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  • 1. Overview ofMiddle EastRespiratorySyndrome(MERS-CoV)Prepared by :Dr.Safaa TunkarDr.Dina Al-HabibSaudi Board CommunityMedicine (R1).King Khalid UniversityHospital.6/11/13
  • 2. Introduction›  MERS-CoV was first reported in September2012 a Saudi businessman who died fromacute respiratory and renal failure›  The first beta coronavirus›  Enveloped single-stranded RNA viruses›  Ability to infect mammalian and avianhosts6/11/13
  • 3. Relation to SARS›  MERS-CoV is similar to SARS-CoV in termsof:Ø  VirulenceØ  Clinical symptomsØ  Zoonotic origin ?6/11/13
  • 4. Relation to SARS (cont’d)›  MERS-CoV is distinguished fromSARS-CoV by:Ø  Absence of severe disease among theclose contacts of patients of MERS,except among immunosuppressionØ  The genetic sequence of MERS is notsimilar to any other coronavirus inhumans, including SARS6/11/13
  • 5. Global Status›  From September 2012 to the last update(on 7 June 2013), WHO has been informedof a total of 55 laboratory-confirmedcases of infection with MERS-CoV,including 31 deaths›  Case-fatality rate: 56%›  Male-to-female ratio: 2.6 to 1›  All patients > 24 years old except 2children ( 2 & 14 y/o)6/11/13
  • 6. Global Status (cont’d)›  Several countries in the Middle East havebeen affected : Jordan, Qatar, SaudiArabia, and the United Arab Emirates(UAE)›  Cases have also been reported byadditional countries: France, Germany,Italy, Tunisia and the United Kingdom›  They were either transferred there for careof the disease or returned from the MiddleEast and subsequently became ill6/11/13
  • 7. Global Status (cont’d)6/11/13
  • 8. Global Status (cont’d)http://www.cdc.gov/mmwr/preview/mmwrhtml/mm62e0607a1.htm?s_cid=mm62e0607a1_w#fig16/11/13
  • 9. Saudi Arabia Status›  To date, there have been 40 confirmed cases inKSA including 25 deaths›  First case was reported in Besha region inSeptember 2012›  There was MERS-CoV outbreak at Al-Ahsa region inApril-May 2013 consisting 25 cases including 14deaths›  On June 5th 2013; the MOH reported a new case;a 14-year-old girl with underlying medicalconditions who became ill on 29 May 2013, fromthe Eastern region, but not from Al-Ahsa6/11/13
  • 10. Saudi Arabia’s First CaseCase 1 (fatal): Bisha- 60 yrs old Saudi businessman.Previously healthy. Non-smoker.- June 10 Admitted local hospital, CAP.-Transfer to Dr.Soliman Fakeeh Hospital,Jeddah, June 13th 2012Day 2 => ARDS intubated, ICU admissionDay 3 = ARF, hemodialysis.- Died June 24th 20126/11/13
  • 11. Health Care Workers›  15 MAY 2013 - MOH reported 2 laboratory-confirmed MERS cases›  Patients were health care workers›  Exposed to patients with confirmed MERS›  The first patient is a 45-year-old man who becameill on 2 May 2013 and is currently in a criticalcondition›  The second patient is a 43-year-old woman with acoexisting health condition, who became ill on 8May 2013 and is in a stable condition6/11/13
  • 12. Saudi Arabia Status(cont’d)6/11/13
  • 13. Epidemiological patterns1- Sporadic cases occur in communities2- Clusters of infections occur in families3- Clusters of infections in health carefacilitiesØ  Such events have been reported inFrance, Jordan and KSA6/11/13
  • 14. Characteristics of MERS-CoV› Clinical Presentation;Ø  FeverØ  Respiratory symptoms (not necessary theinitial presentation)Ø  +/- GI symptomsØ  Un-explained pneumonia6/11/13
  • 15. Characteristics of MERS-CoV(cont’d)› Risk Factors:Ø  Comorbidities and immunosuppression› Investigations:Ø  LRT specimen and nasopharyngealsamplesØ  PCR6/11/13
  • 16. EpidemiologicalCharacteristics of MERS-CoV›  Incubation period estimated: 9-12 days›  Small clusters of infection suggestingperson-to-person transmission in closecontact› Agent: from genetic sequencing; thevirus is most closely related tocoronaviruses detected in bat›  The original source and risk factors of theinfection are still under investigation6/11/13
