This document provides information on Middle East Respiratory Syndrome Coronavirus (MERS-CoV), including: - MERS-CoV is a novel coronavirus that was first identified in Saudi Arabia in 2012 and causes severe respiratory illness. About half of confirmed cases have been fatal. - The virus is thought to originate from bats and possibly be transmitted by camels, though the animal reservoir is still unknown. Limited human-to-human transmission can occur in healthcare settings and among family contacts. - Recommendations are provided for testing, treatment, prevention, and healthcare worker protocols for suspected MERS-CoV cases. Ongoing surveillance is needed as the virus poses a risk of spread outside the Middle East.

1. Middle East respiratory Syndrome Coronavirus
(MERS-CoV)
By
Dr. ASHRAF ELADAWY
Consultant Chest Physcian
TB TEAM Expert – WHO
September -2O13

2. Middle East respiratory Syndrome Coronavirus
(MERS-CoV)
Middle East Respiratory Syndrome (MERS) is viral
respiratory illness first reported in Saudi Arabia in 2012.
It is caused by a novel 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
half of these people died.
Background information
 Human coronaviruses were first identified in the mid 1960s and are named
after the crown-like projections that can be seen on the surface of the virus.
 These viruses cause respiratory infections of varying severity in humans and
animals.
 in humans Coronaviruses may cause illness ranging from mild symptoms
such as common cold to more serious respiratory illnesses, such as Severe
Acute Respiratory Syndrome (SARS).
 There are 4 main sub-groupings of coronaviruses, known as alpha, beta
,gamma and delta.
Infectious agent
 The Middle East respiratory syndrome coronavirus (MERS-CoV) is a novel
coronavirus (nCoV) first reported on 24 September 2012 by Egyptian
virologist Dr. Ali Mohamed Zaki in Jeddah, Saudi Arabia.

3.  “Middle East Respiratory Syndrome Coronavirus” (MERS-CoV) is a Novel
coronavirus (particular strain of coronavirus that has not been previously
identified in humans).
 Early reports compared the virus to severe acute respiratory syndrome
(SARS), and it has been referred to as Saudi Arabia's SARS-like virus
 MERS-CoV used to be called “novel coronavirus,” or “nCoV” , however the
Coronavirus Study Group (CSG) of the International Committee on
Taxonomy of Viruses (ICTV) decided in May 2013 to call the novel
coronavirus “Middle East Respiratory Syndrome Coronavirus” (MERS-CoV)
 Middle East Respiratory Syndrome Coronavirus (MERS-CoV) belongs to the
genus Betacoronavirus as does SARS-CoV
 MERS-CoV is not the same coronavirus that caused severe acute respiratory
syndrome (SARS) in 2003. However, like the SARS virus, the novel
coronavirus is most similar to those found in bats.
 Although both viruses are capable of causing severe disease, current
information indicates that MERS-CoV does not appear to transmit easily
between people whereas the SARS virus was much more transmissible.
Source of the infection
 No definitive animal host for the MERS-CoV has been confirmed to date but
bats and camels are suspects for now.
 At this stage the exact origin is unclear, but studies of the virus’s genetic
material suggest that bat corona viruses are the nearest relatives.

4.  In addition, scientists have recently discovered antibodies circulating
within the camel population, which may have been directed against either
the MERS virus, or a remarkably similar virus. Whether this finding has any
direct implications on infectivity and spread amongst the human
population remains to be seen
Global distribution of MERS-CoV cases...
 Cases are all be linked to a point of origin in the Arabian Peninsula, in
particular, the Kingdom of Saudi Arabia (KSA).
 Nine countries have now reported cases of human infection with MERS-
CoV
o Countries where cases acquired infection in-country from an
unknown source Jordan, KSA, Qatar, UAE (United Arab Emirates)
o Countries where cases are associated with travel or contact with a
returned infected traveler Germany, France, Tunisia, UK, Italy
o All reported cases have had some connection (whether direct or
indirect) with the Middle East and have been linked to four countries
in or near the Arabian Peninsula.
o In France, Italy, Tunisia and the United Kingdom, limited local
transmission has occurred in people who had not been to the Middle
East but who had been in close contact with laboratory-confirmed or
probable cases.
o No cases have been identified in the Egypt uptill now.
MERS Cases and Deaths
April 2012 – Present

