Middle East respiratory syndrome coronavirus infection primary prevention

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: João André Alves Silva, M.D. [2]

Overview

Middle East Respiratory Syndrome (MERS) is a viral respiratory illness. It is caused by an emerging coronavirus, specifically a betacoronavirus called MERS-CoV (Middle East Respiratory Syndrome Coronavirus), first discovered in 2012. Being a relatively novel virus, there is no virus-specific prevention or treatment options for MERS patients. Attending to the fact that a vaccine hasn't been developed yet, enhancing infection prevention and control measures is critical to prevent the possible spread of MERS-CoV in hospitals and communities. Health‐care facilities that provide care for patients suspected or confirmed to be infected with MERS-CoV infection, should take appropriate measures to decrease the risk of transmission of the virus from an infected patient to others, health‐care personnel or visitors. It is not always possible to identify patients with MERS-CoV early in time due to the fact that some have mild or unusual symptoms. For this reason, it is mandatory that health‐care providers apply standard precaution measures consistently with all patients, regardless of their diagnosis, in all work practices.

Primary Prevention

Considering that there is no antiviral therapy nor evidence that sustains a proper treatment regimen for MERS-CoV, primary prevention of infection by this agent gains increased relevance. Appropriate planing, preventive measures and predefined precautions may protect the individual's health and at the same minimize the risks of accidentally acquiring the disease. Therefore:

• Urgent investigations are required to better understand the transmission pattern of this virus. The most urgent include detailed outbreak investigations, case‐control studies to understand risk factors for infection, enhancing community studies, surveillance of community‐acquired pneumonia to assess whether significant numbers of mild cases resulting from human to human transmission are being missed, and identifying risk factors for infection in the hospital setting. Detailed information on the surveillance strategy and contact tracing would help understand limitations of current data.
• Although the immediate focus should be to clarify the magnitude of human‐to‐human transmission, no control will be possible until the transmission from the animal/environment source to humans is understood and interrupted. Based on current information, it is prudent for people at high risk of severe disease from MERS-CoV, including those with diabetes, chronic lung disease, pre‐existing renal failure, or those who are immunocompromised, to take appropriate precautions when visiting farms, barn areas or market environments where camels are present. These measures might include:

• washing hands with soap, during at least 20 seconds. Particular attention should be give to children, who should act accordingly. In case water and soap are not available, then an alcohol-based solution should be used instead
• avoiding touch of eyes, nose and mouth by unwashed hands
• covering nose and mouth when during cough or sneeze with a tissue that should be disposed afterwards
• avoiding personal physical contact or sharing of eating utensils with sick people
• frequent cleaning of touched surfaces, such as doorknobs
• avoid drinking raw milk or eating food that may be contaminated with animal secretions or products, unless they have been properly washed, peeled, or cooked.
• for the general public, when visiting a farm or a barn, general hygiene measures, such as regular hand washing before and after touching animals, avoiding contact with sick animals, and following food hygiene practices, should be adhered to.

• WHO recommends increasing efforts to raise awareness of MERS among travelers going to and traveling from MERS-affected countries, but otherwise does not advise special screening at points of entry with regard to this event nor does WHO currently recommend the application of any travel or trade restrictions.

Vaccination

Currently there is no vaccine available for the prevention of MERS infection.

Pre-Travel Medical Consult

Before traveling individuals should consult their primary care physician, at least 4 to 8 weeks prior to the due date. However, last minute consults are also beneficial. During the consult the physician will address important health risks, evaluate the need for vaccinations and/or antimalarial medication and at the same time identify medical items the person should carry with her.

Travel Guidance

The peak travel season to Saudi Arabia is July through November, coinciding with the religious pilgrimages of Hajj and Umrah. CDC encourages pilgrims to consider recommendations from the Saudi Arabia Ministry of Health regarding persons who should postpone their pilgrimages this year, including persons aged ≥65 years, children, pregnant women, and persons with chronic diseases, weakened immune systems, or cancer. WHO advises that persons with preexisting medical conditions consult a health-care provider before deciding whether to make a pilgrimage.

CDC continues to recommend that U.S. travelers to countries in or near the Arabian Peninsula protect themselves from respiratory diseases, including MERS-CoV, by washing their hands often and avoiding contact with persons who are ill. If travelers to the region have onset of fever with cough or shortness of breath during their trip or within 14 days of returning to the United States, they should seek medical care. They should also tell their health-care provider about their recent travel.

Infection Control

With multiple health-care associated clusters identified, infection control remains a primary mean of preventing and controlling MERS-CoV transmission. The CDC has recently made checklists available that highlight key actions that health-care providers and facilities can take, in order to prepare for MERS-CoV patients. CDC's infection control guidance has not changed. Standard, contact, and airborne precautions are recommended for management of hospitalized patients with known or suspected MERS-CoV infection.

Close contacts with confirmed or probable cases of MERS

In case of contact with a person with confirmed MERS-CoV infection, immediate contact with an health-care provider should be made. Depending on the findings of the evaluation, the physician may request additional laboratory or auxiliary tests and provide additional recommendations. Likely, the person will be asked to monitor their health during the following 14 days and look for symptoms, such as:

• Fever ≥ 100° F. Temperature should be taken twice/day.
• Cough
• Shortness of breath
• Other symptoms, include: chills, runny nose, sore throat, nausea/vomiting, body aches, headache, diarrhea

In case of symptoms appear, the healthcare provider should be contacted as early as possible. Before the medical appointment, it is important to call the healthcare provider in order to tell him or her about the possible exposure to MERS-CoV. This will help the healthcare provider’s office take steps to keep other people from getting infected.