MERS ( Middle East Respiratory Syndrome)

Definition : MERS Co-V is a viral disease caused by Coronavirus. It attacks the respiratory tract
and leads to mild to severe disease, even the fatal one.

The first case was reported in 2012 in Saudi Arabia

TRANSMISSION METHOD

The virus can be transmitted between humans by droplet and contact with objects contaminated with the
virus

DIAGNOSTIC CRITERIA

a. Diagnose
a. Fever ≥ 38 ° C
b. Cough, Shortness of Breath.
c. In some cases, there are gastrointestinal problems such as diarrhea.
d. History of travel from the Arabian Peninsula or neighboring countries1 within 14 days

b. Radiology : predominantly peripheral lesions, commonly progressing from unilateral focal air-
space opacity to unilateral multifocal or bilateral involvement during treatment.
c. Laboratory : RT – PCR

CASE DEFINITION

1. Suspect Case
• Acute Respiratory Infections , with fever ≥ 38 ° C and cough , AND
• Suspicion of pulmonary parenchymal disease (i.e. Pneumonia or Acute Respiratory Distress
Syndrome based on clinical or radiological evidence of consolidation); AND
• Travel history of the Arabian Peninsula and surrounding countries1 within 14 days

2. Probable Case

• A person fitting the definition of a suspect case with clinical, radiological, and histopathological
evidence of pulmonary parenchyma disease (i.e Pneumonia or ARDS) but no possibilility of
laboratory confirmation either because the patient or samples are not available or there is no
testing available for other respiratory infection, AND
• Close contact with laboratory confirmed case, AND
• Not already explained by any other infection or etiology, including all clinically indicated tests for
community acquired pneumonia according to local management guidelines

3 . Confirmed Case

• A person with laboratory confirmation2 of infection with MERS Co-V.

1
COUNTRIES considered in the Arabian Peninsula and neighboring include: Bahrain, Iraq, Iran, Israel, Jordan, Kuwait,
Lebanon, Oman, Palestinian territories, Qatar, Saudi Arabia, Syria, the United Arab Emirates (UAE), and Yemen
 GENERAL MANAGEMENT OF PATIENTS UNDER INVESTIGATION FOR SEVERE RESPIRATORY DISEASE ASSOCIATED WITH MERS
CORONAVIRUS
PATIENT UNDER INVESTIGATION
Does your patient have
1. Acute respiratory symptoms(temp ≥ 38°C and/or cough) AND
2. History of travel from ARABIAN Peninsula** within 14 days?
Patients with
YES 1. Manage accordingly. 1. SEVERE acute respiratory
YES YES 2. Reclassify after carefully symptoms(temp ≥ 38°C and/or cough) with
considering the possibility of NO known etiology AND
Pneumonia on PE OR Is there any alternative coinfection. 2. Epidemiologic link to confirmed MERS
Pneumonia on CXR + diagnosis on work-upB? 3. Remove from isolation after CoV case
HypoxemiaA appropriate consultation.C

No No

Not MERS CoV MersCoV CASE SUSPECT Laboratory exam cannot

1. Work-up to exclude other diagnoses 1. Inform NEC or RESU be done
2. Send patient for home quarantine for 2. Isolate patient until 10 days after Probable MERS CoV
14 days resolution of fever provided respiratory
symptoms are improving or absent

1. Manage accordingly.
2. Repeat NPS/OPV/Sputum/BAL No Yes
after 48 hours (+) NPS/OPV/Sputum/BAL Confirmed MERS CoV
PCR for MERS CoVE?

(+) NPS/OPV/Sputum/BAL Yes

PCR for MERS CoVE? DIAGNOSIS AND TREATMENT ALGORITHM

No **countries considered in the Arabian Peninsula and neighboring include:

