1. MERS: Middle East Respiratory Syndrome Overview & The Role of Public Health Christine Wigen, MD, MPH Medical Epidemiologist, Acute Communicable Disease Control Program Los Angeles County Department of Public Health

2. THANK YOU LAC DPH –Laurene Mascola, MD, MPH –Wendy Manuel, MPH –Sadina Reynaldo, PhD –Brit Oiulfstad, DVM, MPH D:14\MERS_Tarzana_August 2014No. 1

3. 2 MERS—Overview & The Role of Public Health Notes on emerging diseases MERS basics: transmission, symptoms, treatment, diagnosis, and prevention Likely sources of MERS infections Current MERS case count The role of Public Health

4. New diseases are not uncommon; approx. 12% of new human pathogens are considered “emerging.” 3 MERS is an emerging disease. There are many causes of emerging diseases: –Changes in climate (WNV, dengue, chikungunya) –How we live and travel (allows for more rapid spread of pathogens around the world) –Genetic changes (viruses and bacteria are constantly mutating, becoming resistant to treatment, etc.) –Animals (many pathogens can jump between species; camel exposure likely contributes to MERS)

5. What is MERS? MERS is a coronavirus. –Coronaviruses are very common –Cells characterized by a crown shape 4 To date, all known MERS cases have been linked to countries in and near the Arabian Peninsula MERS was first reported in Saudi Arabia, September 2012

6. Where have MERS cases been detected? –Saudi Arabia –United Arab Emirates (UAE) –Qatar –Oman –Jordan –Kuwait –Yemen –Lebanon –Iran 5 Countries with identified cases (n=9): Countries w/cases from travel (n=11): –United Kingdom –France –Tunisia –Italy –Malaysia –Philippines –Greece –Egypt –USA –Netherlands –Algeria

7. How is MERS spread? Close contact with large respiratory droplets MERS does not spread easily. A study of 280 household contacts of 26 confirmed MERS cases identified only 1 secondary case 6 There is no evidence of sustained spread in community settings!

8. How are people getting MERS? 7 Unknown, but there is mixed evidence of sources: Close contact with cases –Hospital-acquired cases among health-care workers But camels can infect people through multiple ways including consumption of undercooked camel meat and raw camel milk. And MERS sequencing also has been found in bats. Exposure to dromedary (one-hump) camels –A serologic study of dromedary camels in Egypt found 94% positive for MERS-CoV antibodies –3 of 9 recent cases diagnosed in July reported camel exposure

9. MERS is not the same as SARS. SARS had sustained community transmission, and some people were “super spreaders.”

10. What are the symptoms of MERS? –Fever, cough, shortness of breath (similar to flu) –Most known cases have had severe respiratory symptoms –Prevalence of those with mild illness is unknown 9

11. What are the diagnostic tests for MERS? PCR or polymerase chain reaction –Respiratory samples are tested to detect acute infection –Done locally by Los Angeles County Public Health (LACDPH) Serology tests (enzyme-linked immunosorbent assay; confirmatory testing with immunoflorescent assay; definitive confirmatory testing with neutralizing antibody assay) –Blood specimens sent to CDC for testing by LACDPH –Designed to look for antibodies to MERS that would indicate a person had been previously infected and developed an immune response 10

12. How is MERS treated? 11 No treatment currently available for MERS currently available Supportive medical care helps ease MERS symptoms

13. How is MERS infection controlled and prevented? Standard, contact, and airborne precautions for symptomatic patients (under evaluation for MERS or confirmed with MERS) requiring hospitalization Home isolation for those being evaluated or who have been confirmed for MERS not requiring hospitalization No vaccine available for MERS 12

14. Current MERS Case Count (as of June 11, 2014) 13 699 lab-confirmed cases have been reported to World Health Organization. 209 (30%) deaths 677 (97%) were males Median age = 47 old

15. MERS Cases in the United States (US) Two unlinked, imported cases reported in May 2014 1 –First case from Indiana –Second case from Florida Both cases traveled from Saudi Arabia to U.S. Both lived in and worked as healthcare workers in Saudi Arabia Both had respiratory symptoms and recovered from infection No close contacts to date with evidence of MERS 14 1. CDC. First Confirmed Cases of Middle East Respiratory Syndrome Coronoavirus (MERS-CoV) Infection in the United States, Updated Information on the Epidemiology of MERS-CoV Infection, and Guidance for the Public, Clinicians, and Public Health Authorities – May 2014. MMWR Mor Mortal Wkly Rep; 63:431-436.

