It only takes one person to spread a disease to others. With the recent Middle East respiratory syndrome coronavirus (MERS-CoV) outbreak in the Republic of Korea, that person appears to be a 68-year-old man who had traveled to Bahrain, the United Arab Emirates, the Kingdom of Saudi Arabia and Qatar before returning to South Korea on May 4, according to a June 11 CDC Health Alert Network (HAN) advisory.(emergency.cdc.gov) The patient became ill on May 11 and was diagnosed on May 20.
Image of Middle East respiratory syndrome coronavirus (yellow cells) attacking Vero E6 cell (blue).
As of June 12, the Republic of Korea had reported 126 cases of MERS-CoV infection, including 11 deaths, according to a World Health Organization (WHO) Global Alert and Response.(www.who.int) That total encompasses a secondary case that was exported from South Korea to China on May 26 and confirmed via testing on May 29.
During a June 11 CDC Clinical Outreach and Communication Activity call,(www.bt.cdc.gov) Susan Gerber, M.D., team lead for the division of viral diseases at the CDC's National Center for Immunization and Respiratory Diseases, said that all reported Korean cases appear to be linked to the index case and are health care-associated; that is, they involve health care personnel, patients and visitors to health care facilities where case patients had received care in various settings.
The CDC HAN alert explained that MERS-CoV was first identified and reported to cause severe acute respiratory illness in September 2012, with 25 countries since reporting cases.
- As of June 12, the Republic of Korea had reported 126 cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection, including 11 deaths, according to a World Health Organization Global Alert and Response.
- The index case for this outbreak appears to be a 68-year-old man who had traveled to Bahrain, the United Arab Emirates, the Kingdom of Saudi Arabia and Qatar before returning to South Korea on May 4.
- The CDC's Interim Guidance for Health Care Professionals on MERS lists common signs and symptoms of the disease as fever, chills/rigors, headache, nonproductive cough, dyspnea and myalgia.
This most recent outbreak of MERS-CoV infection is prompting CDC officials to urge physicians in the United States to re-educate themselves on how to identify the disease and how to best prepare for its potential arrival in their offices.
Identifying Patients Infected With MERS-CoV
According to a WHO frequently asked questions resource(www.who.int) on MERS-CoV, it is not yet understood exactly how people become infected with the disease.
MERS-CoV is a zoonotic virus, and it has long been thought that humans can be infected through direct or indirect contact with infected dromedary camels in the Middle East. But the virus also is transmitted from infected patients to others through unprotected close contact. During the ongoing South Korean epidemic, this route of transmission was observed among family members, patients and health care workers in various settings.
The CDC's Interim Guidance for Health Care Professionals(www.cdc.gov) on MERS lists common signs and symptoms for the disease as fever, chills/rigors, headache, nonproductive cough, dyspnea and myalgia.
Other symptoms can include sore throat, coryza, sputum production, dizziness, nausea and vomiting, diarrhea, and abdominal pain. Atypical presentations may include mild respiratory illness without fever and diarrheal illness preceding development of pneumonia. The CDC recommends physicians use clinical judgment to decide which patients to test for MERS-CoV infection.
The CDC recommends health care professionals ask patients with suspicious symptoms about their travel history and whether they recently visited a health care facility in South Korea. An individual should be considered a patient under investigation (PUI)(www.cdc.gov) for MERS-CoV infection and be reported immediately to state and local health departments if he or she exhibits the following clinical features and epidemiologic risk:
Countries Affected by MERS-CoV
To date, 25 countries have reported cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection, including countries in the Middle East: Egypt, Iran, Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, United Arab Emirates and Yemen; in Africa: Algeria and Tunisia; in Europe: Austria, France, Germany, Greece, Italy, the Netherlands, Turkey and the United Kingdom; in Asia: China, the Republic of Korea, Malaysia and Philippines; and in North America: the United States. Note: More than 85 percent of cases of MERS-CoV infection have been reported in Saudi Arabia.
Severe illness: Fever and pneumonia or acute respiratory distress syndrome (based on clinical or radiologic evidence) and one of the following:
- A history of travel from countries in or near the Arabian Peninsula within 14 days before symptom onset, or close contact with a symptomatic traveler who developed fever and acute respiratory illness (not necessarily pneumonia) within 14 days after traveling from countries in or near the Arabian Peninsula;
- A history of being in a health care facility (as a patient, worker or visitor) in the Republic of Korea within 14 days before symptom onset;
- A member of a cluster of patients with severe acute respiratory illness (e.g., fever and pneumonia requiring hospitalization) of unknown etiology in which MERS-CoV is being evaluated, in consultation with state and local health departments in the United States.
Milder illness: Fever and symptoms of respiratory illness (not necessarily pneumonia; e.g., cough, shortness of breath) and a history of being in a health care facility (as a patient, worker or visitor) within 14 days before symptom onset in a country or territory in or near the Arabian Peninsula in which recent health care-associated cases of MERS have been identified.
Fever or symptoms of respiratory illness (not necessarily pneumonia; e.g., cough, shortness of breath) and close contact with a confirmed MERS case while the case was ill.
The CDC recommends collecting multiple specimens from PUIs(www.cdc.gov) from different sites after symptom onset for testing with the CDC MERS-CoV real-time reverse transcription polymerase chain reaction assay. This should include a lower respiratory specimen (e.g., sputum, broncheoalveolar lavage fluid or tracheal aspirate), a nasopharyngeal/oropharyngeal swab, and serum.
If someone is considered a PUI, that individual's close contacts should be identified to local and state health departments, and they should be told to monitor themselves for fever and respiratory illness -- seeking medical attention for potential MERS-CoV infection if they become ill within 14 days after contact.
Preparing for Patients With Possible MERS-CoV Infection
AAFP member and infectious disease expert Richard Zimmerman, M.D., M.P.H., professor in the department of family medicine at the University of Pittsburgh Medical Center, told AAFP News that preparing for MERS-CoV starts with getting your supplies, protocols and plans in order now.
"It's too late to begin preparedness when you're face-to-face with a patient who traveled and has a fever," he said.
Besides consistently taking a travel history, Zimmerman suggests bookmarking the CDC's resources for health care professionals on MERS-CoV(www.cdc.gov) to get the most up-to-date information to direct your care of the patient.
Treatment of patients with MERS-CoV infection is only supportive at this point and should be based on the patient's clinical condition.
And because transmission of the disease has occurred primarily in health care facilities, the WHO said it's important to apply standard precautions consistently with all patients. Droplet precautions should be added to standard precautions when providing care to all patients with symptoms of acute respiratory infection. Contact precautions and eye protection should be added when caring for suspected or confirmed cases of MERS-CoV infection. Finally, airborne precautions should be applied when performing aerosol-generating procedures.