Bahrain Jordan Oman Syria,
YES
1. Reclassify after carefully considering Iraq Kuwait Saudi Arabia Israel
Iran Lebanon Qatar Yemen Adequate recovery?F Remove from isolation.
the possibility of coinfection
Palestinian territories United Arab Emirates (UAE)
2. Remove from isolation after
appropriate consultation
NO
A. Hypoxemia is <95% O2 saturation on pulse oximetry taken at room air
B. Factors that may be considered in assigning diagnosis include the strength of the exposure history, the specificity of the diagnostic test and the compatibility of
Re-evaluate clinically, manage and report accordingly.
the clinical presentation and course of illness for the alternative diagnosis. Work ups may include sputum GS/CS for CAP, sputum AFB, urine legionella antigen,
rapid PCR, DFA, serology, NPS/OPS for H1N1, H7N9. NERS Cov v6.2 2014
C. Patients initially classified as suspect or probable MersCoV, for whom an alternative diagnosis can fully explain the illness, reclassify them after carefully
considering the possibility of coinfection. They may be removed from isolation after appropriate consultation with the clinic ian and public health authorities.
Factors that may be considered include the nature of the potential exposure to MersCoV, nature of contact with other in the residential or work s etting and the
strength of the evidence for an alternative diagnosis.
D. Supportive care includes antipyretics, adequate hydration, and oxygenation
E. Adequate sample is assumed. In the event that sputum cannot be given an oropharyngeal swab may be submitted for analysis
 LABORATORY EXAMINATION

1 . Routine Clinical Specimens

• Sputum and blood culture from a patient with pneumonia

2 . Specimens from the upper and lower respiratory tract

• Run test for Influenza A and B viruses. Subtypes of influenza A virus: H1, H3, H5 and H5N1

3 . Specimens for New Corona Virus (Inspection to have a confirmatory diagnosis)

• Run Reverse Transcriptase using Polymerase Chain Reaction ( RT - PCR )

• Collecting Specimens from
 Upper respiratory tract (nasal / nasopharyngeal / throat swabs)
 Lower respiratory tract (sputum , endotracheal aspirate, bronchoalveolar drainage)
• Send to Laboratory Research and Development Agency of Republic of Indonesia, Jakarta
• Collecting serial specimens from several places within a few days ( every 2-3 days ) to see Viral
Sheeding

2
LABORATORY CONFIRMATION c/o RITM Virology
TREATMENT OF SEVERE RESPIRATORY DISEASE ASSOCIATED

WITH MERS CO-V

 INFECTION PREVENTION AND CONTROL

The Prevention of MERS Co-V is as same as the prevention of SARS or other respiratory infectious
diseases.

Precautions of MERS Co-V as follow:

 Droplet transmission.
 Standard precautions are applied to any patient who has acute respiratory infections,
including patients with suspected, probable or confirmed MERS Co-V
 Infection prevention and control measures has to be initiated when a patient enters triage
with symptoms of acute respiratory infections with fever.
 Setting the room and bed separate each other at least 1 meter for patients with upper
respiratory infectious disease and other patients who do not use personal protective
equipment.
 Ensure triage and waiting room with good ventilation.
 Do cough etiquette.
 Siloam Hospitals QuestionnaireMiddle East Respiratory
SyndromeCoronavirus(MERS-CoV) Precaution
Please take a minute to answer the questions below and hand it to reception once completed.

1. Do you have any of the below Symptoms

a. High fever (Y/N)

b. Cough or Shortness of breath or Breathing difficulty (Y/N)

c. Other influenza like symptoms (Y/N), please describe:

…………………………………………………………………………………………..

2. Travel History

- Have you been traveling to Arabian Peninsula and neighboring countries (Bahrain, Iran, Iraq,
Israel, Jordan, Kuwait, Lebanon, Palestinian territories, Oman, Qatar, Saudi Arabia, Syria, the
United Arab Emirates (UAE), and Yemen) in the last 14 days? (Y/N), if Yes, please write the
country:
………………………………………………………………………

- Have you been traveling to UK, Germany, Italy, France or Tunisia in the last 14 days? (Y/N), if
Yes, please write the country:
………………………………………………………………….

3. Contact History

- Have you had close contact to a person diagnosed with Middle East Respiratory Syndrome
Coronavirus (MERS-CoV)? (Y/N)

- Have you had direct contact with / handled animal (i.e : camel or bat) that are suspected or
confirmed cases of Middle East Respiratory Syndrome Coronavirus (MERS-CoV)? (Y/N)
If you answer Yes to questions 1:

1. Please disinfect your hands with the provided disinfectant as per the guidelines provided.
2. Please request face mask from our reception and wear it as per guidelines provided or
instructed by our staff.
If you are not able to tolerate using a mask, please help yourself to tissues provided and cover
your mouth and nose whenever you cough or sneeze. Discard tissue directly after use in the
allocated bin next to the disinfectant table.

