Pengurusan Kes Jangkitan MERS CoV 1

5/24/2018 Pengurusan Kes Jangkitan MERS CoV 1

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DR HANIHASELAH BINTI MOHD SALEH

PAKAR PERUBATAN KELUARGA

PEJABAT KESIHATAN KOTA TINGGI10/10/2013

PENGURUSAN KES JANGKITANMiddle East Respiratory syndrome

- CORONAVIRUS (MERS-CoV)


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Ackonowledgement

Dr Benedict Sim , Consultant Infetious Diseases , Hospital Sg Buloh

, Selangor

Dr Anilawati Jelani , Consultant Infectious Diseases, HRPZ11, KotaBharu , Kelantan

Dr. Wan Noraini ; Surveillance Section, Disease Control Division,

KKM

Dr. Shahanizan bt Mohd Zin; Medical Development Division, KKM

Dr . Masliza Bt Zaid, ID Physician, HAS JB

Mas, July 22,2013, Hosp Permai


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OUTLINE

What will MERS Co-V infection look like ?

Who to test ?

How, what and when to test?

When to admit?

Where to admit?

What Infection control is needed ?

How to manage MERS CoV infection ?



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The epidemic so far cases and

mortality

**SO FAR WHO HAS NOT RELEASED ANY TRAVEL ADVISORY NOR

ANY TRAVEL RESTRICTIONS TO ANY COUNTRY **



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MIDDLE EAST RESPIRATORY

SYNDROME VIRUS( MERS CoV)



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Middle East Respiratory Syndrome Virus

(MERS CoV)

Genus -Coronavirus

Acronym : SARS-like virus, The Saudi virus

( novel Coronavirus , nCoV)

First reported in SEPTEMBER 2012 as a novel Coronavirus

Source of infection and mode of transmission is yet to be accuratelydetermined



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What will MERS CoVinfection look like ?



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MERS CoV :FACTS

Evidence of non-sustainedhuman-to-humantransmission Communities: sporadic cases with unknown exposure

Families: contact with infected family members

Health care facilities: patients & health care workers

Most people confirmedto have MERS CoV infectiondeveloped Severe Acute Respiratory illness

The virus has spread from ILL patientsto othersthrough CLOSE CONTACTS.



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MERS CoV

Has strong tropism fornonciliated bronchial epithelial

cells --> LOWER RESPIRATORY TRACT INFECTION



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MERS CoV

Based on Hospital outbreak of MERS-CoV published on

June 19, 2013 , NEJM

Incubation period

Where exposure is known or strongly suspected : generally < 1

week In a case : 9 to 12 days

Minority of cases : More than a week but < 2 weeks

More common among adults

Male to female ratio 2.6 : 1.0

Affect all ages . Median age 56 years (range: 294 years)

Case fatality rate = 31/55 = 56%

4~14d after onset, 2~10d after hospitalization



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Hospital outbreak of MERS-CoV published on June 19, 2013 , NEJM

23 confirmed cases April - May 2013

Fever

Cough

Shortness of breath

Gastrointestinal symptoms

Diarrhoea

Vomiting

Abnormal CXR

20/23 (87%)

20/23 (87%)

11/23 (48%)

8/23 (35%)

5/23 (22%)

4/23 (17%)

20/23 (87%)



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CLINICAL SYMPTOMS

Mostly - pneumonia. Some - GI symptoms, diarrhoea

1 immuno-compromised patient - fever and diarrhoea;

pneumonia only on CXR.




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CLINICAL SYMPTOMS

Mostly - pneumonia. Some - GI symptoms, diarrhoea

1 immuno-compromised patient - fever and diarrhoea;

pneumonia only on CXR.


Complications

Respiratory failure

ARDS with multi-organ failure

Renal failure requiring dialysis

Consumptive coagulopathy

Pericarditis.

Co-infections : influenza, herpes simplex, and pneumococcus



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Important findings

Limited person-to-person

transmission

Settings: Hospital, Household

Most family members and

HCWs closely exposed did not

develop disease

No evidence at present of

sustained person-to-person

transmission

Coinfection with influenza &

parainfluenza - ? Roles in

transmissibility and/or the

severity of the illness.

Transmissibility pattern ?

SARS

Reported case of milder nCoVillnessspectrum of clinical

disease maybe wider



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Who has MERS CoV?



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Case definitionMOH June 14, 2013/ WHO Ju ly 3 , 2013

1. Confirmed case

2. Probable case



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MOH / WHO Case definition

June 14, 2013

Confirmed case

A person with laboratory confirmationofMERS-CoV infection.

molecular diagnostics including either positive PCR

on at least two specific genomic targets or a single

positive target with sequencing on a second.



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MOH Case definition

June 14, 2013

Probable Case: SARI* with clinical, radiological, or HPE evidence of pulm parenchymal dz

(PPD) [e.g. pneumonia or ARDS];

AND

No possibility of lab confirmationAND

Close contact** with lab-confirmed case.

