MERS-CoV From the Middle East to the Midwest Shawn Richards, Outbreak Supervisor Epidemiology Resource Center Indiana State Department of Health APIC Conference October 10,

MERS CoV Media 2

Indiana Timeline April 30: 1:20pm ISDH Laboratory receives call from hospital requesting specimen submission for MERS testing. 1:24 pm ISDH Virology Supervisor calls Respiratory Epi per established protocol 1:34 pm Respiratory Epi calls Community Munster for epi consult Respiratory Epi asks for more information as to why suspect MERS, to check/collect travel history, symptoms and see if HCP worked in hospital with +MERS CoV patients. 3

Timeline Continued 1:56 pm Community Munster calls back with information and specimens were authorized. 2:20 pm Respiratory Epi informs State Epi that we have a “Real” suspect MERS CoV case. 2:30 pm Respiratory Epi contact CDC EOC. 2:44 pm ISDH reaches out IL DOH 2:47pm Respiratory Epi notifies ISDH Lab, Field Epi and Director and State Epi of authorized specimen. 4

Timeline Continued 3:33pm CDC provides ISDH with contact info 4:00 Samples picked up at Community Hospital 4:00pm ISDH updates CDC and sends de-identified patient record. 4:40pm CDC provided Submission Guidelines to ISDH and PUI form 6:27pm a comprehensive contact list with CDC, ISDH, Lake County HD, IL DOH, Community Hospital Munster established * and plans made in case it is prelim + on somewhere between 3-5:30 with update call if +. 5

Timeline Continued 10:35 am ISDH Lab reports to epi that they received NP and serum, OP and Stool to arrive –Expect prelim results by close of business. 10:45am- Respiratory Epi notifies CHM receipt of specimens 11:02 am Updated ISDH MERS CoV website* 11:09am Received patient update from IP and travel itinerary from Community Hospital Munster for CDC and quarantine station 11:16am ERC Digest on MERS CoV article written just in case 11:25am Update CDC on patient status, specimens and expected time of results Lake County Health Department receives forms and family info to start tracking 6

Timeline 3:26pm results are available and to call NOW- LHO division secured room by at Sheraton Hotel and set up for an internal partners conference call at 4pm to go over plan. 3:49pm Respiratory epi sent out message advising partners that a call was imminent will forward call in number and time as soon as established. 4:30pm call with hospital and CDC 6:45pm call with stakeholders ( IL DOH, MA DOH, Lake County, CDC) 7

Other Public Health Actions Performed and collected information on contact tracing of household contacts and HCW’s Contacted IL Department of Health, Chicago Health Department, and Massachusetts HD about cases or potential of cases in their jurisdictions Sent an EPIX message on CDC’s secure data network to all states describing the current situation Sent an Indiana Health Alert Network message following the CDC telebriefing held at 3:00 on 5/2 to alert the Indiana medical community and provide ISDH call center information Assisted in the development of the press release by providing subject matter expertise Consulted with CDC about correction to the International Health Regulation report to be sent to HHS and the President of the United States. 8

Public Health Actions Provided subject matter expertise on a national telebriefing with the CDC ,5.1.14, Participated in numerous conference calls with CDC Updated the Surveillance and Investigation website to contain the most up to date MERS CoV documents Provided standard operating procedure to authorize specimens to go to lab for testing Expanded the number of persons eligible to grant submissions for testing. Call Center activated for providers and general public 133 calls 9

Public Health Actions CDC Epi-Aid six-member team arrives at ISDH approximately 6:15 p.m. Met with ISDH staff to provide situational briefing. Conducted conference call with ISDH District 1 Field Epidemiologist and Community Hospital Munster to discuss objectives and logistics of visit. Epi-Aid team will meet with District 1 Field Epidemiologist and hospital staff at 11:00 EDT/10:00 CDT. 10

Timeline April 18 Index Case started feeling unwell Case flew Riyadh London Chicago Bus- Highland 25 Case visits business associate in IL 26 Case visits business associate in IL 27 Case develops fever, SOB, cough 28 Case visits ED and admitted 29CXR shows bilateral infiltrates Placed in resp isolation 30 Case placed in contact isolation Hosp, ISDH lab/epi authorize specimen ISDH contacts CDC EOC May 1 Specimen received at ISDH 10:35am tests + around 3:40pm Notified and sent to CDC ISDH staff contacted CDC EOC call; Epi-Aid requested 2 CDC confirms MERS CoV at 1:30 pm ERC begins IC Call Center set up in prep for news release IHAN, PR sent Epi-Aid arrives 3 Call Center resumes daily operations Collect spec from HCW’s Sit rep q2h CDC HAN 4 HCW and HH - 5 CDC Press Conference IHAN update 6 CDC COCA Call 789 Case negative per CDC testing IHAN issued Call Center closed 10 11

MERS-CoV Investigation Detailed investigation of case clinical syndrome, travel history, occupation Contact tracing: detailed information on exposures and symptom monitoring Specimen collection, authorization, transportation, and testing Communication of findings –Conference calls –Situational briefings 12

MERS-CoV Investigation Activated call center for health care providers and public Issued messaging to health care providers and public Conducted media event at hospital Provided guidance on infection control Developed algorithms and tools –Case definition –Specimen authorization 13

Contact Tracing 53 health care workers (HCW) 7 household (HH) contacts 1 business associate (April 25-26) All asked to monitor twice daily for symptoms and fever 14 days after exposure HCW and HH contacts –quarantine at home for 14 days after last exposure (HCW on paid leave) –wear mask outside home or in contact with other HH members 14

