This document summarizes updated guidelines from the Ministry of Health in Saudi Arabia regarding Middle East Respiratory Syndrome Coronavirus (MERS-CoV). It discusses what coronaviruses are, symptoms of MERS-CoV, case definitions, diagnostic testing, infection control protocols, and management of confirmed cases. Key points include that MERS-CoV causes severe acute respiratory illness, transmission is still under investigation but likely includes direct/indirect contact or droplets, and management involves isolation precautions, monitoring of contacts, and supportive care for patients.

1. Updates in MOH Guidelines for
Middle East Respiratory
Syndrome Corona virus
(MERS-CoV)
Dr Mostafa Mahmoud, MD, Ph D,
Consultant Microbiologist
Labs & Blood Banks Admin, Riyadh.
Head of IPC Dept. Iman Hospital
Assist. Prof. of Medical Microbiology &
Immunology

2. Coronaviruses are common viruses that
most people get some time in their life.
Human coronaviruses usually cause mild
to moderate upper-respiratory tract
illnesses in 25% of Common cold.
Q: What are coronaviruses?
Why it is called Coronavirus?
Because of the surface glycoprotein
spikes seen by EM and surrounding
the whole virus like a crown.

3. EM Picture. Diagrammatic

4.  Single-stranded RNA virus 30 000
nucleotide, positive-sense, enveloped.
 Enveloped virus i.e. not affecting GIT die out
due to gastric secretions.
 3 groups of the virus affecting human and
animals.
 Coronavirus can undergo dramatic change in
virulence and tissue tropism e.g. change in
spike gives SARS-CoV or MERS-CoV.

6. Group Representative Virus
Group 1 Human coronavirus 229E (HCoV-229E)
Human coronavirus NL63 (HCoV-NL63)
Canine enteric coronavirus (CCoV)
Feline coronavirus (FCoV)
Porcine transmissible gastroenteritis coronavirus (TGEV)
Porcine epidemic diarrhoea coronavirus (PEDV)
Bat coronaviruses (BtCoVs)
Group 2 Human coronavirus HKU1 (HCoV-HKU1)
Bovine coronavirus (BCoV)
Canine respiratory coronavirus (CRCoV)
Porcine hemagglutinating encephalomyelitis coronavirus (HEV)
Murine hepatitis coronavirus (MHV)
Feline infectious peritonitis virus (FIPV)
SARS coronaviruses (SARS-CoVs)
Bat coronaviruses (BtCoVs)
Group 3 Infectious bronchitis coronavirus (IBV)
Turkey coronavirus (TCoV)
Pheasant coronavirus (PhCoV)

7.  No; it affects human
allover the world and was
known since 1960s.
Affecting all people but
mostly children.
Causing 25% of Colds.
The only severe form of it
was SARS-CoV who
disappeared since 2004.

8.  Direct and Indirect contact.
Droplet infections.
But still needs to be more
determined.

9.  It is mild to moderate upper respiratory
tract infection “cold”.
 Re-infection of the individual with the
same serotype can occur within months
i.e. short lived immunity.

10. The first new one was called SARS-CoV.
The running one nowadays is the Middle
East Respiratory Syndrome corona virus
“MERS-CoV”.

11. Appeared in 2002 in China.
Emerged from animal reservoir.
 IP 2-14 days, droplet infection.
Affected 8000 patients in 29 countries
of the world .
Had 9.6% Mortality rate (744 cases).
Disappeared in 2004.
Low pathogenicity, not transmitted
from human to human, no vaccine.

12.  Appeared in 2012.
Human –to-human transmission confirmed.
Mode of transmission not yet confirmed.
(respiratory secretion, direct & Indirect
contact)
Reservoir of infection not yet determined.
(from Bats to Camels to Humans?)
Incubation period (2-14 days) not yet
confirmed.