16. 15 MERS-CoV Case Definition – Person Under Investigation (PUI)

17. CDC MERS-CoV Case Definitions – Confirmed and Probable Cases Confirmed case: person with laboratory confirmation (by RT-PCR on at least two specific genomic targets or a single positive target with sequencing on a second) Probable case: PUI with absent or inconclusive laboratory results for MERS-CoV infection who is a close contact of a laboratory-confirmed MERS-CoV case 16

18. 17 Los Angeles County is one of a handful of cities with very high volume of travel from Saudi Arabia and the United Arab Emirates. CDC. First Confirmed Cases of Middle East Respiratory Syndrome Coronoavirus (MERS-CoV) Infection in the United States, Updated Information on the Epidemiology of MERS-CoV Infection, and Guidance for the Public, Clinicians, and Public Health Authorities – May 2014. MMWR Mor Mortal Wkly Rep; 63:431-436.

19. What is Los Angeles County Department of Public Health (LACDPH) doing? 18

20. What is LACDPH doing? 19 A lot!! Education of key health care partners through continual communications to ensure providers remain alert to possible cases and report any suspect cases to ACDC immediately.

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23. What is LACDPH doing? 22 A lot!! Education of key health care partners through continual communications to ensure providers remain alert to possible cases and report any suspect cases to ACDC immediately.

24. What is LACDPH doing? 23 A lot!! Education of key health care partners through continual communications to ensure providers remain alert to possible cases and report any suspect cases to ACDC immediately. Medical consultations for health care professionals (ACDC takes phone calls 24/7) Public education (website, 211, press releases, FAQs, etc.).

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26. What is LACDPH doing? 25 A lot!! Education of key health care partners through continual communications to ensure providers remain alert to possible cases and report any suspect cases to ACDC immediately. Medical consultations for health care professionals (ACDC takes phone calls 24/7) Public education (website, 211, press releases, FAQs, etc.).

27. What is LACDPH doing? 26 A lot!! Medical consultations for health care professionals (ACDC takes phone calls 24/7) Public education (website, 211, press releases, FAQs, etc.). Maintain special partnerships with LAX Quarantine and Coroner. Conduct testing on suspect cases at LAC Public Health Laboratory. Education of key health care partners through continual communications to ensure providers remain alert to possible cases and report any suspect cases to ACDC immediately. Conduct contact investigations of cases

28. What is LACDPH doing? 27 This is not new! We have performed these responsibilities for many emerging diseases (e.g., Ebola, enterovirus D68, etc.). For example, recent travel was part of the SARS rule-out case definition. In 2003, LACDPH conducted testing (and investigation, follow-up, etc.) for 22 possible SARS cases. More than any other US county!

29. What is LACDPH Health doing? 28 As of September 19, 2014, LACDPH has conducted MERS rule-out testing on 9 possible cases. To date, no LAC suspect case has tested positive. Los Angeles County MERS-CoV rule-out cases 2013-2014 Case#AdmitDateAgeGender Travel History CountryDates* 16/25/201365FAbu Dhabi (UAE)lives in Dubai 28/18/201319M Dubai (UAE), Sudan, Istanbul June-8/14 310/1/201359FIsrael7/14-10/01 410/8/201371FIsrael9/15-10/9 510/23/201366FSaudi Arabia9/22-10/22 610/28/201370FSaudi Arabia10/7-10/21 74/24/201484MIsrael4/12-4/22 86/19/201425MDubai (UAE) lives in Dubai (arrived US 6/8/14) 99/11/201422FIran8/21-9/10

30. What would happen if a positive MERS case was identified in LAC? 29 LACDPH would report this to the CDC and the California Department of Public Health. Press releases and alerts would be issued to the public, the medical community, and all other community partners (DRCs, etc.). DPH would conduct contact investigations and track contacts. –Contacts not requiring hospitalization will be urged to self-isolate and monitor themselves for illness (fever, cough, SOB) for 14 days. –DPH would track contacts for the full length of their self-isolation and conduct testing on contacts if recommended by the CDC and if they become ill during that time period. In May 2014, as part of the CDC case investigation for the second US travel-associated MERS, LACDPH interviewed and provided specimens for 17 conveyance contacts.

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32. 31 MERS—Overview & The Role of Public Health Emerging diseases are not uncommon. MERS is a viral illness with symptoms similar to the flu. MERS does not spread easily from person-to-person. Basic infection control can be sufficient for this disease. The cause of MERS infections is unknown, but camels are suspected. Public Health plays a central role in the identification and control of MERS cases. SUMMARY

33. 32 MERS—Overview & The Role of Public Health Questions???

34. Resources CDC website – Information for health professionals and the public: http://www.cdc.gov/coronavirus/mers/index.htmlhttp://www.cdc.gov/coronavirus/mers/index.html WHO website – MERS FAQs: http://www.who.int/csr/disease/coronavirus_infections/faq/ en/ http://www.who.int/csr/disease/coronavirus_infections/faq/ en/ LAC DPH ACDC Program – Medical consultations for healthcare providers: ph (213) 240-7941, M-F 8am-5pm 33

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