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Middle East Respiratory Syndrome Coronavirus (MERS-CoV)Presented by:Indera bin Mansor (P77052)Normawati binti Yusoff (P77039)Hawa Bee binti Ibrahim (P77046)Noor Hasmadi bin Mohamad Noor (P77042)

CONTENTIntroduction (Presenter 1)MERS-CoV Cases (Presenter 1)First & Only Case in Malaysia (Presenter 1)Source of Transmission (Presenter 2)Mode of Transmssion (Presenter 2)Speculated Transmission (Presenter 2)Pathogenesis (Presenter 2)Incubation Period (Presenter 2)Symptoms (Presenter 3)People at Risk (Presenter 3)Treatment (Presenter 3)Prevention (Presenter 4)

What is MERS-CoV

3ItemMERS-CoVSARS-CoVVirus typeLineage C/BetacoronaviridaeLineage B/Betacoronaviridae

History of diseaseSeptember 2012 Saudi ArabiaUntil nowNovember 2002 ChinaUntil July 2003OriginatedSuspected from animalSuspected from bat to fox before transmitted to human No. of cases909 cases331 death8273 cases725 deathCase Fatality Rate36%8.76%INTRODUCTIONBefore I elaborate further on Mers CoV let us first see the comparison between Mers Cov and Sars

4ContinuedFirst identified: Saudi Arabia - September 2012 two patients who suffered severe pneumonia (Zaki et al. 2012).

Different from the SARS coronavirus (Muller et al. 2012).

Until 7th Nov. 2014, 23 countries reported MERS-CoV confirmed case to WHO.Middle EastSaudi ArabiaUnited Arab Emirates (UAE)IranJordanKuwaitLebanonOmanQatarYemen

AfricaAlgeriaEgyptTunisia

EuropeAustriaHollandGreeceItalyGermanyFranceTurkeyUnited Kingdom (UK)

AsianPhilippinesMalaysia

AmericaUnited States of America (USA)MERS-CoV CASES(Source : MOH 2014)DISTRIBUTION OF CONFIRMED CASES (2012 -2014)

(Source : ECDC 2014)MERS-CoV CASESAs of 7th November 2014909 laboratory-confirmed cases of infection with MERS-CoV including 331 related deaths have been reported to WHO.

(Source : MOH 2014)

8FIRST & ONLY CASE IN MALAYSIA(Source : MOH 2014)29th March 2014 - returning from Umrah4th April 2014 - not Feeling well7th April 2014 - went to clinic9th April 2014 refer to the hospitalSymptoms : fever, cough, shortness of breath13th April 2014 Died54 year old Male Diabetic9

SOURCE OF TRANSMISSIONUncertain.Animal origin?Speculated animals : BatsA number of viruses detected in bats in Europe and China (Li et al. 2005); Saudi Arabia (Memish et al. 2013)MERS-CoV in a bat faeces samples

CamelsSeveral studies have identified MERS-CoV in high proportion of camels - Likely reservoir (Perera et al. 2013 ; Reusken et al. 2013)

Unclear. But most likely thru direct contact (contamination of the environment) or inhalation (coughing, sneezing).

Reservoir' or zoonotic transmission has yet to be identified for MERS-CoV (Memish et al. 2013).

MODE OF TRANSMISSION11Pandemic potential risk for MERS-CoV does not exceed 5% (Brban et al. 2013). This indicates a low risk potential for transmission from person to person (Cauchernez et al. 2013).