5. Quick numbers
 Total human cases of MERS-CoV: 130
 Total deaths attributed to infection with MERS-CoV: 58
 Current Case Fatality Rate (CFRd
): 45%
 April 2012 – Present
Current as of September 30
Countries Cases (Deaths)
France 2 (1)
Italy 1 (0)
Jordan 2 (2)
Qatar 5 (3)
Saudi Arabia 108 (47)
Tunisia 3 (1)
United Kingdom (UK) 3 (2)
United Arab Emirates (UAE) 6 (2)
Total 130 (58)
Transmission...
 The original source(s), route(s) of transmission to humans, and the mode(s)
of human-to-human transmission have not been determined.
 Droplet and direct contact probably
 Settings where infection has occurred :
1. Communities: Sporadic cases with unknown exposure
2. Families: contact with infected family members
3. Health care facilities: patients & health care workers

6. Evidence for limited person-to-person transmission in some clusters
 The mechanism by which transmission occurred in all of these cases,
whether respiratory (e.g. coughing, sneezing) or contact (contamination of
the environment by the patient), is unknown.
 All clusters reported to date have occurred among family contacts or in a
health care setting.
 Human-to-human transmission is not sustained, has only been observed in
health care facilities and close family contacts and sustained transmission in
the community has not been observed.
 So far there is only evidence of limited, non-sustained person-to-person
transmission
 Given the severity of the illness caused by the virus it is considered prudent
to use a high level of personal protective equipment when caring for any
case with a confirmed diagnosis. Additional measures include isolation of
the patient and barrier nursing.
 Transmission has occurred in health-care facilities, WHO recommends that
health-care workers consistently apply appropriate infection prevention and
control measures.
 Any clusters of severe acute respiratory infection (SARI) in health-care
workers should be thoroughly investigated.
Incubation period
 Persons who develop severe acute respiratory illness within 14 days after
traveling from the Arabian Peninsula or neighboring countries should be
evaluated according to current WHO guidelines

7. Clinical features
 All of the laboratory confirmed cases had respiratory disease as part of the
illness, and most had severe acute respiratory disease requiring
hospitalization.
 Common symptoms are acute, serious respiratory illness with fever, cough,
shortness of breath and breathing difficulties.
 Pneumonia has been the most common clinical presentation
 Most patients were reported to have at least one comorbidity.
 Patients with comorbidities or immunosuppression might be at increased
risk for infection, severe disease, or both.
 In people with immune deficiencies, the disease may have an atypical
presentation, such as diarrhoea ,may present atypically, and initially without
respiratory symptoms
 Although most cases have been characterised by a severe illness, milder
illness has been detected
 Most cases are in males older than 45-years with underlying medical
conditions. Disease in children seems to be milder. No deaths, and few cases
have occurred among those under the age of 21-years.
 Complications: In fatal cases, Acute Respiratory Distress Syndrome (ARDS),
acute renal failure requiring hemodialysis, and disseminated intravascular
coagulation, pericarditis, heart failure, and multiple organ failure were
predominant.

Diagnosis
 The main test for this particular coronavirus is a screening PCR tests
(polymerase chain reaction) test followed by a more specific confirmatory
test
 Nasopharyngeal swabs may be less sensitive than specimens of the lower
respiratory tract according to WHO, June 2013.
Laboratory testing
Collect specimens for MERS-CoV testing from all PUIs (patient under investigation)
 An upper respiratory specimen:
 Nasopharyngeal AND oropharyngeal swab

