1.
MIDDLE EAST
RESPIRATORY SYNDROME
- CORONAVIRUS
DR.T.V.RAO MD

2.
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.

3.
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

4.
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

5.
STRUCTURE OF MERS VIRUS

6.
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

7.
WHY PALM TRESS IN THE MERS-COV
ACQUISITION MODEL...? A HYPOTHESIS?

8.
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

9.
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

10.
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

11.
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

12.
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.

13.
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

14.
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.

15.
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.

16.
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.

17.
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

18.
PATIENT UNDER INVESTIGATION
(PUI)
• A PATIENT UNDER
INVESTIGATION (PUI) IS A
PERSON WITH THE FOLLOWING
CHARACTERISTICS: FEVER
(≥38°C, 100.4°F) AND
PNEUMONIA OR ACUTE
RESPIRATORY DISTRESS
SYNDROME (BASED ON
CLINICAL OR RADIOLOGICAL
EVIDENCE)

19.
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

20.
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

21.
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

22.
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.

23.
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

24.
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

25.
WHAT SPECIMEN TO
COLLECT• AS
• BRONCHO ALVEOLAR
LAVAGE SPUTUM AND
TRACHEAL ASPIRATES
CONTAIN THE
HIGHEST VIRAL LOADS
AND THESE SHOULD BE
COLLECTED WHEN
POSSIBLE

26.
RT-PCR THE GOLD STANDARD
•USE OF CDC'S 2012
REAL-TIME REVERSE
TRANSCRIPTION–PCR
ASSAY TO TEST FOR
MERS-COV IN CLINICAL
RESPIRATORY, BLOOD,
AND STOOL SPECIMENS.

27.
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.

28.
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.

29.
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.

30.
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

31.
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

32.
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

33.
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

34.
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

35.
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.

36.
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 CDC’S
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.

37.
MANY COUNTRIES TRACKING MERS
INFECTION SPREAD

38.
• 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