Cases have occurred in a health care facility or among close family members (Buchholz et al. 2012; Puzelli et al. 2013)

ContinuedSPECULATED TRANSMISSIONOR

CoronavirusAgent

BatReservoirCamelHostPerson handling camelTransmission

CoronavirusAgentCamelReservoirPerson sneezingTransmission

Person handling camelHost

13PATHOGENESISPeople direct contact with camel or thru inhalationCoronavirus enterthe respiratory tract

Coronavirus multiplies & spreads Symptoms : Hi Fever, cough etc. Coronavirus causes injury to the lung : Pneumonia

14INCUBATION PERIOD1.9 - 14.7 days (Assiri et al. 2013)

15PneumoniaDiarrheaFever above 38cHeadache

Shortness of breath

Sore throatCoughVomittingAbdominal painSymptomSymptomSYMPTOMS(Source : MOH Saudi Arabia 2014)PEOPLE AT RISKPeople with low immune system

Elderly

Children under 12 years old

Pregnant women

People with chronic diseases

Close contact :Any person who provided care for the patient. (healthcare worker or family member, or had similarly close physical contact).

Any person who stayed at the same place.(e.g. lived with, visited) as the patient while the patient was ill.(Source : Jadav 2013)

17TREATMENT

(Source : Jadav 2013)Currently awaiting clinical trial.No specific treatmentNo vaccine availableTreatment based on the patients symptoms.Supportive care is highly effective Exposure Information and travel history Animal exposuresHuman exposuresFood exposuresTravel history

Clinical Information Signs and symptoms at initial presentation.Dates and results of any ancillary tests performed (X-Ray, CT scan)

(Source : WHO 2013)

DIAGNOSIS

Confirmation lab teststhroat swabs samples (throat swab) test using the 'Real-time Reverse Transcriptase Polymerase Chain Reaction (RT-PCR)

(Source : Corman et al. 2012)

ContinuedPRIMORDIAL PREVENTIONTo prevent the emergence of risk factors

PRIMORDIAL PREVENTIONAVOID of visits to farm animals (especially camel farm).

Personal hygiene.

AVOID raw food & the use of drinking untreated water supply.

DO NOT touch the fruit of vegetables that are not washed.

AVOID direct contact of pilgrims & visitors from middle east who have symptoms of respiratory infection (such as fever, cough, running nose and sore throat)

PRIMARY PREVENTIONTo Prevent Infection via :Specific ProtectionHealth Promotion

Theres no specific vaccination for MERS-CoV.

Vaccination : against influenza & pneumococcal.

Mask to cover mouth & nose and hand sanitizer.SPECIFIC PROTECTION IN MALAYSIAHEALTH PROMOTION IN MALAYSIA

Standee at AirportStreamer25

HEALTH PROMOTION IN MALAYSIA

Pamphlets26Health education to the Umrah & Hajj pilgrims through Hajj Intensive Courses & Course Hajj pilgrimage undertaken by the Lembaga Tabung Haji (LTH).

Health advisory issued by the MOH will be uploaded by the LTH website.

HEALTH PROMOTION IN MALAYSIA

http://www.moh.gov.my

Info KesihatanMASS MEDIA CAMPAIGN28SECONDARY PREVENTIONTo Prevent Disease by :Early DiagnosisTreatment

HEALTH SCREENINGTravellers from Middle east countries30FEVERFEVER/ TEMPERATURE SCREENINGSCREENING AT THE ENTRY POINTArrival at the international entry pointsImmediate referral to the identified hospital; for admission and further managementTo initiate infection prevention and control measures including disinfection of the aircraft/ conveyanceTo initiate contact tracing and obtain flight manifest of the affected flightTo share information of referred case and flight manifest to CPRC-MOH as soon as possibleSEVERITY?FURTHER ASSESSMENTHistory takingClinical examinationAllow to go home with Health Alert CardAllow to go home with BOTH, the :Health Alert CardHome Assessment Tool31HEALTH ALERT CARD