  • 17. KSA Response6/11/13
  • 18. Situation in Hajj 20126/11/13
  • 19. 6/11/13
  • 20. Initial Stages for Investigation6/11/13
  • 21. KSA Response›  International experts were invited to help›  Surveillance for MERS-CoV cases›  Reporting to WHO›  Epidemiological investigations wereinitiated to identify the sources ofinfection, risk factors and routes oftransmission›  Household investigations›  Healthcare settings investigations›  Animal and ecological studies6/11/13
  • 22. Prevention Measures›  Systematic implementation of infectionprevention and controlØ  Especially droplet precautions among HCWand contact›  No vaccination available›  Increase awareness6/11/13
  • 23. International Actions›  Preparedness and protection ofcommunities›  Provide case definition, treatmentguidelines›  Action plan for risk assessment andmanagement›  Minimize the economic impact›  Share information and experiences6/11/13
  • 24. Challenges›  Limited information about the virus›  No treatment , only supportive›  Pressure of local community›  International concern about thetransmission around the world6/11/13
  • 25.    The  cases  seen  may  only  represent  the  0p  of  the  iceberg    6/11/13  
  • 26. References›  Zaki AM, Van Boheemen S, Bestebroer TM, Osterhaus ADME, FouchierRAM: Isolation of a novel coronavirus from a man with pneumonia inSaudi Arabia. N Engl J Med 2012, 367:1814-1820.›  WHO | Novel coronavirus infection – updatehttp://www.who.int/csr/don/2013_02_13/en/index.html›  Al-Ahdal MN, Al-Qahtani AA, Rubino S: Coronavirus respiratory illness inSaudi Arabia. J Infect Dev Ctries 2012, 6:692-694.›  AlBarrak AM, Stephens GM, Hewson R, Memish ZA: Recovery from severenovel coronavirus infection. Saudi Med J 2012, 33:1265-1269›  European Centre for Disease Prevention and Control. Updated rapid riskassessment: severe respiratory disease associated with Middle Eastrespiratory syndrome coronavirus (MERS-CoV). Stockholm, Sweden:European Centre for Disease Prevention and Control; 2013. Available athttp://www.ecdc.europa.eu/en/publications/publications/risk-assessment-middle-east-respiratory-syndrome-coronavirus-mers-cov-17-may-2013.pdf6/11/13
  • 27. References (cont’d)›  Al-Tawfiq JA, Zumla A, Memish ZA. Respiratory tract infections during theannual Hajj: potential risks and mitigation strategies. Curr Opin PulmMed. 2013 May;19(3):192-7. ›  Evidence of person-to-person transmission within a family cluster of novelcoronavirus infections, United Kingdom, February 2013. Euro Surveill2013;18(11):20427. available athttp://www.eurosurveillance.org/images/dynamic/EE/V18N11/art20427.pdf›  Novel coronavirus infection - update as of 22 May 2013. Geneva: WorldHealth Organization. http://www.who.int/csr/don/2013_05_22_ncov/en/Last accessed 22 May 2013.›  Al Rabeeah AA et al. Mass gatherings medicine and global healthsecurity. Lancet, 2012, 380:3–4.6/11/13
  • 28. References (cont’d)›  Al-Tawfiq J.A., Smallwood C.A.H., Arbuthnott K.G., Malik M.S.K., Barbeschi M., MemishZ.A. Emerging respiratory and novel coronavirus 2012 infections and mass gatherings.EMHJ. Vol. 19. 2013. Avalable at http://applications.emro.who.int/emhj/v19/Supp1/EMHJ_2013_19_Supp1_S48_S54.pdf›  Joseph C., Malik M.R., Mounts A.W., Mafi A. R., Briand S., Memish Z.A. Highlights andconclusions from the technical consultative meeting on novel coronavirus infection,Cairo, Egypt, 14–16 January 2013. EMHJ. Vol. 19. 2013. Avalable athttp://applications.emro.who.int/emhj/v19/Supp1/EMHJ_2013_19_Supp1_S68_S74.pdf›  Overview of the Novel Coronavirus. Ministry of Health.http://www.moh.gov.sa/en/HealthAwareness/Corona/Pages/AboutCorona.aspxLast accessed 10 June 2013›  Middle East respiratory syndrome coronavirus (MERS-CoV) – update. World HealthOrganization. http://www.who.int/csr/don/2013_06_07/en/index.html Last accessed11 June 20136/11/13
  • 29. 6/11/13