Taklimat berkenaan MERS-COV (Middle East Respiratory Syndrome-Corona Virus) berkenaan pengurusan sample yang diambil dari pesakit. Virus ini mula tersebar di Arab Saudi, dan perhatian lebih perlu diberikan kepada jemaah-jemaah yang baru pulang dari Umrah di Makkah & Madinah, Arab Saudi.

1. Pengurusan Sample Bagi Kes
Jangkitan “Middle East Respiratory
Syndrome- Coronavirus” (Mers-
CoV)
1
Ref:NIAID

2. • Background of the Virus
• Samples suitable for testing and WHO
Guidelines
• Real time RT-PCR for Mers-CoV
• Main Hospitals and MKAK Sg Buloh and
MKA Kota Kinabalu
Overview

3. Virus classification
-RNA viruses

4. Middle East Respiratory Syndrome-
Coronavirus (Mers-CoV)
 First reported in June 2012, Saudi Arabia
 Coronaviridae Family, Genus Betacoronavirus (same
as SARS-CoV).
 Positive sense, single stranded RNA virus
 About 26-32 Kb with “crown-like” feature
 Transmission- Close Contact -aerosol (droplet),
further investigation.
(SARS-CoV- “unique pathogenesis” as involved
both upper and lower respiratory tract and gastro
enteritis)

5. WHO Guidelines (27 June 2013)
 Generally incubation period for cases of strong
suspicion is less than 1 week
 BUT in at least 1 case, known exposure occurred 9 to
12 days prior to onset of illness
Longer period of observation for contacts of cases
 Incubation period may exceed 1 week but is less than 2
weeks

6. Source of Clinical Specimens
Hospitals
– Inpatients with severe Influenza
NO clinical specimens from outpatients and contacts!

7. Preferred Sample For Testing
(WHO Guidelines, 27 June 2013)
 Lower Respiratory Tract
 Sputum
 Endotracheal Aspirate
 Bronchoalveolar Lavage
 If pt without signs and symptoms of lower respiratory tract
infection and if lower respiratory tract specimen NOT
Possible or Clinically Indicated
Both Nasopharyngeal and Oropharyngeal specimens
should be collected

8.  If initial testing of Nasopharyngeal swab is
NEGATIVE BUT pt is Strongly Suspected of
Mers-CoV, pt MUST be RE-TESTED using
Lower Respiratory Tract Specimen
 Others: tissue from biopsy/autopsy
including lung, whole blood (in EDTA),
paired serum for serology (4 weeks apart)

9. When to collect specimen
• As soon as possible after symptoms begin
(24-72hrs)
• Best before antiviral medications are
administered

10. Swabs
• Ideal – synthetic tip
• Specimens collected with swabs made of
calcium alginate, cotton or wooden sticks
are NOT ACCEPTABLE (inhibit PCR)

11. Sample collection
Nasopharyngeal
swab

13. Transport media
- Plain sterile bottles for aspirates and
sputum
- VTM for swabs
- Plain tubes for paired sera

14. Viral Transport Media (VTM)
• Place swabs in sterile
collection vials containing
1-2 ml of VTM
• Vials can be stored in a
freezer at -20 o
C until use
• Vials can be stored for short
periods of time at 4 – 6o
C

15. Storage and transport of specimens
• Transport to the laboratory as soon as possible
• Store specimens and transport at 4o
C
• Store specimens at -70o
C beyond 48 hours.
• If a -70°C freezer is not available, specimens
should be kept at 4°C, preferably no longer
than 4 days.
• Freezing at higher temperatures (e.g., -20°C)
can reduce the likelihood of virus detection.

16. 3 layer
packaging

17. 1
2
3

18. • Shipping clinical specimens:
- Clinical specimens should be shipped in ice
(cold chain) in appropriate packaging
- All specimens should be labeled clearly and
include information requested .

19. Transportation of Samples to Testing Facilities
Clinicians/Health care providers advised to wear
appropriate PPE during sample taking from patients
All secretions should be placed in sterile bottle and t
transported on ice
All swabs must be placed in sterile tubes with
sufficient VTM and transported on ice.
All samples must use “triple packaging” format with
request forms before being transported to testing
facilities

20. Issues

21. Laboratory Testing Methods
1. Real time RT-PCR (molecular lab)
2. Cell Culture
3. RT-PCR & Sequencing
4. Serology (paired sera 4 weeks apart)

22. Lower Respiratory Tract (Sputum, Endotracheal
Aspirate, Bronchoalveolar Lavage)
Other respiratory tract samples (Both Nasopharyngeal
and oropharyngeal specimens), T/S
IMR will provide
laboratory testing for these
facilities until 01/08/2013

24. False Negative Results:
Samples NOT from Lower Respiratory Tract
(request for fresh sample from lower respiratory
tract if HIGH disease suspicion index)
Poor quality of specimen/ PCR inhibition
 Specimen was collected late or very early in the illness
 The specimen was not handled or shipped appropriately

25. Quality Control of Testing during rRT-PCR
 In the event of “positive results”, Samples should be
referred to IMR for confirmation (sequencing)- only in
INITIAL stage
 IMR will provide Quality Assurance Programme for all
testing facilities this year onwards for rRT-PCR Mers-CoV.

26. Briefing
Testing Procedures

27. List Of Facilities Trained To Perform rRT-PCR for Mers-CoV
1. Makmal Kesihatan Awam Kebangsaan, Sg Buloh
2. Makmal Kesihatan Awam Kota Kinabalu
3. Hospital Sungai Buloh
4. Hospital Kuala Lumpur
5. Hospital Umum Sarawak, Kuching
6. Hospital Pulau Pinang
7. Hospital Sultanah Aminah Johor Bahru
8. Hospital Raja Permaisuri Bainun Ipoh
9. Hospital HTAA, Kuantan
10.Hospital Melaka
11.Hospital HSNZ Kuala Trengganu
12.Hospital HRPZ II Kota Bharu
13.Hospital Sultanah Bahiyah Alor Setar
14.Hospital Tuanku Jaafar Seremban
Tentative Start Date for Testing : 01/08/2013