(Source : MOH 2014)32HOME ASSESSMENT TOOL

(Source : MOH 2014)33REFERENCES1. Assiri A, Al-Tawfiq JA, Al-Rabeeah AA, Al-Rabiah FA, Al-Hajjar S, Al-Barrak A, et al. 2013. Epidemiological, demographic, and clinical characteristics of 47 cases of Middle East respiratory syndrome coronavirus disease from Saudi Arabia: a descriptive study. Lancet Infect. 13(9):752-61.2. Breban R, Riou J, Fontanet A. 2013. Interhuman transmissibility of Middle East respiratory syndrome coronavirus: estimation of pandemic risk. Lancet. 382(9893):694-9.3.Buchholz U, Mller MA, Nitsche A, Sanewski A, Wevering N, Bauer-Balci T, et al. 2012. Contact investigation of a case of human novel coronavirus infection treated in a German hospital.34REFERENCES4. ECDC 2014. Severe respiratory disease associated with Middle East Respiratory Sydrome Coronavirus (MERS-CoV).http://www.ecdc.europa.eu/en/publications/Publications/mers-cov-severe-respiratory-disease-risk-assessment-16-october-2014.pdf(Access on 16 Disember 2014 ).

5. Cauchemez S, Van Kerkhove MD, Riley S, Donnelly CA, Fraser C, Ferguson NM. 2013.Transmission scenarios for Middle East Respiratory Syndrome Coronavirus (MERS-CoV) and how to tell them apart. Euro Surveill [Internet]. 18(24). 6. Corman VM, Eckerle I, Bleicker T, Zaki A, Landt O, Eschbach-Bludau M, et al. 2012. Detection of a novel human coronavirus by real-time reverse-transcription polymerase chain reaction. Euro Surveill. 17(39):pii=20285.

35REFERENCES7. Jadav H.A. 2013. Middle East Respiratory Syndrome Corona Virus (MERS-CoV) : A Deadly Killer. Journal of Pharmacy and Biological Sciences . Volume 8, Issue 5 , PP74-81. www.iosrjournals.org. (Access on 16 Disember 2014).

8. Li W, Shi Z, Yu M, Ren W, Smith C, Epstein JH, et al. 2005. Bats are natural reservoirs of SARS-like coronaviruses. Science. 310(5748):676-9.9. Memish ZA MN, Olival KJ, Fagbo SF, Kapoor V, Epstein JH, et al. 2013.Middle East respiratory syndrome coronavirus in bats, Saudi Arabia. Emerg Infect .

10. Ministry of Health. 2014. Maklumat terkini berkaitan jangkitan Middle East Respiratory Syndrome Coronavirus (MERS-CoV). Wilayah Persekutuan Putrajaya. 10 Disember 2014.

11. Ministry of Health Saudi Arabia. 2014. Infection prevention and control guidelines for patients with Middle East Respiratory Syndrome Coronavirus (MERS-CoV).36REFERENCES12. Muller MA, Raj VS, Muth D, Meyer B, Kallies S, Smits SL, et al. 2012. Human coronavirus EMC does not require the SARS-coronavirus receptor and maintains broad replicative capability in mammalian cell lines. MBio. 3(6). pii: e00515-12. doi: 10.1128/mBio.00515-12.Perera RA, Wang P, Gomaa MR, El-Shesheny R, Kandeil A, Bagato O, et al. 2013. Seroepidemiology for MERS coronavirus using microneutralisation and pseudoparticle virus neutralisation assays reveal a high prevalence of antibody in dromedary camels in Egypt. Euro Surveill 14. Reusken C, Mou H, Godeke GJ, van der Hoek L, Meyer B, Muller MA, et al. 2013. Specific serology for emerging human coronaviruses by protein microarray. Euro Surveill. 18(14): 20441. 37REFERENCES15. WHO. 2013. Guidelines for investigation of cases of human infection with middle east respiratory syndrome cornavirus (MERS-CoV). http://www.who.int/csr/disease/coronavirusinfection/MERS CoV in investigation guideline Jul13.pdf. (Access on 16 Disember 2014).

16. Zaki AM, Van Boheemen S, Bestebroer TM, Osterhaus AD,Fouchier RA. 2012.Isolation of a novel coronavirus from a man withpneumonia in Saudi Arabia. N Engl J Med. 367(19):1814-20.

38Thank You