Novel coronavirus (MERS-CoV)

About Coronavirus

– Human coronaviruses are responsible for 10 - 30% of all common colds; – – – – All age groups are affected; The incubation period is short, being 2 to 4 days; Infection may also be subclinical or very mild; Reports of more severe lower respiratory tract involvement in young children and old people; – No anti-virals for coronavirus, symptomatic & supportive treatment; – Previously identified human types (Alpha coronavirus: 229E, NL63; Beta coronavirus HKU1, OC43 and SARS-CoV)

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Severe Acute Respiratory Syndrome (SARS)

– Outbreak of SARS peaked in April 2003 and by June had tailed off. By that time, there had been about 8,000 cases worldwide and 775 deaths – More severe than other typical coronavirus infection: • • fever above 38 degrees accompanied by headache, general malaise and aches a dry non-productive cough and breathing difficulty (dyspnea). • Respiratory distress leads to death in 3-30% of cases. – Since 2004, SARS coronavirus no longer in circulation

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Global cases of MERS-CoV 2012-2013

 First identified in Europe in male from Middle East – Unique, new coronavirus  Current count: 130 laboratory confirmed, 17 probable cases  61/147 (42%) have died – – – CFR decreasing over time Higher among sporadic cases than secondary, 63% vs. 29% Asymptomatic and mild cases being found frequently among contacts  89/140 (64%) male – Changing slightly over time but still higher in sporadic cases  Median age = 49.5 years – Higher among sporadic cases, 59 years.  High frequency of pre-existing co-morbid conditions: 74%

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Sequencing

Occurrence of cases over time

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Cases with presumed non-human exposures

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Location of confirmed cases since 17 July 2013

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Notable recent clusters

 Secondary cases increasingly recognized as contact testing increases – – – – – Many are mild or asymptomatic, though frequent fatalities as well Often involve health care workers, sometimes fatally Recent clusters in UAE, Qatar, KSA: Asir, Medina, Riyadh, Hafr al-Batin – i.e. all the hotspots Continue to occur in households and health care facilities.

No community extension recognized  Medina: index case 55 y.o. male, – – 4 cases among contacts including 2 asymptomatic HCW.

1 additional HCW died but contact history not reported  Riyadh: – – 53 y.o. transmitted to 5 others, including 2 HCW who had mild course.

Second cluster, index case was 41 y.o. female, transmitted to 2 HCW  Hafr al-Batin: index case 38 y.o. male – Four family members aged 7 to 79 yrs. Infected two additional children with contact infected

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MERS-CoV in Animals

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  KSA* found a 190 nt sequence with 100% similarity to MERS-CoV from the 1 st human case in a bat near his home; No other animals found with MERS-CoV so far; Camels in Egypt were found to have seroprevalence of antibody reactive to MERS-CoV The positive camels had been imported from Sudan and other East African countries

Comment: camels have unusual antibodies that may cause unexpected results EID 2013;19; Eurosurveillance 2013; 18

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Gaps in our Understanding

  Exposures that result in infection = critical unanswered question Animal reservoir ? (a secondary question needed to help answer #1) – Bats? Camel intermediary or incidental?

– Virus has not been found in camels – could be a false lead.

• Camels, if infected, may not have anything to do with transfer to humans.

 Transmissibility becoming more clear – – Period of infectivity Risks for transmission in HCF, households  Geographic distribution: if camel truly involved, where else is virus?

 Best clinical management practices?

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Hajj and Umrah

Context

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Umrah is a year-round event

– – – – Relatively short compared to Hajj Doesn't necessarily include Medina Relatively limited interaction with local population Peaks during Ramadan 

Projections for Umrah in 2013

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400,000 pilgrims/month, double during Ramadan 5.5 million Umrah pilgrims in 2013

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Hajj starts around 8 September this year

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Surveillance Data

 No cases reported by KSA or other members states in pilgrims during or after Ramadan – Surveillance is limited in many of the countries sending pilgrims  Only 1 case ever reported in a pilgrim – Man of Pakistani origin, resident of UK, stopped through KSA to do Umrah Jan. 2013 – Subsequent transmission to family members in UK  Recent cases reported in Medina associated with human-to-human transmission, including health care workers – Transmission occurring in Medina since late August but was in Al Taif and Jeddah (both near Mecca) in June

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Recommendations

 July 2013:

“World Health Organization interim travel advice on MERS-CoV for pilgrimages to the Kingdom of Saudi Arabia ”

– – – Before Hajj: risk communication to travelers, health officials, HCW, etc.

During Hajj: general infection prevention advice, isolation and avoidance After Hajj: self monitoring, voluntary isolation if symptomatic, reporting for testing.

– Increase awareness on conveyances and at transit points  August 2013: WER

“Requirements and recommendations for entry visas for the Hajj seasons in 2013 ”

– – Re-emphasizes need for infection prevention measures Recommends high risk individuals postpone Hajj

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Actions to take before Umroh or Hajj

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Countries should advise pilgrims that pre-existing major medical conditions can increase the likelihood of MERS-CoV infection, during travel;

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thus, pilgrims should consult a health care provider before travelling.