8.  A lower respiratory specimen:
 Sputum, OR
 Broncheoalveolar lavage, OR
 Tracheal aspirate, OR
 Pleural fluid
 Patient samples from the lower respiratory tract, not just the
nasopharynx/throat.
 if lower respiratory tract specimens are not possible both nasopharyngeal
and oropharyngeal swab specimens should be collected, as well as stool and
serum.
WHO criteria for “patient under investigation (PUI)” for MERS-CoV
infection:
The following people should be investigated and tested for MERS-CoV:
1. A patient with SARI (A person with an acute respiratory infection, which
may include history of fever or measured fever (≥ 38 °C, 100.4 °F) and
cough) AND indications of pulmonary parenchymal disease (e.g. pneumonia
or ARDS), based on clinical or radiological evidence of consolidation, who
requires admission to hospital. In addition,
clinicians should be alert to the possibility of atypical presentations in
patients who are immunocompromised.
AND any of the following:
a) The disease is in a cluster that occurs within a 14 day period, without
regard to place of residence or history of travel, unless another
aetiology has been identified.
b) The disease occurs in a health care worker who has been working in
an environment where patients with severe acute respiratory
infections are being cared for, particularly patients requiring intensive
care, without regard to place of residence or history of travel, unless
another aetiology has been identified.

9. c) The person has history of travel to the Middle Eastwithin 14 days
before onset of illness, unless another aetiology has been identified.
d) The person develops an unusual or unexpected clinical course,
especially sudden deterioration despite appropriate treatment,
without regard to place of residence or history of travel, even if
another aetiology has been identified, if that alternate aetiology does
not fully explain the presentation or clinical course of the patient.
2. Individuals with acute respiratory illness of any degree of severity who,
within 14 days before onset of illness, were in close physical contactwith a
confirmed or probable case of MERS-CoV infection, while that patient was
ill.
3. For countries in the Middle East, the minimum standard for surveillance
should be testing of patients with severe respiratory disease requiring
mechanical ventilation.
o Countries in the Middle East are also strongly encouraged to consider
adding testing for MERS-CoV to current testing algorithms as part of
routine respiratory disease surveillance and diagnostic panels for
pneumonia.
o Any patients currently in the hospital with unexplained SARI should be
considered for testing for MERS-CoV.
o It is not necessary to wait for test results for other pathogens before
testing for novel coronavirus.
Treatment
 There is no specific treatment for novel coronavirus infection; care is
supportive.
 Although the patient may be suspected to have novel coronavirus infection,
administer appropriate empiric antimicrobials as soon as possible for
community-acquired pathogens based on local epidemiology and guidance
until the diagnosis is confirmed

10. Vaccine availability
 No vaccine is currently available.
Travel advice to the Middle East
 Given that there have only been a relatively small number of confirmed
cases worldwide, WHO does not recommend any travel or trade restrictions
with respect to MERS-CoV.
 Because of the risk of MERS, Saudi Arabia recommends that the following
groups should postpone their plans for Hajj and Umrah this year:
1. People over 65 years old
2. Children under 12 years old
3. Pregnant women
4. People with chronic diseases (such as heart disease, kidney disease,
diabetes, or chronic respiratory diseases)
5. People with weakened immune systems
6. People with cancer or terminal illnesses
 The virus that causes MERS can spread from person to person through
close contact, so pilgrims living and traveling in crowded conditions may
be at risk.
How can people protect themselves from getting MERS-CoV?
o It is not possible to give specific advice on prevention, as neither the source
of the virus nor the mode of transmission is yet certain.
o Maintain good hand hygiene, Wash your hands often with soap and water
for 20 seconds, If soap and water are not available, use an alcohol-based
hand sanitizer.
o Practise proper cough and sneeze etiquette: Cover your mouth and nose
with your arm to reduce the spread of germs. Remember if you use a tissue,
dispose of it as soon as possible and wash your hands afterwards.
o Avoid touching your eyes, nose, and mouth with unwashed hands.

11. o Avoid close contact, when possible,with sick people.
o Clean and disinfect frequently touched surfaces, such as toys and
doorknobs.
What Health Care workers should do in case of a suspected MERS-CoV
infection:novel ?
1. Place the patient (suspect, confirmed and probable cases ) in a negative
pressure room if available, or in a single room from which the air does not
circulate to other areas .
2. Implement standard and transmission-based precautions (contact and
airborne), including the use of personal protective equipment (PPE).