13.  Based on DNA sequencing, researcher speculate that MERS coronavirus started
in infected bats in Egypt or the horn of Africa (left panel). They suspect that the
winged mammals transmitted the microbe to one-humped camels, where the virus
circulated possibly for decades, before hopping into humans. Since camels are an
accessible intermediate host, some groups have proposed vaccines for the
hooved animals to prevent future spread to humans. Source: Papaneri, AB et al.
Expert Rev. Vaccines. 2015.

14. Are we the
reservoir of
MERS CoV my
dear??

15. Calm down
my dear we
love you
anyway

18. Total cases Total deaths Last case
Korea & 185 36 (19.4%) 4-7-2015
China 1
KSA 1225 521 (42.5%)
9-9-2015
Still running

19. 1* Suspected cases:
A- ADULTS (> 14 years):
I. Acute respiratory illness with clinical and/or
radiological, evidence of pulmonary
parenchymal disease (pneumonia or Acute
Respiratory Distress Syndrome (ARDS).
II. A hospitalized patient with healthcare
associated pneumonia based on clinical and
radiological evidence.

20. III. Upper or lower respiratory illness within 2
weeks after exposure to a confirmed or
probable case of MERS-CoV infection
IV- Unexplained acute febrile (≥38°C) illness,
AND body aches, headache, diarrhea, or
nausea/vomiting, with or without respiratory
symptoms, AND leucopenia (WBC < 3.5 x
109/L) and thrombocytopenia (platelets
<150 x 109/L).

21. I. Meets the above case definitions and
has at least one of the following
a. History of exposure to a confirmed or
suspected MERS CoV in the 14 days
prior to onset of symptoms
b. History of contact with camels or
camel products in the 14 days prior to
onset of symptoms
II. Unexplained severe pneumonia.

22. A probable case is a patient in category I or
II above (Adult or pediatrics) with
inconclusive laboratory results for MERS-
CoV and other possible pathogens who is a
close contact of a laboratory-confirmed
MERS-CoV case OR who works in a
hospital where MERS-CoV cases are cared
for OR had recent contact with camels or
camel’s products.

23. A confirmed case is a suspect case with
laboratory confirmation of MERS-CoV
infection.
 More information about case definitions:
1- WHO:
http://www.who.int/csr/disease/coronavirus_infections
/case_definition_jul2014/en/
2- CDC:
http://www.cdc.gov/coronavirus/mers/case-def.html

24. 1- Exclude other causes of pneumonia and respiratory tract
infections.
2- The suitable samples are sputum, BAL, tracheal aspirate
(No VTM).
3- Swabbing of nasopharynx, nose/throat, on VTM.
4- All samples are to sent to the lab immediately or kept
frozen in dry ice > 24 H.
5- Serum for serology or virus detection and EDTA
whole blood for PCR.

25. N.B.
The diagnostic test approved and applied
by the MOH is the PCR one.
Serology by finding seroconversion in
double samples is applied by some other
countries.

28. 1. History of contact with camels or its products
in the last 14 days.
2. All suspected cases nasopharyngeal swab +
orophryngeal swab & LRT secretions when
intubated.
3. Swabbing for asymptomatic contacts only for
exposed unprotected HCWs or in outbreaks.
4. Positive lab test for other causes of
pneumonia does not exclude MRES CoV.

29. A- Standard precautions;
1- Hand hygiene (5 moments- washing or
rubbing- water when soiled- gloves not
eliminate washing).
2- Respiratory precautions:
-Visual alerts:- (coughing- HH- tissues)
- Separation of respiratory patients:
(Triage- mask- cough etiquette- no
overcrowding and distances in waiting).

30. Units Recommended distances
General ward A minimum of 1.2 meters between beds
Critical care unit (ICUs) A minimum of 2.4 meters between beds
Hemodialysis Units A minimum of 1.2 meters between beds
Emergency Units A minimum of 1.2 meters between beds
3– Environmental ventilation in all areas within a
health-care facility.
4– Environmental cleaning and/or disinfection.
5– Prevention of needle-stick or sharps injury.
6– Safe waste management (Medical waste).

