MERS G Blackburn DO, MACOI Clinical Professor of Medicine MSUCOM
November, 2002 Quietly and out of nowhere, an outbreak of undiagnosed severe respiratory illness with high mortality develops in Guangdong Province, a rural area of southern China Initial reporting suppressed by Chinese authorities Canada picks up reports of a flu outbreak in China via internet media monitoring; however, not translated into English until late Jan., 2003
February, 2003 A physician attending a wedding from that same area becomes ill while staying overnight at a hotel in Hong Kong 12 other hotel guests subsequently are infected before returning home to multiple different regions of the world
February, 2003 An American businessman traveling from China to Singapore becomes ill and is hospitalized in Hanoi, Vietnam, where he dies of a respiratory illness Medical staff caring for this patient, utilizing usual precautions, also become ill. Ultimately, 7 HCWs die Dr. Carlo Urbani, an Italian physician who investigated and reported this outbreak to W.H.O. also becomes ill. He, too, dies
March 12th, 2003: W.H.O. issues Global Alert about cases of an apparently new cause of atypical pneumonia Severe Acute Respiratory Syndrome
SARS Data regarding a novel corona virus (SARS - CoV) published on March 24th, 2003 Zoonotic origin - most likely crossing from bats to palm civets (a Chinese delicacy) to humans through close contact Significant human - human transmission w/ 10% mortality Ro = 3
SARS Acute febrile respiratory illness, but otherwise, non-specific symptoms No effective treatment No vaccine Significant post-illness sequelae
SARS Ultimately, worldwide, >8000 cases / >800 deaths Most cases in China, particularly Hong Kong Many cases in HCWs caring for SARS patients Rapid spread to 37 countries, INCLUDING Canada (Toronto, Ottawa; 251 cases / 44 deaths) and U.S. (San Francisco)
We were Lucky (sort-of) Incredibly heroic (and very expensive) efforts by Chinese and Canadian health authorities, care providers, WHO, CDC, and numerous others in multiple countries contained this outbreak and prevented further spread No additional cases since 2003
Middle Eastern Respiratory Syndrome
MERS - CoV First isolated from the lungs of a 60 y.o. male who died of respiratory failure in June, 2012, in Jeddah, Saudi Arabia by Dr. A. Zaki, an Egyptian virologist In September, a 49 y.o. Qatari man developed respiratory and renal failure and was transferred to the U.K. for ECMO Never before seen strain of coronavirus
As of 10/4/2013: 136 cases; 58 deaths - 50% case mortality Majority of deaths from respiratory and renal failure Majority of cases from the Middle East Saudi Arabia: 82 cases, 41 deaths also France, Italy, UK none (yet) in the U.S.
Male >> female; mean age 56 Incubation period: 2-13 days (mean 5.2) Non-specific respiratory and/or GI symptoms. Most all had fever (98%), cough (83%), SOB (72%) Almost none had rhinorrhea (4%) Risk factors: most all had some comorbidity. Particularly high risk: diabetes, CRF Treatment: supportive only
?? Pipistrellus pipistrellus- European brown bat Egyptian tomb bat (Taphozous perforatus) - 50/50 Dromedary camels (from Oman) + ab to MERS - Egyptian serosurvey: 94% camels ab positive - No correlation with illness in camels - Bat to human transmission infrequent Reusken C, Lancet Infect Dis, 8/9/2013; Perera RA, Eurosurveillance, Sept 7 1013
Human - human transmission? YES, though (currently) not easily; HOWEVER, intrahospital transmission to other patients and health care providers has been observed w/ some deaths. Intrafamial transmission also described Ro = 0.69 (est. worst case scenario)
Big Questions: Is the mortality really 50% - or is there a significant degree of asymptomatic or less severe infection? What are the implications of this answer? If so, are these individuals contagious? How contagious? Which contributes most to contagion? Aerosols? Large droplets? Direct contact? Stool? Will MERS-CoV evolve into a highly contagious virus?
So... Question: a patient comes into my office/er with an acute respiratory illness. When should I worry about MERS-CoV? Answer: has he/she traveled to the Arabian Peninsula within the past 2 weeks, or been around others who have? Is he/she febrile? Coughing? SOB? Rhinorrhea?
What if the answer is yes to the first two questions? Airborne (N-95 masks, goggles) and contact precautions Call your state health department - IMMEDIATELY! (Dx is currently via PCR of various body fluids; highest yield from lower respiratory specimens)
Question: my patient (one of ~ 11,000 Americans who do so each year) wishes to travel to the Middle East for the Hajj pilgrimage (Oct. 13-18). Are there any travel restrictions in that regard? Answer: currently no CDC recommendations regarding restriction of travel. Check the CDC or WHO website for the most current advice
Summary: MERS-CoV is not currently considered a Public Health Emergency, but, whether it s H7N9, MERS, pandemic H1N1 or GOK - When the Next Big One arrives...it will be signaled first by quiet, puzzling reports from faraway places - reports to which disease scientists and public health officials, but few of the rest of us, pay close attention. * Quammen *D.
References: http://www.cdc.gov/coronavirus/mers Assiri A et al. Hospital outbreak of Middle East respiratory syndrome coronavirus. N Engl J Med 2013;369:407-416 D. Quammen. The Next Pandemic: Not if, but When (ed) New York Times, May 9, 2013 M. Osterholm The Next Contagion: Closer Than You Think (ed) New York Times, May 9, 2013 Perlman S et al. Person-to-Person Spread of the MERS Coronavirus - An Evolving Picture. N Engl J Med 2013;369:466-467 Zuki AM et al. Isolation of a novel coronavirus from a man with pneumonia in Saudi Arabia. N Engl J Med 2012;367:1814-1820
Thank You!