SARI = Syndrome of acute respiratory illness

PPD = Pulmonary Parenchymal diseases

*Include history of fever or measured fever** Close contactanyone who

- Provided care for the pt, including HCW or family member;- Stayed at the same place (e.g., lived with, visited) while pt ill



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WHO Interim Case definition July 3,2013

Clinical + Epidemiolgical + Laboratory

Probable Case:

1. Febrile ARI with clinical, radiological, or HPE evidence of pulm

parenchymal dz (PPD) e.g. pneumonia or ARDSANDTesting for MERS-CoV isunavailable / negative on a singleinadequate specimen*

ANDDirect epid-link with a confirmed MERS-CoV case.

*Inadequate specimen

Nasopharyngeal swab without lower resp specimen, specimen with

improper handling, judged to be poor quality by lab, taken too late.



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WHO Interim Case definition

July 3, 2013

Probable Case:

2. Febrile ARI with clinical, radiological, or HPE evidence of pulm

parenchymal disease (PPD)ANDInconclusive MERS-CoV#(positive screening test withoutconfirmation)AND

A resident of or traveler to Middle East 14 days before onset of illness.

#Inconclusive testsmay include: A positive screening test without further confirmation eg positive on a

single PCR target A serological assay positive.



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WHO Interim Case definition July 3,2013

Clinical + Epidemiolgical + Laboratory

Probable Case:

3. Febrile Acute Respiratory Illness of any severityANDInconclusive MERS-CoV (positive screening test withoutconfirmation)ANDDirect epid-linkwith a confirmed MERS-CoV case.

Direct epid link may include: Close physical contact

Working together in close proximity or sharing the same classroom environment

Traveling together in any kind of conveyance

Living in the same household

14/7 period before or after the onset of illnessin the case under consideration.



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Who to test for MERS CoV?

MOH June 14, 2013



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Screening for MERS CoV

OBJECTIVES:

1. To detect early, sustained human-to-human transmission.

2. To determine the geographic risk areafor infection with the virus.

Clinical and epidemiological investigation to:1. Determine clinical characteristics - incubation period, spectrum of disease

and natural history.

2. Determine epidemiological characteristics

- exposures that result in infection, risk factors, secondary attack

rates, and Mode of transmission



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Patient Under Investigation (PUI)

SARI, (include history of fever and cough) andindications of PPD (e.g., pneumonia or ARDS), based onclinical or radiological evidence of consolidation,(possibility of atypical presentations in immunocompromised)

AND

Travel to the Middle East 10 days before

AND

Not explained by other aetiology


PPD = Pulmonary Parenchymal diseases Mas, July 22,2013, Hosp Permai


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Contacts

ARI of any severity, 10 days before onset of illness,

close physical contact* with a confirmed or probable case ofMERS-CoV infection

Health care worker (HCW) working where pt with SARI cared for, (esp ICU)

without regard to history of travel (WRTHOT)

Not explained by other aetiology

ARI = Acute respiratory illnessSARI = Syndrome of acute respiratory illness



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Who should be investigated?-

summarized

1. SARI + PPD+ either

In a cluster (within 14 days)

HCW exposed to patient with severe LRTI

Traveled to middle east (within 14 days)

unexpected clinical course unexplained by current aetiology2. ARI of any severity

close contact with confirmed/probable MERS-CoV within 14days

3. Travel to Middle East within 14 days - any ventilated patientCLUSTER (>1 persons in a specific setting -classroom, workplace, household, extended family, hospital,

other residential institution, military barracks or recreational camp) that occurs within 14-days, without

regard to history of travel(WRTHOT)

unless another aetiology identified (UAAI).



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What test to do ?

What specimen to send?

How to send specimens ?



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WHO 27 June 2013 update

A longer period of observation for contacts of cases ( 14 days) .

Stronger recommendations for LOWER RESPIRATORY TRACT

SPECIMENS (BAL, tracheal aspirate, sputum), rather than

Nasopharyngeal swabs, to be used to diagnose MERS-CoV

infection.

- If patients do not have LRTI or specimens not possible both

nasopharyngeal swab and Oropharyngeal swabs should be

collected



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BAL = BROCHOSCOPIC ASPIRATION & LAVAGE

TRACHEAL ASPIRATE

NASOPHARYNGEAL SWAB SPECIMENS ( LESS SENSITIVE)Mas, July 22,2013, Hosp Permai


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Laboratory Testing Methods (IMR)

1. Real time RT-PCR

2. Cell Culture

3. RT-PCR & Sequencing

4.Serology (paired sera 4 weeks apart)



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How to send specimen?

Send specimen to laboratory in ice AS SOON AS POSSIBLE .(Temp = 4c)DO NOT FREEZE SPECIMENS

Triple packing

Specimens will be sent to Virology Unit IMR until *1/8/2013 ( then HSAJB )

* tentative date



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When to admit ?



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HOME ASSESSMENT TOOL

(HAT)


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TATACARA PENILAIAN

KESIHATAN KENDIRI


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Amalkan langkah mudah:

TATACARA PENILAIAN KESIHATAN

KENDIRI


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When to admit?

