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Management MERS-COV 12 july 2013
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Management MERS-COV 12 july 2013


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Taklimat berkenaan MERS-COV (Middle East Respiratory Syndrome-Corona Virus) - 12 Julai 2013 …

Taklimat berkenaan MERS-COV (Middle East Respiratory Syndrome-Corona Virus) - 12 Julai 2013

Virus ini mula tersebar di Arab Saudi, dan perhatian lebih perlu diberikan kepada jemaah-jemaah yang baru pulang dari Umrah di Makkah & Madinah, Arab Saudi.

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  • In consultation with WHO, the period for considering evaluation for MERS-CoV infection in persons who develop severe acute lower respiratory illness days after traveling from the Arabian Peninsula or neighboring countries* has been extended from within 10 days to within 14 days of travel. In new outbreaks, it is common for cases with the shortest incubation period to surface first, and for estimates of incubation periods to increase. Also, it would appear that respiratory symptoms may be mild or even absent at the outset of illness caused by the Middle East respiratory syndrome coronavirus. Clinicians should be alert to the possibility of infection with this pathogen and should contact the CDC if they encounter patients who develop severe acute lower respiratory illness within 14 days after returning from the endemic area — or are close contacts of such individuals.
  • We found that the index case in this cluster was co- infected with influenza. Type 2 parainfluenza virus was detected in the two secondary cases. This raises ques- tions about what roles these other infections might play in relation to nCoV transmissibility and/or the severity of the illness. In addition, as the index case was diag- nosed initially with influenza, this lead to a delay in recognition of nCoV. This highlights the importance of considering a diagnosis of nCoV in atypical cases (in this case the poor response to antiviral drugs), even if a putative alternative diagnosis has already been made. HPA guidance has been adapted accordingly [7]. irst reported case of a milder nCoV illness raises the possibility that the spectrum of clinical disease maybe wider than initially envisaged, and that a significant propor- tion of cases now or in the future might be milder or even asymptomatic.
  • Transcript

