 DAYS (RANGE
2-13 DAYS). IN MERS-COV
PATIENTS, THE MEDIAN TIME
FROM ILLNESS ONSET TO
HOSPITALIZATION IS
APPROXIMATELY 4 DAYS.
COMMON CLINICAL
PRESENTATIONS
COMMON SIGNS AND SYMPTOMS INCLUDE FEVER, CHILLS/RIGORS,
HEADACHE, NON-PRODUCTIVE COUGH, DYSPNEA, AND MYALGIA.
OTHER SYMPTOMS CAN INCLUDE SORE THROAT, CORYZA, NAUSEA
AND VOMITING, DIZZINESS, SPUTUM PRODUCTION, DIARRHEA,
VOMITING, AND ABDOMINAL PAIN. ATYPICAL PRESENTATIONS
INCLUDING MILD RESPIRATORY ILLNESS WITHOUT FEVER AND
DIARRHEAL ILLNESS PRECEDING DEVELOPMENT OF PNEUMONIA
HAVE BEEN REPORTED. PATIENTS WHO PROGRESS TO REQUIRING
ADMISSION TO AN INTENSIVE CARE UNIT (ICU) OFTEN HAVE A HISTORY
OF A FEBRILE UPPER RESPIRATORY TRACT ILLNESS WITH RAPID
PROGRESSION TO PNEUMONIA WITHIN A WEEK OF ILLNESS ONSET.
PATIENTS PRESENT WITH
WATCH FOR THESE SYMPTOMS:

FEVER (100 FAHRENHEIT OR
HIGHER). TAKE YOUR
TEMPERATURE TWICE A DAY.
COUGHING
SHORTNESS OF BREATH
OTHER EARLY SYMPTOMS TO
WATCH FOR ARE CHILLS, BODY
ACHES, SORE THROAT,
HEADACHE, DIARRHOEA,
NAUSEA/VOMITING, AND RUNNY
NOSE.

PROBABLE CASE
A PROBABLE CASE IS A PUI
WITH ABSENT OR
INCONCLUSIVE4
LABORATORY RESULTS
FOR MERS-COV
INFECTION WHO IS A
CLOSE CONTACT2 OF A
LABORATORY-CONFIRMED
MERS-COV CASE.
PATIENT UNDER INVESTIGATION
(PUI)
A PATIENT UNDER
INVESTIGATION (PUI) IS A
PERSON WITH THE FOLLOWING
CHARACTERISTICS: FEVER
(38C, 100.4F) AND
PNEUMONIA OR ACUTE
RESPIRATORY DISTRESS
SYNDROME (BASED ON
CLINICAL OR RADIOLOGICAL
EVIDENCE)
PATIENT UNDER INVESTIGATION
(PUI)
A HISTORY OF TRAVEL FROM COUNTRIES
IN OR NEAR THE ARABIAN PENINSULA1
WITHIN 14 DAYS BEFORE SYMPTOM
ONSET, OR
CLOSE CONTACT2 WITH A SYMPTOMATIC
TRAVELLER WHO DEVELOPED FEVER
AND ACUTE RESPIRATORY ILLNESS (NOT
NECESSARILY PNEUMONIA) WITHIN 14
DAYS AFTER TRAVELING FROM
COUNTRIES IN OR NEAR THE ARABIAN
PENINSULA
PATIENT UNDER INVESTIGATION
(PUI)
A MEMBER OF A CLUSTER OF
PATIENTS WITH SEVERE
ACUTE RESPIRATORY
ILLNESS (E.G. FEVER AND
PNEUMONIA REQUIRING
HOSPITALIZATION) OF
UNKNOWN AETIOLOGY IN
WHICH MERS-COV IS BEING
EVALUATED, IN
CONSULTATION WITH STATE
AND LOCAL HEALTH
DEPARTMENTS.
RADIOLOGICAL FINDINGS
RADIOGRAPHIC FINDINGS
MAY INCLUDE UNILATERAL OR
BILATERAL PATCHY
DENSITIES OR OPACITIES,
INTERSTITIAL INFILTRATES,
CONSOLIDATION, AND
PLEURAL EFFUSIONS. RAPID
PROGRESSION TO ACUTE
RESPIRATORY FAILURE,
ACUTE RESPIRATORY
DISTRESS SYNDROME
(ARDS),
CO-INFECTIONS IN MERS
CO-INFECTION WITH OTHER
RESPIRATORY VIRUSES AND A
FEW CASES OF CO-INFECTION
WITH COMMUNITY-ACQUIRED
BACTERIA AT ADMISSION HAS
BEEN REPORTED; NOSOCOMIAL
BACTERIAL AND FUNGAL
INFECTIONS HAVE BEEN
REPORTED IN MECHANICALLY-
VENTILATED PATIENTS.