Travelers CDC and ISDH conducted contact tracing to identify U.S. travelers possibly exposed to the case and provided information to international partners about non-U.S. citizens who were identified 27 states were involved in contact tracing due to the flights of the U.S. cases Almost all exposed were contacted; none had evidence of infection with MERS-CoV 15

Does patient have fever (≥38°C, 100.4°F) and acute respiratory illness (not necessarily pneumonia), based on clinical or radiological evidence? Did patient have history of travel from countries in or near the Arabian Peninsula within 14 days before symptom onset? Did patient have recent 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? Is patient 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. Evaluate for EXPOSURE CRITERIA Laboratory Testing Algorithm for Patients with MERS-CoV CLINICAL CRITERIA Patient must meet clinical criteria AND exposure criteria for testing authorization! Patient meets CLINICAL criteria. Determine if patient meets at least one of the exposure criteria. Patient DOES NOT meet clinical criteria. No specimen authorized. Instruct patient if symptoms worsen to return for re-evaluation. If NO to all three, then the patient DOES NOT meet exposure criteria. No further action needed. Can call ISDH for consultation. Patient meets EXPOSURE criteria. Place patient in contact/airborne isolation Call ISDH for testing authorization at After hours call Patient meets EXPOSURE criteria. Place patient in contact/airborne isolation Call ISDH for testing authorization at After hours, call Patient meets EXPOSURE criteria. Place patient in contact/airborne isolation Call ISDH for testing authorization at After hours call YES NO Countries considered in or near the Arabian Peninsula: Bahrain, Iraq, Iran, Israel, Jordan, Kuwait, Lebanon, Oman, Palestinian territories, Qatar, Saudi Arabia, Syria, the United Arab Emirates (UAE), and Yemen. Close contact is defined as a) any person who provided care for the patient, including a healthcare worker or family member, or had similarly close physical contact; or b) any person who stayed at the same place (e.g. lived with, visited) as the patient while the patient was ill. Consult CDC website at for more information. YES Document last updated: 5/9/

Specimen Authorization Pre-authorization and epidemiology consultation must be obtained before specimens will be tested by ISDH Labs. Unauthorized specimens will NOT be tested. Prior to calling, collect the following information: name, date of birth, travel history (including dates, locations, and mode(s) of travel), signs and symptoms (current),illness onset date with signs/symptoms and current patient status. For authorization during normal business hours contact the ISDH Surveillance and Investigation Division at or Shawn Richards at If after hours, call the ISDH Duty Officer at Advise person answering the phone that you are requesting a MERS-CoV consult and guidance in specimen submission. 17

Specimen Authorization Upon authorization, facility will be given an authorization number that should be included in Section 7 of the Virology submission form under Influenza Sentinel Physician Number. All unauthorized specimens will not be tested. Specimens will be submitted using LIMSNET. To sign up for a LIMSNET account, the ISDH Lab can be contacted at the LIMS HelpDesk or Specimen collection guidance is available at: idelines-clinical-specimens.pdf idelines-clinical-specimens.pdf 18

Acceptable Specimens Broncheoalveolar lavage, tracheal aspirate, pleural fluid Sputum Nasopharyngeal swab Oropharyngeal swab Serum (for rRT-PCR testing) Stool Specimens from suspected MERS cases must be packaged, shipped, and transported according to the current edition of the International Air Transport Association (IATA) Dangerous Goods Regulations at Shipments from outside of the United States may require an importation permit that can be obtained from CDC. 19

Bottom Line No other cases identified All case contacts tested negative for MERS-CoV Data from contact investigation will be used to create guidance for future investigations 20

Strengths Relationships between ISDH Lab and hospital labs Relationship between ISDH Lab and ERC staff Established laboratory capability and capacity Early CDC EOC notification Rapid deployment of skilled Epi-Aid team Communication with CDC-Atlanta/Epi-Aid team Daily and afterhours contact list Engaged hospital and RFID tags/cameras to track HCW locations Surveillance of HCW and HH contacts Indiana MERS CoV case provided fresh blood for future MERS CoV studies and development 21

Strengths Local support of field epidemiologists Creation of MERS-CoV website and documents Algorithms for case definition, specimen submission Online specimen authorization instructions Rapid call center activation-133 calls Preparedness team taking over situation reports Messaging to public Mobile technology Prior experience with H3N2v and H1N1 22

Lessons Learned Lack of MERS-CoV knowledge and US experience Delayed isolation at hospital Specimen collection—Lower respiratory specimens much better than NP and OP Non-use of LIMSNet to submit specimens—many extra hours per day of prep for lab staff and communication with epi Changing case history information Frequency of situational reports Investigating additional “suspect cases” “Feeding the beast” of information 23

Acknowledgements ISDH Staff –Epidemiology –Laboratory –Acute Care Division –Public Health Preparedness –Office of Public Affairs Lake County Health Department Community Hospital Munster CDC-Atlanta –National Center for Immunization and Respiratory Diseases –Division of Global Migration and Quarantine CDC Epi-Aid Team –Danny Feikin –Nora Chea –Kim Pringle –Lucy Breakwell –Nicole Cohen –Dave Dagle 24

Hospital Media Event 25

ISDH Lab and Epi Staff 26

Shawn Richards Indiana State Department of Health Epidemiology Resource Center