32. 1- Isolation:

33. Pressure Monitor
Private Bathroom
AnteroomHEPA filter
Air Pumping & suction separated from hospital

35. - Non-critically ill: segregated single room +
HEPA, AGP in negative pressure room.
- Critically-ill: airborne negative pressure
isolation room.
- If not available : well ventilated single room
- If not available: cohorting
- If not available: put patients in beds with
1.2 meters distances.
- Transport of patient limited and prepared if
necessary and patient must wear surgical
mask on transport.

36. A must when caring isolated patients.
Donning order:
1- HH 2- Gown
3- Mask (surgical for rooms & N95 for airborne)
4- Eye protection 5- Gloves
Doffing order in anteroom:
1- Gloves, 2- Eye protection,
3- Gown 4- Mask (removed outside
negative pressure room). 5- HH

38. Fit test is a must for HCWs entering negative
pressure and performed annually.

39.  Aerosol are particles < 5 µm in diameter.
 Infectious aerosol particles travel in air more than 1
meter.
 These procedures include: bronchoscopy, sputum
induction, elective intubation and extubation, also
emergency procedures such as CPR, emergency
intubation, open suctioning of airways, manual
ventilation via umbo bagging through a mask.
 Bilevel Positive Airway Pressure – BiPAP is not
recommended in MERS patients.
 PPE for AGP include N95 mask, gown, eye
protection in a negative pressure room.

40.  Hypoxemia, and/or clinical or radiological
evidence of pneumonia should be admitted.

41. For mild cases of MER-CoV infections.
Home should be suitable for isolation.
Instructions for the patient in home isolations to
be clear and followed.
Instructions for the care givers to the patient at
home.
Instructions for the other house-hold contacts.
Close contacts to be followed for 14 days for
any symptoms or signs of MERS.

42.  High-risk unprotected exposure (Contact with
confirmed MERS-CoV case within 1.5 meters for >
10 minutes): single swabbing, off work till negative
results.
 Low-risk unprotected exposure (Contact with
confirmed MERS-CoV case more than 1.5 meters
and/or for < 10 minutes): continue work and not
testing.
 Protected exposure (Contact with confirmed
MERS-CoV case and having appropriate isolation
precautions including the PPE): continue work and
no testing.

43.  Definitely unknown
 However it is guided by clinical picture and 2
negative lower respiratory samples for MERS-CoV.
 Negative samples to be repeated after 1 week for
improving patient.
 No need for repeated sampling for non-improving
patient.
 Home-isolated patients to be tested after 1 week
isolation and then every 3 days, stop isolation
when patient is asymptomatic or negative single
PCR test.

44. Deceased bodies should be washed by
regional secretariats and municipalities of the
ministry of municipality and rural affairs.
If family member wishes to do washing, this
must be under supervision and wearing all PPE.

45.  Malik Peiris JS and LLM Poon 2009. Coronaviruses and Toroviruses, pp 511-531. In,
Principle and Practice of Clinical Virology, 6th edition. Edited by A. J. Zuckerman, J. E.
Banatvala, B. D. Schoub, P. D. Griffiths and P. Mortimer © 2009 John Wiley & Sons
Ltd. ISBN: 978-0-470-51799-4.
 Command and Control Center, Ministry of Health, Kingdom of Saudi Arabia, Scientific
Advisory Board, Infection Prevention and Control Guidelines for Middle East,
Respiratory Syndrome Coronavirus (MERS-CoV) Infection, 3rd Edition. June 2015.
 MOH CCC website: http://www.moh.gov.sa/en/ccc/Pages/default.aspx.
 http://www.cdc.gov/coronavirus/about/index.html.
 http://www.who.int/csr/disease/coronavirus_infections/LaboratoryTestingNovelCoronavi
rus_21Dec12.pdf.
 http://www.who.int/csr/disease/coronavirus_infections/InterimRevisedSurveillanceReco
mmendations_nCoVinfection_18May13.pdf.