Clinical Review

Identification and Management of Middle East Respiratory Syndrome

Federal health care providers need to be vigilant to this new coronavirus from the Arabian Peninsula, not only to properly treat patients, but also to minimize the risk of exposure and transmission.

Fed Pract. 2015 March;32(3):12-16

Author(s):

References

1. To KK, Hung IF, Chan JF, Yuen KY. From SARS coronavirus to novel animal and human coronaviruses. J Thorac Dis. 2013;5(suppl 2):S103-S108.

2. Woo PC, Lau SK, Chu CM, et al. Characteristics and complete genome sequence of a novel coronavirus, coronavirus HKU1, from patients with pneumonia. J Virol. 2005;79(2):884-895.

3. van der Hoek L, Pyrc K, Jebbink MF, et al. Identification of a new human coronavirus. Nat Med. 2004;10(4):368-373.

4. de Groot RJ, Baker SC, Baric RS, et al. Middle East respiratory syndrome coronavirus (MERS-CoV): Announcement of the Coronavirus Study Group. J Virol. 2013;87(14):7790-7792.

5. World Health Organization. Middle East respiratory syndrome coronavirus (MERS-CoV) summary and literature update–as of 11 June 2014. http://www.who.int/csr/disease/coronavirus_infections/MERS-CoV_summary_update_20140611.pdf. Accessed February 3, 2015.

6. Byrd RP Jr, Roy TM. Severe acute respiratory syndrome. Fed Pract. 2003;20(9):62-71.

7. International Society for Infectious Diseases. Novel coronavirus–Saudi Arabia: Human isolate; Archive number: 20120920.1302733. ProMED-mail Website. http://www.promedmail.org/direct .php?id=20120920.1302733. Published September 20, 2012. Accessed January 23, 2015.

8. Centers for Disease Control and Prevention. Middle East respiratory syndrome (MERS). Centers for Disease Control and Prevention Website. http://www.cdc.gov/coronavirus/mers. Updated July 31, 2014. Accessed January 23, 2015.

9. Centers for Disease Control and Prevention. MERS in the U.S. Centers for Disease Control and Prevention Website. http://www.cdc.gov/coronavirus/mers/US.html. Updated December 9, 2014. Accessed January 23, 2015.

10. Lau SK, Li KS, Huang Y, et al. Ecoepidemiology and complete genome comparison of different strains of severe acute respiratory syndrome-related Rhinolophus bat coronavirus in China reveal bats as a reservoir for acute, self-limiting infection that allows recombination events. J Virol. 2010;84(6): 2808-2819.

11. Zaki AM, van Boheemen S, Bestebroer TM, Osterhaus AD, Fouchier RA. Isolation of a novel coronavirus from a man with pneumonia in Saudi Arabia. N Engl J Med. 2012;367(19):1814-1820.

12. Cotten M, Lam TT, Watson SJ, et al. Full-genome deep sequencing and phylogenetic analysis of novel human betacoronavirus. Emerg Infect Dis. 2013;19(5):736-742B.

13. Annan A, Baldwin HJ, Corman VM, et al. Human betacoronavirus 2c EMC/2012-related viruses in bats, Ghana and Europe. Emerg Infect Dis. 2013;19(3):456-459.

14. Ithete NL, Stoffberg S, Corman VM, et al. Close relative of human Middle East respiratory syndrome coronavirus in bat, South Africa. Emerg Infect Dis. 2013;19(10):1697-1699.

15. Memish ZA, Mishra N, Olival KJ, et al. Middle East respiratory syndrome coronavirus in bats, Saudi Arabia. Emerg Infect Dis. 2013;19(11):1819-1823.

16. Chu DK, Poon LL, Gomaa MM, et al. MERS coronavirus in dromedary camels, Egypt. Emerg Infect Dis. 2014;20(6):1049-1053.

17. Reusken CB, Haagmans BL, Müller MA, et al. Middle East respiratory syndrome coronavirus neutralising serum antibodies in dromedary camels: A comparative serological study. Lancet Infect Dis. 2013;13(10):859-866.

18. Haagmans BL, Al Dhahiry SH, Reusken CB, et al. Middle East respiratory syndrome coronavirus in dromedary camels: An outbreak investigation. Lancet Infect Dis. 2014;14(2):140-145.

19. Abdel-Moneim AS. Middle East respiratory syndrome coronavirus (MERS-CoV): Evidence and speculations. Arch Virol. 2014;159(7):1575-1584.

20. World Health Organization. Global Alert and Response. MERS-CoV summary and literature update—as of 31 May 2013. http://www.who.int/csr/disease/coronavirus_infections/update_20130531 /en. Accessed January 23, 2015.

21. Assiri A, McGeer A, Perl TM, et al; KSA MERS-CoV Investigation Team. Hospital outbreak of Middle East respiratory syndrome coronavirus. N Engl J Med. 2013;369(5):407-416.