    • 1. Middle East respiratory syndrome coronavirus (MERS-CoV) Extract from the presentation by Dr Benedict Sim Infectious disease physician Hosp Sg Buloh 4 July 2013 1
    • 2. Outline • What will MERS-CoV look like? • Who has MERS-CoV? • Who to test? • How do test? • When and where to admit? • What infection control needed? • How to treat ? 2
    • 3. What will MERS-CoV look like? 3
    • 4. Pt characteristics (as of 7.6.13) Male to female ratio 2.6 : 1.0 Median age 56 years (range: 2–94 years) All aged >24 years, except 2 children(2 & 14 yrs) Deaths: Case fatality rate = 31/55 = 56% 4~14d after onset, 2~10d after hospitalization4
    • 5. Mortality 55% 5
    • 6. N Engl J Med 2013;368:2487-94. 6
    • 7. 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 nCoV illness – spectrum of clinical disease maybe wider 7
    • 8. This article was published on June 19, 2013, at 8
    • 9. 23 confirmed cases in Eastern Saudi Arabia • 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 9
    • 10. Clinical symptoms • Most - pneumonia. Some - GI symptoms, diarrhoea • 1 immuno-compromised patient - fever and diarrhoea; pneumonia only on CXR • Half have died. • Complications – respiratory failure – ARDS with multi-organ failure – renal failure requiring dialysis – consumptive coagulopathy – pericarditis 10
    • 11. Incubation period • Where exposure is known or strongly suspected - generally < 1/52 • In at least one case, 9 to 12 days • In a minority of cases, may exceed one week but is less than 2 weeks 11
    • 12. Route of transmission Undetermined Droplet and direct contact probably Large droplet transmission is suspected as the most likely route. B Guery 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). 12
    • 13. What we know • infections can occur across the age range – most in older people with comorbids • very high fatality rate • Sporadic cases in communities • limited person to person transmission – families & healthcare settings • Some travel-related cases, but no big outbreaks What we do not know • How people in communities get infected? • what is the main exposure? • what are the main risk factors? • what is the animal reservoir? 13
    • 14. Who has got MERS-CoV? 14
    • 15. 15
    • 16. WHO Interim case definition 3.7.13 Confirmed case • A person with laboratory confirmation of MERS-CoV infection. – molecular diagnostics including either +ve PCR on at least two specific genomic targets or a single +ve target with sequencing on a second. Probable case 16
    • 17. WHO Interim case definition 3.7.13 Probable case Febrile ARI Clinical, radiological/ HPE evidence (C/R/HPE) of pulm parenchymal ds (PPD) eg. pneumonia or ARDS Testing for MERS- CoV Contact history unavailable / negative on a single inadequate specimen Direct epid-link with a confirmed MERS-CoV case Inconclusive MERS- CoV (+ve screening test w/out confirmation) A resident of or traveler to Middle East 14/7 before onset of illness Of any severity Inconclusive MERS- CoV (+ve screening test w/out confirmation) Direct epid-link with a confirmed MERS-CoV case 17
    • 18. 1 Inadequate sp • NP swab without lower resp sp, • sp with improper handling, • judged to be poor quality by lab, • taken too late. 2 A 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 illness in the case under consideration. 3 Inconclusive tests may include: • A positive screening test without further confirmation eg positive on a single PCR target • A serological assay positive. 18
    • 19. Inconclusive testing: 3.7.13 1. Should undergo additional virologic and serologic testing. 2. Strongly advised that lower resp sp such as sputum, ET aspirate, or BAL be used. 3. If no S&S of LRTI and lower track sp not available or clinically indicated, both NP and OP swab sp should be collected. 4. If NP swab is negative in a pt strongly suspected to have MERS-CoV infection, retest using a lower resp sp or a repeat NP sp with additional OP sp and paired acute and convalescent sera. 19
    • 20. Who to test? MOH 14.6.13 20
    • 21. Patient Under Investigation (PUI) • SARI, (include history of fever and cough) and indications of PPD (e.g., pneumonia or ARDS), based on clinical or radiological evidence of consolidation, (possibility of atypical presentations in immunocompromised) AND • Travel to the Middle East 14/7 before AND • Not explained by other aetiology SARI = severe acute respiratory illness PPD = pulmonary parenchymal disease 21
    • 22. Contacts • ARI of any severity, – 14 days before onset of illness – close physical contact with a confirmed or probable case of MERS-CoV infection  • 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 illness 22
    • 23. Who to test? WHO 27.6.13 23
    • 24. Who should be investigated?- summarized • SARI + PPD + either – In a cluster (within 14/7) – HCW exposed to pt with severe LRTI – Traveled to middle east - 14/7 – unexpected clinical course unexplained by current aetiology • ARI of any severity – close contact with confirmed/probable MERS-CoV within 14/7 • Middle East, any ventilated pt SARI = severe acute respiratory illness PPD = pulmonary parenchymal disease 24
    • 25. SARI + PPD + either • cluster (>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, WRTHOT unless another aetiology identified (UAAI). • HCW working with severe ARI patients (particularly ICU) WRTHOT UAAI • travel to the Middle East within 14 days before onset of illness, UAAI. • unusual or unexpected clinical course, especially sudden deterioration despite appropriate treatment, WRTHOT , even if another aetiology has been identified, if it does not fully explain the presentation or clinical course of the patient. WRTHOT = without regard to history of travel 25
    • 26. How to test? 26
    • 27. WHO 27 June 2013 update • Stronger recommendations for lower respiratory specimens, rather than NP swabs, to be used to diagnose MERS-CoV infection. 27
    • 28. WHO 27.6.13 • NP swabs are not as sensitive as lower respiratory specimens – BAL, tracheal aspirate, sputum • If patients do not have LRTI or specimens not possible, both NP and OP should be collected 28
    • 29. When to admit? Where to admit? 29
    • 30. Respiratory impairment: any of the following Tachypnoea, respiratory rate > 24/min Inability 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 Respiratory exhaustion Chest pains Evidence of clinical dehydration or clinical shock Systolic BP < 90mmHg and/or diastolic BP < 60mmHg Capillary refill time > 2 seconds, reduced skin turgor Altered Conscious level (esp. in extremes of age) New confusion, striking agitation or seizures Other clinical concerns: Rapidly progressive (esp. high fever > 3 days) or serious atypical illness Severe & persistent vomiting 30
    • 31. 31
    • 32. 32
    • 33. 33
    • 34. 34
    • 35. 35
    • 36. What infection control needed? 36
    • 37. 37
    • 38. Administrative controls • Most important • From door to door • Infrastructures and equipment • Education of HCWs • Prevent overcrowding in waiting areas • Placement of hospitalized patients • Occupational health; seeking medical care • Monitoring of compliance. • Rapid identification of patients. Triaging ! 38
    • 39. Environmental and engineering controls • Adequate ventilation • Regular environmental cleaning • Spatial separation of at least 1 m 39
    • 40. PPE • Rational and consistent use of PPE and appropriate hand hygiene. In this document, the term "medical mask" refers to disposable surgical or procedure masks. 40
    • 41. 41
    • 42. Isolation precautions Standard precautions + Droplet precautions + Contact precautions Airborne for aerosol generating proceedures 42
    • 43. 43
    • 44. 44
    • 45. 45
    • 46. How to treat ? 46
    • 47. No antiviral available ! 47
    • 48. 48
    • 49. Early recognition and management • Recognize SARI • Initiate infection control measures • Give supplemental O2 therapy • Collect respiratory and other sp for lab testing • Empiric antimicrobials for suspected pathogens • Conservative fluids when no 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/shock49
    • 50. 50
    • 51. Thank you 51