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Countries should make information known to departing pilgrims and travel organizations on general travel health precautions, which will lower the risk of infection in general (wash hands, avoid animals etc) 17 | World Health Organization |

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Actions to take before Umroh or Hajj

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Health advisories should be made available to all departing travellers to Umra or Hajj eg. travel agent offices or points of departure in airports.

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Current WHO guidelines, or their national equivalents, on surveillance, infection prevention and control measures and clinical management of MERS-CoV should be distributed to health sector.

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Countries should ensure that there are adequate laboratory services for testing for MERS-CoV including referral mechanisms.

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Medical staff accompanying pilgrims should be up to date on MERS-CoV information and guidance.

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Actions to take during Umra or Hajj

 Travelers who develop a significant acute respiratory illness with fever and cough (severe enough to interfere with usual daily activities) should be advised to:    minimize their contact with others to keep from infecting them; Apply cough and sneeze ettiquette; report to the medical staff accompanying the group or to the local health services.

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Actions to take after Umra or Hajj

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Returning pilgrims should be advised that if they develop a significant acute respiratory illness with fever and cough (severe enough to interfere with usual daily activities) during the two weeks after their return, they should seek medical attention and immediately notify their local health authority.

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Persons who have had close contact with a pilgrim or traveller with a significant acute respiratory illness with fever and cough (severe enough to interfere with usual daily activities) and who themselves develop such an illness should be advised to report to local health authorities to be monitored for MERS-CoV.

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Practitioners and facilities should be alerted to the possibility of MERS-CoV infection in returning pilgrims with acute respiratory illness

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laboratory testing,

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infection prevention and control measures implemented. 20 | World Health Organization |

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Measures at borders and for conveyances

 WHO does not recommend the application of any travel or trade restrictions or entry screening.  WHO encourages countries to raise awareness of this travel advice to reduce the risk of MERS-CoV infection among pilgrims and those associated with their travel, including transport operators and ground staff, and about self-reporting of illness by travellers.

 As required by the IHR, countries should ensure that routine measures are in place for assessing ill travellers detected on board conveyances (such as planes and ships) and at points of entry, as well as measures for safe transportation of symptomatic travellers to hospitals or designated facilities for clinical assessment and treatment.

 If a sick traveller is on board a plane, a passenger locator form can be used.

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WHO Statement on the Second Meeting of the IHR Emergency Committee concerning MERS-CoV

“It is the unanimous decision of the Committee - Public Health Emergency of International Concern (PHEIC) have not at present been met.

” The Third Meeting of the Emergency Committee concerning MERS-CoV took place on 25 September

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Summary

    Transmission pattern consistent but recent increase in sporadic cases is concerning – Multiple sporadic cases associated with sizable household and health care facility outbreaks – Genomic data supports multiple introductions rather than sustained human-to-human transmission but not definitively – Concern about expanding reservoir or changing exposures: increasing sporadic cases, change in demographics.

Cases in guest workers raise concerns about exportations to countries with limited capacity to detect and respond.

Urgent need for improved infection control in HCF, homes – Including countries with high numbers of pilgrims and foreign workers in the region Critical gaps in understanding place world at risk – Highest priority for investigation, exposures that result in infection

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Summary

 Reason for optimism regarding Hajj – – – No recent cases among pilgrims Exposures may be different Human-to-human clusters tend to extinguish  Recent surge and known transmission in the area raises concerns – Hajj more intense than Umrah – longer duration, more movement, higher concentration of people – – If infected, many likely to return home before symptomatic Home likely to be a country with limited surveillance, health infrastructure  Concerns also about preparedness of countries that send pilgrims – Surveillance being gradually implemented but pace of testing slow.

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WHO guidelines and Recommendations

       Case Definition (revised) http://www.who.int/csr/disease/coronavirus_infections/case_definition/en/index.html

Travel Advice to Pilgrimage http://www.who.int/ith/updates/20130725/en/index.html

Laboratory Testing http://www.who.int/csr/disease/coronavirus_infections/LaboratoryTestingNovelCoronavirus_21Dec12.p

df Interim Surveillance recommendations http://www.who.int/csr/disease/coronavirus_infections/InterimRevisedSurveillanceRecommendations_n CoVinfection_27Jun13.pdf

Infection Prevention and Control http://www.who.int/csr/disease/coronavirus_infections/IPCnCoVguidance_06May13.pdf

Rapid advice note on home care http://www.who.int/csr/disease/coronavirus_infections/MERS_home_care.pdf

WHO guidelines for investigation of cases http://www.who.int/csr/disease/coronavirus_infections/MERS_CoV_investigation_guideline_Jul13.pdf

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Terima kasih….

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Data on Specimen Collection

 At least one case reported with a negative NP and positive lower respiratory specimen   French MERS-CoV patients: – Index case • Sputum taken on day 3 were positive • NP swabs taken on day 7 were negative • Virus detected in lower respiratory samples up to day 30 – Second patient • Nasal swabs taken on day 1 were “just slightly positive” • • Sputum on Day 3 was highly positive Nasal swab on day 3 was “inconclusive” • Virus detected in lower respiratory samples up to day 26 Two probable cases had NP swabs were negative – No lower specimens were taken – However, strong epidemiologic-links to confirmed MERS-CoV cases and compatible clinical picture

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