22. Gulland A. Two cases of novel coronavirus are confirmed in France. BMJ. 2013;346:f3114.

23. Guery B, Poissy J, el Mansouf L, et al; MERS-CoV study group. Clinical features and viral diagnosis of two cases of infection with Middle East Respiratory Syndrome coronavirus: A report of nosocomial transmission. Lancet. 2013;381(9885):2265-2272.

24. Memish ZA, Zumla AI, Al-Hakeem RF, Al-Rabeeah AA, Stephens GM. Family cluster of Middle East respiratory syndrome coronavirus infections. N Engl J Med. 2013;368(26):2487-2494.

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Human coronaviruses (CoVs) were first identified in the mid-1960s. Coronaviruses are a large family of viruses that cause a range of illnesses in humans, from the common cold to severe acute respiratory syndrome (SARS).¹

In 2003, SARS caused one of the most devastating global epidemics known to the developed world. The important lesson learned from the SARS epidemic was that CoVs can cause severe and rapidly spreading infection. Since then, 2 human CoVs, HCoV-HKU1 and HCoV-NL63, have been identified as common causes of human respiratory tract infections.^2,3 In September 2012, a novel CoV was recognized to cause a fatal human infection. This virus has become known as the Middle East respiratory syndrome CoV (MERS-CoV).⁴

Similar to SARS-CoV, MERS-CoV human infection has a high fatality rate and the ability to spread from person to person.^5,6 Person-to-person transmission has resulted in secondary cases among close contacts, including health care providers (HCPs) who should, therefore, be cognizant of this infection. Federal HCPs in particular may be more likely to become involved in the care of patients with this disease, because many military personnel are returning from deployment in the Middle East.

History of MERS-CoV

MERS-CoV was first identified as an infectious disease in humans in Saudi Arabia. In June 2012, the index case was hospitalized with pneumonia and acute renal injury.⁷ Since then, MERS-CoV human infections and clusters of infection have been identified in multiple countries in the Arabian Peninsula (Table 1).⁸ There have also been cases of MERS-CoV infection in other countries involving travelers who had visited the Arabian Peninsula and, in some instances, after returning home, their close contacts (Table 1).⁸

On May 2, 2014, the first confirmed U.S. case was reported in Indiana in a HCP who had recently been to Saudi Arabia.⁹A second case of a HCP traveling from Saudi Arabia was identified on May 13, 2014, in Orlando, Florida.⁹As of June 11, 2014, 699 laboratory‐confirmed cases of MERS-CoV infection had been reported to the World Health Organization in 20 countries, resulting in 209 deaths. All cases to date have originated in 6 countries of the Arabian Peninsula.^5,8

The Organism

Coronaviruses are enveloped RNA viruses named for the crownlike spikes on their surface. They are common viruses known to cause respiratory infections in humans.¹ It is thought that most people are infected with these viruses during their lifetime. These viruses generally cause mild-to-moderate upper respiratory tract illnesses, otherwise known as the common cold. On occasion, CoVs can cause lower respiratory tract infections in elderly patients, neonates, and immune-compromised individuals.¹

Coronaviruses are also known to infect animals. Most known CoVs cause disease in only 1 animal species or, at most, in a small number of closely related species. However, SARS-CoV was noted to infect people and various animals, including monkeys, civets, raccoon dogs, cats, dogs, and rodents. The origin and natural reservoir of SARS-CoV was ultimately determined to be bats.¹⁰

Genetic sequencing has determined that the MERS-CoV is different from any other known human CoV. MERS-CoV is a beta-CoV and, like the SARS-CoV, is closely related to bat CoVs.^11-1⁵ The origin of the MERS-CoV is not known, but an animal reservoir is suspected. Because MERS-CoV is similar to SARS-CoV, bats are considered a possible animal reservoir. Dromedary camels may act as intermediate hosts by spreading the virus to humans.^16-18 However, there is no consensus on the animal reservoir for MERS-CoV. It is also not known how the virus has spread from animals to humans.

Case Definition

In order to aid in the rapid recognition of MERS, the CDC has established case definitions.⁸

A patient under investigation is an individual with fever (> 38^oC, > 100.4^oF) and pneumonia or acute respiratory distress syndrome (ARDS); and either:

history of travel from countries in or near the Arabian Peninsula within 14 days before the onset of symptoms; or
close contact with a symptomatic traveler who developed fever and ARDS within 14 days after traveling from countries in or near the Arabian Peninsula; or
is a member of a cluster of patients with severe acute respiratory illness of unknown etiology in which MERS-CoV is being evaluated, in consultation with state and local health departments.

A confirmed case is a patient with laboratory confirmation of MERS-CoV infection. A probable case is a patient under investigation with absent or inconclusive laboratory results for MERS-CoV infection who is a close contact of a laboratory- confirmed MERS-CoV case.