1. MERS-CoV (Middle Eastern Respiratory Syndrome) Mike Wade – 16/06/15, updated 23/7/15

2. What is MERS-CoV -Coronaviruses are common – most people infected throughout life course – cause mild to moderate upper-respiratory tract infections -MERS-CoV is a new strain of coronavirus (first known case Saudi Arabia 2012) -Symptoms include fever and cough that progress to a severe pneumonia causing shortness of breath and breathing difficulties. In some cases, a diarrheal illness has been the first symptom to appear -There is insufficient information to make generic treatment recommendations and patients have to be assessed on a case by case basis -There is no vaccine available for MERS-CoV 2Presentation title - edit in Header and Footer

3. Epidemiological Update At 7/7/15 – 1368 cases of MERS-CoV reported to WHO (487 related deaths). 65% males median age: 50 years (9 months-99 years) Incubation period: 5.5-6.5 days (Maximum 14 days) Majority of cases from Saudi Arabia & Republic of Korea Camels are an identified host (likely source of primary infection in some cases) Most cases are now due to human-to human transmission Outbreaks linked to health care facilities / no evidence of sustained community transmission Recent cluster in South Korea – largest outside Arabian Peninsula but cluster remains limited to patients, visitors to patients, health care workers and close relatives of cases The risk of infection with MERS-CoV to UK residents in the UK remains very low 3Presentation title - edit in Header and Footer

4. Case Definition Any person with severe acute respiratory infection requiring admission to hospital with symptoms of fever (≥ 38 ⁰ C) or history of fever, and cough AND With evidence of pulmonary parenchymal disease (refers to disease affecting the tissue and space around the air sacs of the lungs) e.g.. clinical or radiological evidence of pneumonia or Acute Respiratory Distress Syndrome (ARDS) AND Not explained by any other infection or aetiology 4Presentation title - edit in Header and Footer

5. Case Definition AND AT LEAST ONE OF History of travel to, or residence in an area where infection with MERS-CoV could have been acquired in the 14 days before symptom onset* OR Close contact during the 14 days before onset of illness with a confirmed case of MERS-CoV infection while the case was symptomatic OR Healthcare worker based in ICU caring for patients with severe acute respiratory infection, regardless of history of travel or use of PPE OR Part of a cluster of two or more epidemiologically linked cases within a two week period requiring ICU admission regardless of history of travel *This definition includes all countries within the geographical Arabian Peninsula, plus countries with cases that cannot be conclusively linked to travel. As of 08/06/2015: Bahrain, Jordan, Iraq, Iran, Kingdom of Saudi Arabia, Kuwait, Oman, Qatar, United Arab Emirates, Yemen and South Korea. 5Presentation title - edit in Header and Footer

6. Response to Possible Case Refer to algorithm (use those available online) https://www.gov.uk/government/publications/mers-cov-public-health-investigation-and- management-of-possible-cases -Check meets case definition (may require liaison between CCDC/Microbiology/ID Consultant) – consider atypical presentation in immunocompromised -If yes - clinical risk assessment required (normally in-patient) -Check receiving acute is compliant with infection control arrangements and PPE (full PPE warn) https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/361569/MERS- CoV_infection_control.pdf https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/361569/MERS- CoV_infection_control.pdf -Ensure appropriate samples sent to local PHE lab & PHE MERS CoV testing lab Charles Irish to clarify -If cluster suspected – establish any epidemiological links between cases -Notify PHE Colindale – respiratory.lead@phe.gov.uk / duty doctor if out of hours (CCDC)respiratory.lead@phe.gov.uk -Complete initial dataset FORM 1: https://www.gov.uk/government/publications/mers-cov-minimum- data-set-form-for-possible-caseshttps://www.gov.uk/government/publications/mers-cov-minimum- data-set-form-for-possible-cases 6Presentation title - edit in Header and Footer

7. PHE Testing Lab Positive (presumptive positive) -Stand-up Incident Control Meeting (include PHE Colindale/Duty Doc (if OOHs) and DsPH) -Ensure residual material is sent to PHE reference laboratory (RVU) -Identify and collate list of contacts and email to PHE Colindale 7Presentation title - edit in Header and Footer

8. Reference Lab Positive – Confirmed Case -Continue Incident Control Meeting (include PHE Colindale/Duty Doc (if OOHs) and DsPH) -Complete confirmed case record – FORM 1A: https://www.gov.uk/government/publications/mers- cov-epidemiological-protocols-to-assess-cases-and-their-close-contacts-in-the-ukhttps://www.gov.uk/government/publications/mers- cov-epidemiological-protocols-to-assess-cases-and-their-close-contacts-in-the-uk -Identify and collate list of contacts and email to PHE Colindale: Close contact definition: pro-longed face to face contact >15 minutes with a symptomatic confirmed case in a household or other closed setting OR healthcare or social care worker who provided direct clinical or personal care or examination of a symptomatic confirmed case, or within close vicinity of an aerosol generating procedure AND who was not wearing full PPE at the time. -Follow close contact algorithm: https://www.gov.uk/government/publications/mers-cov-public- health-investigation-and-management-of-close-contacts-of-confirmed-caseshttps://www.gov.uk/government/publications/mers-cov-public- health-investigation-and-management-of-close-contacts-of-confirmed-cases 8Presentation title - edit in Header and Footer

9. Follow-up Complete confirmed case follow-up form 1b – 14 to 21 days since form 1a completed Stand-down incident control meeting but consider de-brief (to support learning). ISSUES: Collecting appropriate samples in the community (e.g. symptomatic contact / base-line clotted blood samples in asymptomatic contacts) Lab capacity to respond / courier services etc… Health care response to multiple cases. 9Presentation title - edit in Header and Footer