MERS-COV AND PREGNANCY
THERE HAVE BEEN LESS OF A
HANDFUL CASES OF CONFIRMED
MERS-COV IN PREGNANCY. SO IT IS
VERY DIFFICULT TO DRAW
CONCLUSIONS ON THE EFFECT OF
MERS TO PREGNANCY. HOWEVER
TRADITIONALLY PREGNANT MOTHER
ARE CONSIDERED TO BE IN THE
HIGH RISK GROUP FOR MERS
COMPLICATIONS DUE TO THE
CHANGES IN THEIR IMMUNE
RESPONSE AND THE FETAL EFFECTS
OF A SEVERE RESPIRATORY
SYNDROME.
ROLE OF LABORATORIES
MOST STATE LABORATORIES
ARE APPROVED TO TEST FOR
MIDDLE EAST RESPIRATORY
SYNDROME CORONAVIRUS
(MERS-COV) USING CDC'S
RRT-PCR ASSAY. HOWEVER,
THEY SHOULD COORDINATE
WITH CDC FOR SPECIMEN
TESTING SINCE WIDELY
AVAILABLE DIAGNOSTIC
TESTS ARE NOT SUITABLE.
WHAT SPECIMEN TO
COLLECT
AS
BRONCHO ALVEOLAR
LAVAGE SPUTUM AND
TRACHEAL
ASPIRATES CONTAIN
THE HIGHEST VIRAL
LOADS AND THESE
SHOULD BE
COLLECTED WHEN
POSSIBLE

RT-PCR THE GOLD STANDARD
USE OF CDC'S 2012
REAL-TIME REVERSE
TRANSCRIPTIONPCR
ASSAY TO TEST FOR
MERS-COV IN CLINICAL
RESPIRATORY, BLOOD,
AND STOOL
SPECIMENS.
WHEN TO CONSIDER AS MERS-
COV INFECTION
CLUSTERS4 OF PATIENTS WITH SEVERE ACUTE
RESPIRATORY ILLNESS (E.G., FEVER AND PNEUMONIA
REQUIRING HOSPITALIZATION) WITHOUT RECOGNIZED LINKS
TO A CASE OF MERS-COV INFECTION OR TO TRAVELLERS
FROM COUNTRIES IN OR NEAR THE ARABIAN PENINSULA
SHOULD BE EVALUATED FOR COMMON RESPIRATORY
PATHOGENS.3 IF THE ILLNESSES REMAIN UNEXPLAINED,
PROVIDERS SHOULD CONSIDER TESTING FOR MERS-COV, IN
CONSULTATION WITH STATE AND LOCAL HEALTH
DEPARTMENTS.
INFECTION CONTROL MEASURES
HEALTHCARE PERSONNEL SHOULD
ADHERE TO RECOMMENDED INFECTION
CONTROL MEASURES, INCLUDING
STANDARD, CONTACT, AND AIRBORNE
PRECAUTIONS, WHILE MANAGING
SYMPTOMATIC CLOSE CONTACTS,
PATIENTS UNDER INVESTIGATION, AND
PATIENTS WHO HAVE PROBABLE OR
CONFIRMED MERS-COV INFECTIONS.
RECOMMENDED INFECTION CONTROL
PRECAUTIONS SHOULD ALSO BE UTILIZED
WHEN COLLECTING SPECIMENS.
PREVENTIVE MEASURES IN THE
HOSPITAL
FOCUS ON THE HOSPITAL SETTING,
THE RECOMMENDATIONS FOR
PERSONAL PROTECTIVE EQUIPMENT
(PPE), SOURCE CONTROL (I.E.,
PLACING A FACEMASK ON
POTENTIALLY INFECTED PATIENTS
WHEN OUTSIDE OF AN AIRBORNE
INFECTION ISOLATION ROOM), AND
ENVIRONMENTAL INFECTION
CONTROL MEASURES ARE
APPLICABLE TO ANY HEALTHCARE
SETTING.
UPDATED RECOMMENDATION
SUSPECTED HIGH RATE OF
MORBIDITY AND MORTALITY AMONG
INFECTED PATIENTS
EVIDENCE OF LIMITED HUMAN-TO-
HUMAN TRANSMISSION
POORLY CHARACTERIZED CLINICAL
SIGNS AND SYMPTOMS
UNKNOWN MODES OF
TRANSMISSION OF MERS-COV
LACK OF A VACCINE AND
CHEMOPROPHYLAXIS
INTERIM LABORATORY BIOSAFETY
GUIDELINES
TIMELY COMMUNICATION
BETWEEN CLINICAL AND
LABORATORY STAFF IS
ESSENTIAL TO MINIMIZE THE
RISK INCURRED IN HANDLING
SPECIMENS FROM PATIENTS
WITH POSSIBLE MERS-COV
INFECTION. SUCH SPECIMENS
SHOULD BE LABELED
ACCORDINGLY, AND THE
LABORATORY SHOULD BE
ALERTED TO ENSURE PROPER
SPECIMEN HANDLING.