Hospital admissions :

1. Clinical assessment tool ( CAT)

2. Co-morbidities & risk factors



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CLINICAL ASSESSMENT TOOLS ( CAT)

Respiratory impairment: Any of the following

Tachypnoea, respiratory rate > 24/minInability to complete sentence in one breath

Use of accessory muscles of respiration, supraclavicular recession

Oxygen saturation < 92% on pulse oximetry

Decreased effort tolerance since onset of ILI ( Influenza-like illness)

Respiratory exhaustionChest pains

Evidence of clinical dehydration or clinical shockSystolic BP < 90mmHg and/or diastolic BP < 60mmHgCapillary refill time > 2 seconds, reduced skin turgorAltered Conscious level (esp. in extremes of age)New confusion, striking agitation or seizuresOther clinical concerns:Rapidly progressive (esp. high fever > 3 days) or serious atypical illness

Severe & persistent vomitingMas, July 22,2013, Hosp Permai


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Where to admit ?



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Hospital admissions : refer Criteria for Hospital Admission

Clinical assessment tool

Co-morbidities & risk factors

Admission to any nearest MOH hospital

non-specialist hosp MO to inform & consult specialists opinion for further

Mx

Urgent referral and transfer to the respective hospital to be done if the nearest

hospital doesnt have any of the facilities needed (ICU, isolation rooms)

Non-MOH Hospitals to admit & manage patients

Admission policies will be updated from time to time

HOSPIT L DMISSION

Medical Development DivisionMinistry of Health Malaysia

MERS-CoV



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WHAT INFECTION CONTROL

IS NEEDED ?



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Administrative controls

Most important ( From door to door) Infrastructures and equipment

Adequate ventilation

Regular environmental cleaning

Spatial separation of at least 1 m

Education of HCWs

Prevent overcrowdingin waiting areas

Surgical 3-ply mask ( droplet precaustion ) & Hand hygiene

Standard Precaution

Placement of hospitalized patients

Occupational health; seeking medical care

Monitoring of compliance.

Rapid identificationof patients.



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Infection control

Limit number of visitors & family members to those essentialfor patient's support should be trained on risk of transmission

use same infection control as HCWs

PPE ( medical mask, eye shield or goggles, clean non sterile gowns andgloves )

Perform HAND HYGIENEbefore and after contact with patient and thesurroundings AND immediately on removal of PPE

Limit number of HCWs Assign care to exclusive group of skilled HCWs if possible

refrain from touching eyes , nose , mouth with contaminated gloves or

ungloved hands

PPE = personal protective equipment

HCW = Health care workersMas, July 22,2013, Hosp Permai


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Infection control

Use disposable equipments or dedicated equipments ( X-rayequipments , Blood pressure , thermometer, stethoscopes )

Adequately ventilatedrooms or airborne precautions rooms

Cohort patients with same diagnosis together , beds placed ATLEAST 1 metre apart

Avoid movement and transport of patients out of isolation roomsunless necessary . If required , use routes of transport with minimal

contacts with other patients , staffs and visitors.

Notify receiving area to prepare precautions before arrival of thepatients



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Isolation precautions

Standard precautions ( Including Hand Hygiene)

+

Droplet precautions

WHEN IN CLOSE CONTACT (WITHIN 1 METRE)

OR UPON ENTERING THE ROOM OR CUBICLE

OF THE PATIENTS



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Isolation precautions

Airborne for aerosol generating proceedures


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How to treat MERS CoV

infection?



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Early recognition and management

RECOGNIZE SARIand NOTIFICATION




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of MERS CoV RecognizeSARI and NOTIFICATION

Initiate infection control measures

Give supplemental O2 therapy

Collect respiratory and other specimens for lab testing - including other possiblerespiratory pathogens

Empiric antimicrobials for suspected pathogens

Conservative fluids when not in shock

No high-dose steroids or other adjunctive therapies outside the context of clinical

trials

Watch for clinical deterioration, eg severe resp distress/resp failure; tissue

hypoperfusion/shockMas, July 22,2013, Hosp Permai

E l iti d t


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Managing severe respiratory distress,hyoxemia and ARDS Mechanical ventilation or NIV (non

invasiveventilation) depending on level of

consciousness and severityof pneumonia

Manging septic shock


of MERS CoV

SUPPORTIVE TREATMENT

NO ANTIVIRALS AVAILABLE


TAKE HOME MESSAGES


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TAKE HOME MESSAGES

MERS CoV As virulent as SARS-CoV but is distinguished by relative abscence of severe

disease among close contacts of patients except among those withimmunosuppression

Natural host and reservoir remains unknown

Evidence of nonsustained human to human transmission

Settings : Household , Hospital Close contacts

Incubation period 14 days

Most people confirmedto have MERS CoV infection developed SevereAcute Respiratory illness

Standard and droplet precaution when managing PUI. Airborne precaution inaerosol generating procedures

SUPPORTIVE TREATMENT Mas, July 22,2013, Hosp Permai


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Thank you and Good Luck!

AIDIL ADHA

Documents

Pengurusan Kes Jangkitan MERS CoV 1