12. 3. Airborne transmission precautions, including routine use of a P2 (N95)
respirator, disposable gown, gloves, and eye protection when entering
a patient care area;
4. Standard and contact precautions, including close attention to hand hygiene
5. If transfer of the patient outside the negative pressure room is necessary,
asking the patient to wear a correctly fitted submicron face (surgical) mask
while they are being transferred and to follow respiratory hygiene and
cough etiquette.
6. Appropriate specimens should also be collected for MERS-CoV PCR testing.
7. Investigate and manage the patient as for community acquired pneumonia,
administer appropriate empiric antimicrobials as soon as possible for
community-acquired pathogens based on local epidemiology and guidance
until the diagnosis is confirmed
8. The local Medical Officer of Health should be notified promptly of any
suspected (and probable or confirmed) cases.
This document is based on WHO and CDC guidance.
Based on the current situation and available information,
 WHO encourages all Member States to enhance their surveillance for severe
acute respiratory infections (SARI) and to carefully review any unusual
patterns of SARI or pneumonia cases
 There is a great possibility of transmitting the virus outside Saudi Arabia
because many people are working in Saudi Arabia, many people are visiting
Saudi Arabia for religious tourism
 Countries in the Middle East in particular should maintain a high level of
vigilance and a low threshold for testing of suspect cases
 At this point, several urgent actions are needed. The most important ones
are the need for countries to increase their levels of awareness among all
people but especially among staff working in their health systems and to
increase their levels of surveillance about this new infection

13.  Health care facilities that provide care for patients with suspected MERS-
CoV infection should take appropriate measures to decrease the risk of
transmission of the virus to other patients and health care workers.
 Health care facilities are reminded of the importance of systematic
implementation of infection prevention and control (IPC) when
MERS-CoV is suspected.
 WHO does not advise special screening at points of entry.
Final Messages!
“The only thing more difficult than planning for an emergency is having to explain
why you didn’t.” Be
Proactive NOT Reactive!!!!
Protocol For Management of Severe acute respiratory
infections when MERS- CoV is suspected
(A) The following people should be investigated and tested for
MERS-CoV: (WHO 27 June 2013)
1. A patient with SARI (A person with an acute respiratory infection, which
may include history of fever or measured fever (≥ 38 °C, 100.4 °F) and
cough) AND indications of pulmonary parenchymal disease (e.g.
pneumonia or ARDS), based on clinical or radiological evidence of
consolidation, who requires admission to hospital.
In addition, clinicians should be alert to the possibility of atypical
presentations in patients who are immunocompromised.
AND any of the following:
I. The disease is in a cluster that occurs within a 14 day period, without
regard to place of residence or history of travel, unless another aetiology
has been identified.
II. The disease occurs in a health care worker who has been working in an
environment where patients with severe acute respiratory infections are

14. being cared for, particularly patients requiring intensive care, without
regard to place of residence or history of travel, unless another aetiology
has been identified.
III. The person has history of travel to the Middle Eastwithin 14 days before
onset of illness, unless another aetiology has been identified.
IV. The person develops an unusual or unexpected clinical course, especially
sudden deterioration despite appropriate treatment, without regard to
place of residence or history of travel, even if another aetiology has been
identified, if that alternate aetiology does not fully explain the presentation
or clinical course of the patient.
2. Individuals with acute respiratory illness of any degree of severity who,
within 14 days before onset of illness, were in close physical contactwith a
confirmed or probable case of MERS-CoV infection, while that patient was
ill.
3. For countries in the Middle East, the minimum standard for surveillance
should be testing of patients with severe respiratory disease requiring
mechanical ventilation.
(B) Recommendations for specimen collection (WHO -July 2013)
1. Lower respiratory tract specimens (sputum, brochoalveolar lavage,
endotracheal) are preferred for PCR testing as they are expected to have
greater sensitivity than other specimens
2. If patients do not have signs or symptoms of lower respiratory tract
infection and lower tract specimens are not possible , both nasopharyngeal
and oropharyngeal specimens should be collected. The two can be
combined in a single collection container and tested together.
3. If initial testing of a nasopharyngeal swab is negative in a patient who is
strongly suspected to have MERS-CoV infection, patients should be retested
using a lower respiratory specimen or a repeat nasopharyngeal specimen
with additional oropharyngeal specimen if lower respiratory specimens are
not possible.
4. Collect routine clinical specimens (e.g. blood and sputum bacterial cultures)
for community-acquired pneumonia, ideally before antimicrobial use.