STANDARD PRECAUTIONS
APPLY ROUTINELY IN ALL HEALTH-CARE SETTINGS FOR ALL
PATIENTS. STANDARD PRECAUTIONS INCLUDE:
HAND HYGIENE AND USE OF PERSONAL PROTECTIVE EQUIPMENT
(PPE) TO AVOID DIRECT CONTACT WITH PATIENTS BLOOD, BODY
FLUIDS, SECRETIONS (INCLUDING RESPIRATORY SECRETIONS) AND
NON-INTACT SKIN. WHEN PROVIDING CARE IN CLOSE CONTACT WITH
A PATIENT WITH RESPIRATORY SYMPTOMS (E.G.-COUGHING OR
SNEEZING), USE EYE PROTECTION, BECAUSE SPRAYS OF
SECRETIONS MAY OCCUR. STANDARD PRECAUTIONS INCLUDE:
PREVENTION OF NEEDLE-STICK OR SHARPS INJURY; SAFE WASTE
MANAGEMENT;CLEANING AND DISINFECTION OF EQUIPMENT; AND
CLEANING OF THE ENVIRONMENT
DROPLET
PRECAUTIONS
USE A MEDICAL MASK IF WORKING WITHIN 1 METER OF THE
PATIENT. PLACE PATIENTS IN SINGLE ROOMS, OR GROUP
TOGETHER THOSE WITH THE SAME ETIOLOGICAL
DIAGNOSIS. IF AN ETIOLOGICAL DIAGNOSIS IS NOT
POSSIBLE, GROUP PATIENTS WITH SIMILAR CLINICAL
DIAGNOSIS AND BASED ON EPIDEMIOLOGICAL RISK
FACTORS, WITH A SPATIAL SEPARATION OF AT LEAST 1
METER. LIMIT PATIENT MOVEMENT AND ENSURE THAT
PATIENTS WEAR MEDICAL MASKS WHEN OUTSIDE THEIR ROOMS
AIRBORNE
PRECAUTIONS
ENSURE THAT HEALTHCARE
WORKERS PERFORMING AEROSOL-
GENERATING PROCEDURES USE
PPE, INCLUDING GLOVES, LONG-
SLEEVED GOWNS, EYE
PROTECTION AND PARTICULATE
RESPIRATORS (N95 OR
EQUIVALENT). WHENEVER
POSSIBLE, USE ADEQUATELY
VENTILATED SINGLE ROOMS WHEN
PERFORMING AEROSOL-
GENERATING PROCEDURES
WORKING WITH POTENTIALLY
INFECTIOUS MATERIALS
LABORATORY WORKERS
SHOULD WEAR PERSONAL
PROTECTIVE EQUIPMENT
(PPE) WHICH INCLUDES
DISPOSABLE GLOVES,
LABORATORY COAT/GOWN,
MASK, AND EYE PROTECTION
WHEN HANDLING
POTENTIALLY INFECTIOUS
SPECIMENS.
MERS AND TRAVEL
CDC DOES NOT RECOMMEND THAT ANYONE CHANGE THEIR TRAVEL PLANS
BECAUSE OF MERS. THE CURRENT CDC TRAVEL NOTICE IS AN ALERT
(LEVEL 2), WHICH PROVIDES SPECIAL PRECAUTIONS FOR TRAVELERS.
BECAUSE SPREAD OF MERS HAS OCCURRED IN HEALTHCARE SETTINGS,
THE ALERT ADVISES TRAVELERS GOING TO COUNTRIES IN OR NEAR THE
ARABIAN PENINSULA TO PROVIDE HEALTHCARE SERVICES TO PRACTICE
CDCS RECOMMENDATIONS FOR INFECTION CONTROL OF CONFIRMED OR
SUSPECTED CASES AND TO MONITOR THEIR HEALTH CLOSELY.
TRAVELLERS WHO ARE GOING TO THE AREA FOR OTHER REASONS ARE
ADVISED TO FOLLOW STANDARD PRECAUTIONS, SUCH AS HAND WASHING
AND AVOIDING CONTACT WITH PEOPLE WHO ARE ILL.
MANY COUNTRIES TRACKING MERS
INFECTION SPREAD

PROGRAMME CREATED AND DESIGNED BY
DR.T.V.RAO MD FROM WEB RESOURCES OF WHO
AND CDC FOR UNIVERSAL EDUCATION ON
INFECTIOUS DISEASES
EMAIL
DOCTORTVRAO@GMAIL.COM