Slides from my invited presentation to the zoonosis session of the International Congress for Tropical Medicine and Malaria (ICTMM), 18-22 September, 2016

1. Humans and healthcare facilities
Ian M. Mackay, PhD
Public and Environmental Health – Virology
Forensic & Scientific Services | Health Support Queensland
Department of Health
& Associate Professor, The University of Queensland
Ian.Mackay@health.qld.gov.au
Opinions expressed here are my own; citations available upon request
Middle East respiratory
syndrome (MERS)

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Middle East respiratory syndrome coronavirus (MERS-CoV)

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Kingdom of Saudi Arabia (KSA) is the hotzone
• 1st report of novel CoV– 20th Sept 2012
• Most cases human-to-human
• acquired via healthcare setting
• weak transmission between humans
• Seroprevalence 0.15%
• 2013, 10,009 adults, KSA
• highest seroprevalence among shepherds and slaughterhouse
workers

4. The hotzone is a hot subtropical zone
4
heatmapcases

5. Hajj: “The massest of Mass gatherings”
-Helen Branswell
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6. The MERS coronavirus (MERS-CoV)
• Enveloped, 30,000nt (+) RNA virus
• 4 structural, 16 NS proteins; recombination
• Little sign of adapting to humans so far; single serotype
• Uses dipeptidyl peptidase 4 (DPP4; LRT) for entry
• CEACAM5 helps attach
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7. Hu et al. Virol J .2015 12:221
Ancestors of MERS-CoV
• Bats
• focus of first papers
• many recent CoVs discovered
• likely ancestors do exist among
• “Conspecific” virus
• Neoromicia (Pipistrellus) capensis
• South Africa
• NeoCoV
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MERS-CoV in bats
• 1 rtPCR amplicon
• 1 sample
• 1 bat
• 1 species (Taphozous perforatus)
• 1,003 samples Oct 2012 / April 2013

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Camel cold
• Much contact – mild disease
• 1st case owned camels
• juveniles more often virus positive
• camel-to-human infection inferred
• Same species in camels & humans
• High level of virus in camel secretions
• No other animal found to host virus
• alpaca have antibody
• Camel herds can be 100% seropositive

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Camel virus- human spillover
• 225 genomes
• Camel & human
• interspersed throughout tree
• 96.5-100% nt identity

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MERS-CoV: A distinct virus

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“Contact”

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Rare contact

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16. Persistence
• MERS-CoV is stable on surfaces
• more stable than influenza A(H1N1) virus
• Aerosol (10min) & hard surfaces)
• MERS-CoV RNA can shed for >1 month
• detected from a HCW for 42 days
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17. The disease, MERS
• Incubation period 2-16 days (median 4/5 days)
• Comorbidity (e.g. 87%) & cough (e.g. 100%) common
• asymptomatic
• acute URT illness incl. fever, headache, myalgia
• progressive pneumonitis, respiratory failure, septic shock,
multi-organ failure
• 35% -74% (ICU) mortality (median: 12 days onset>death)
• SARS-10%
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18. Treatment
• No antivirals available
• enzyme inhibitors
• repurposed existing drugs
• Early use of IFN-2b + ribavirin
• 8 hours post-inoculation in macaques
• impossible to achieve!
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19. Treatment
• Passive immunotherapy - clinical effect?
• infrequent donors (2%)
• titres low/short-lived in convalescent human sera
• Vaccines
• a range in the pipeline for humans and animals
• Supportive care
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Spread of MERS-CoV is about humans
•African exports (testing)
•Arabian herds (endemic)
•Recombination

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MERS: a disease of
human errors?

22. King Abdulaziz Medical City Riyadh, KSA 2015
• 81/130 cases confirmed (62%); 51 deaths (39%)
• 43/130 HCWs (33%; no deaths)
• 21/130 (16%) were asymptomatic
• 96 hospitalized (63 in ICU)
• 34 isolated at home
• Four generations of hospital transmission
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23. King Abdulaziz Medical City Riyadh, KSA 2015
• Camel contact
• Thought to have been driven by:
• emergency room overcrowding
• uncontrolled patient movement
• high visitor traffic
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24. South Korea outbreak, May-Dec 2015
• 186 cases, 38 fatalities (20%), 4 waves of infection
• Biggest outbreak outside KSA
• >16,000 people quarantined
• No sustained h2h transmission
• no community outbreaks
• 1/186 case travelled to China
• 7.4 day incubation period (6.2 > 7.7 > 7.9 by generation)
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25. South Korea outbreak, May-Dec 2015
• 1 patient responsible for 81 cases
• visited 4 hospitals
• coughed in the open
• walked through ER to public toilet
• Receptor binding domain mutant in 13/14 variants
• reduced receptor affinity/cell entry
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26. South Korea outbreak, May-Dec 2015
• Lower proportion fatal
• 20% compared to 41% in KSA
• due to the mutation?
• lower % underlying comorbidities in general community -
opportunistic?
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1-Choi. Yonsei Med J. 2015 56(5):1174-76
South Korea outbreak, May-Dec 2015

28. South Korea outbreak fallout
• Quarantine limited to close contacts
• casual contacts needed to be included as well
• 4 beds/room
• Family members responsible for some of care
• prolonged, close contact
• Patients easily moved between hospitals
• Hospitals didn’t share past disease history on patients
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30. Preventing large healthcare outbreaks
• Identify symptomatic patients early; test & re-test
• Strong contact tracing, monitoring and quarantine
• Strong infection, prevention and control measures
• PPE – selection, use, donning/doffing, disposal
• distance between beds
• be aware of aerosol generating procedures
• cleaning & disinfection
• treat/manage patients in isolation
• Communicate with public to build/maintain trust
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Control MERS in the hotzone, avoid global spread

32. Stop hospital outbreaks, MERS cases
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Thankyou