15. 5. Collect respiratory specimens from the upper respiratory tract (i.e. nasal,
nasopharyngeal and/or throat swab) and lower respiratory tract (i.e.
sputum, endotracheal aspirate, bronchoalveolar lavage) for known
respiratory viruses (such as influenza A and B, influenza A virus subtypes H1,
H3, and H5 in countries with H5N1 viruses circulating among poultry)
6. It is not necessary to wait for test results for other pathogens before testing
for novel coronavirus.
7. Health care workers collecting clinical specimens should exercise
appropriate infection control measures including use of personal protective
equipment.
(C) Contact monitoring
Close contacts of confirmed or probable cases should be identified and monitored
for the appearance of respiratory symptoms for 14 days after last exposure to the
confirmed or suspected case, while the case was symptomatic. Any contact that
becomes ill in that period of time should be tested for MERS-CoV. regardless of
severity,
(D) Clinical management
 Give supplemental oxygen therapy
o Give oxygen therapy to patients with signs of severe respiratory distress,
hypoxaemia (i.e. SpO2 < 90%) or shock.
o Initiate oxygen therapy at 5 L/min and titrate to SpO2 ≥ 90% in non-
pregnant adults and SpO2 ≥ 92–95 % in pregnant patients.
o Pulse oximeters, functioning oxygen systems and appropriate oxygen-
delivering interfaces should be available in all areas where patients with
SARI are cared for.
o DO NOT restrict oxygen because of concerns about a patient’s respiratory
drive.
 Give empiric antimicrobials to treat suspected pathogens, including
community-acquired pathogens

16. o Although the patient may be suspected to have novel coronavirus
infection, administer appropriate empiric antimicrobials as soon as
possible for community-acquired pathogens based on local epidemi-
ology and guidance until the diagnosis is confirmed. Empiric therapy can
then be adjusted on the basis of laboratory testing results.
 Patients with SARI should be treated cautiously with intravenous
fluids, because aggressive fluid resuscitation may worsen oxygenation,
 Do not give high-dose systemic corticosteroids or other adjunctive
therapies for viral pneumonitis outside the context of clinical trials
 Closely monitor patients with SARI for signs of clinical deterioration,
such as severe respiratory distress/respiratory failure or tissue
hypoperfusion/shock, and apply supportive care interventions
 Recognize severe cases, when severe respiratory distress may not be
sufficiently treated by oxygen alone, even when administered at high
flow rates Wherever available, and when staff members are trained,
mechanical ventilation should be instituted early
 Prevention of complications
o Reduce incidence of venous thromboembolism, Use pharmacological
prophylaxis (for example, heparin 5000 units subcutaneously twice daily)
o Reduce incidence of pressure ulcers, Turn patient every two hours
o Reduce incidence of stress ulcers and gastric bleeding, Give early enteral
nutrition (within 24–48 hours of admission), administer histamine-2
receptor blockers or proton-pump inhibitors
(E) Infection control
 Standard precautions
o 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.
o 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.

17. o 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
o Use a medical mask if working within 1 meter of the patient.
o Place patients in single rooms, or group together those with the same
etiological diagnosis.
o Limit patient movement and ensure that patients wear medical masks when
outside their rooms
 Airborne precautions
o Airborne precautions should be used for aerosol-generating procedures,
which have been consistently associated with an increased risk of pathogen
transmission .
o The most consistent association of increased risk of transmission to
healthcare workers (based on studies done during the SARS outbreaks of
2002–2003) was found for tracheal intubation
o 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.

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