2,040 reported laboratory-confirmed cases 712 deaths in 27 countries. A single imported case of MERS in South Korea, identified on 20 May 2015,

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2 MERS From 2012 to 21 July 2017, 2,040 reported laboratory-confirmed cases 712 deaths in 27 countries A single imported case of MERS in South Korea, identified on 20 May 2015, 150 laboratory-confirmed cases, 15 deaths within 26 days, mainly among patients, visitors & healthcare personnel

3 Scenario On 17 June, the response team received a notification that there was a suspected case of MERS, 60 year-old male from country O (risk area of MERS). The case travelled with 2 sons and 1 nephew. He went to Hospital B with CC of CHF.

4 Scenario Doctor suspected pneumonia and admitted him to negative pressure unit (NPU). Nasopharyngeal swabs were collected 1 st time: UpE undetectable, Orf 1A undetectable 2 nd time: UpE undetectable, Orf 1A undetectable Patient was transfer red out of NPU You are the rapid response team, what would you do? Investigate or not? Any actions required?

5 Team decide to investigate this case What are the objectives of the investigation? What should be done next?

6 6 At outbreak begins Prepare for Field Work : Rapid Response Team Verify diagnosis and confirm outbreak

7 Prepare for Field Work : Rapid Response Team A. Administration and authorization: inform the concerned B. Brief and mobilize multi-disciplinary team: define tasks and person who be in-charge C. Consultation: clinician, lab, stakeholders, etc. D. Documentation for knowledge: literature, CPG, questionnaires, and preliminary information E. Equipment, material, medical and non-medical supplies, e.g. PPE, specimen collection & transport, communication 7

8 Verify diagnosis & confirm outbreak Differential diagnosis? Review clinical symptoms from pt., relatives, HCWs Verify diagnosis? Lab confirmed? If not, appropriated lab specimen? Confirm outbreak? 8

9 During the team preparing, the hospital B notified that pt. s condition deteriorated and was intubated. The team requested sputum suctioned from ET-T for MERS- CoV for Dx confirmation. What would you do when arrived the hospital B? Interview?, contents? Will you collect specimens from relatives?

10 10/6: dry cough 14/6: crepitation, abnormal CXR in RML, RLL 15/6: travelled to Thailand Taxi1: airport to hotel Y Taxi2: hotel Y to hospital B 4-7/6: Dx ACS, admitted, no fever, dry cough, 13-14/6: dry cough, no fever Country O Thailand

11 sputum suctioned from ET-T: UpE detectable, Orf 1A detectable Pt. was immediately transferred back to NPU (pt was in ICU for 6 hrs) Please evaluate the present situation What should be done, next?

12 12 Steps of an outbreak investigation 1. Prepare for Field Work : Rapid Response Team 2. Confirm outbreak and diagnosis 3. Define case and start case-finding 4. Descriptive data collection and analysis 5. Develop hypothesis 6. Analytical studies to test hypotheses 7. Special studies (e.g. environmental, lab study) 8. Communicate the conclusion and recommend control measures 9. Follow-up the control implementations

13 The 1 st imported confirmed MERS in Thailand was found Active case finding was done Contacts: high risk, low risk groups EOC was activated The objectives were Categorized contacts as high or low risk group in order to quarantine Specimen collection Inform the concerned with administration and authorization: policy to quarantine

14 Please list the group of contacts that we should evaluate What evidences we should look for the clue of exposure to the confirmed case?

15 place Group of contacts evidences Country O Relatives travelled with pt. interview airplane Contacts in country O within 1m radius Passenger esp. 2 rows in the front and back Airline crews Contact country O Boarding pass, interview, seat plan, immigration documents Flight documents airport Ground staff CCTV, interview transportati on Immigration officers Taxi driver 1-2 CCTV, interview Traffic control CCTV, hotel CCTV interview, Hotel Hotel staff CCTV, interview Hospital B HCWs within 1m radius CCTV, interview

16 How you define contacts as High or Low risk group?

17 Contacts A high-risk close-contact person who was within 1 m of contact with the index case while the patient was symptomatic regardless of duration of contact. Airline passengers seated in the two rows surrounding the index case s seat A low-risk contact person who had been > 1 m in contact with the patient while the patient was symptomatic, A non-contact no evidence of direct contact with the pt. or were not likely to be in contact with respiratory droplets

18 What actions for each High or Low risk contact group?

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20 What would you do with the HCWs and other patients in ICU?

21 Quarantined 3 HCWs who directly contacted with pt. Halted the patient transfer in/out ICU Specimen collection

22 Happy ending All specimen testing negative Pt. clinical improved and D/C from hospital after negative results for 3 times, travelled back with relatives

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