3. Our staff will escort you to the allocated consultation room ASAP.
 DAFTAR NAMA RUMAH SAKIT RUJUKAN

NO NAMA RS ALAMAT

1 Jambi
1 RSU Raden Mattaher
Jambi
2 Sumatera Selatan
2 RSU Dr. M. Hoesin
Palembang
3 RSU Lubuk Linggau
Jl. Letjend. Soeprapto No. 31 Telanaipura Jambi Telp. 0741 -
61692
Jl. Jendral Sudirman Palembang 3012 Km. 3,5
Telp. 0711-354088 ext. 801, Faks: 351318
Jl. Yos Sudarso Lubuk Linggau
Telp. 0733 - 321013

4 RSU Kayu Agung Jl. Raya Lintas Timur Kec. Kota Kayuagung
Telp. 0712 - 323889
5 RSD Kab. Lahat Jl .Mayor Ruslan I No 28 Lahat
Telp. 0731 - 321785
3 DKI Jakarta
6 RSPI Dr. Sulianti Saroso Jl. Baru Sunter Permai Raya - Jakarta 14340
Phone 021-6506559 Fax 021-6401411
7 RSU Persahabatan Jln. Persahabatan Raya No.1 Jakarta 13320
Telp. 021- 4891708/4891745, Faks: 4711222
8 RSPAD Gatot Sobroto Jl. Dr A Rahman Saleh No 24 Jakarta Pusat
Telp. 021 - 371008
4 Banten
9 RSU Serang Jl. Rumah Sakit No. 1, Serang
Telp. 0254-200829 Faks: 200724
10 RSU Tangerang Jl. Ahmad Yani No. 9 Tangerang
Telp. 021 - 5523507, Fax : 5527104
5 Jawa Timur
11 RSU Dr. Soetomo Jln. Prof. Dr. Moestopo No. 6 - 8 Surabaya
Telp. 031-5501006/5501078/5501149
12 RSU Dr. Saiful Anwar Jl. Jaksa Agung Suprapto No. 2 M a l a n g
Telp. 0341-35210, Faks: 359384
13 RSU Dr. Soebandi Jl. Dr. Soebandi No. 1 Jember 68111
Telp. 0331-487441
14 RS Dr R Koesma Tuban Jl Dr W S Husodo Tuban No.800
Telp. 0356-321010/32109, Faks: 324419
 15 RS Dr S Djatikoesoemo Jl Dr Wahidin 38 Bojonegoro
Telp. 0353-881193
16 RS Pare Jl Pahlawan Kusuma B I Pare
Telp. 0354-391718
17 RS Blambangan Jl Istiqlah No 49 Banyuwangi
Telp. 0333-421118
18 RS Dr Soedono Jl Sumbawa No 6, Madiun 63116
Telp. 0351-20324325
6 Bali
19 RSU Sanglah JL. Diponegoro Denpasar, Bali
Telp. 0361-227911, Faks: 224206
20 RSU Tabanan Jl Pahlawan No 14 Tabanan
Telp. 0361-811027
21 RSU Sanjiwani Gianyar Jl Ciung Wenara No 2 Gianyar
Telp. 0361-943020
7 Kalimantan Timur
22 RSU Tarakan Jl. Merapi I Tarakan
Telp. 0551-21720 ; Fax. 21116
23 RSU Dr. Kanujoso Jl. MT Haryono Ring Road Balikpapan
Djatiwibowo Telp. 0542-873901-874156
24 RSU H A Wahab Jl Dr Soetomo Samarinda
Sjahranie Telp. 0541-738118
25 RSU Kota Bontang Jl A Yani Rt 11 Bontang
Telp. 0548-21256
26 RSU Panglima Sebaya Jl Ciptomangunkusumo No.2 T Grogot
0543-21118/21363
27 RSU Tanjung Selor Jl Cendrawasih Tanjung.Selor
Telp. 0552-22782/21292, Fax: 22667
8 Sulawesi Utara
28 RSU Prof.DR. RD Kandou Jl . Raya Tanawangko
Telp . 0431-853191/853193
29 RSU Dr Sam Ratulangi Kel. Luaan, Kec. Tondano Timur, Minahasa
Telp. 0431-321172

9 Sulawesi Selatan
30 RSU Dr. Wahidin Jl. Perintis Kemerdekaan Km. 11, Makassar 90245. Telp. 0411-
Sudirohusodo 510675; Fax . 510676
31 RSU Andi Makassar Pare- Jl. Nurussamawati 3 Pare-pare
pare Telp. 0421-21823
32 RSU Lakipadada Jl Pongtiku Mandetek Tn Toraja
Tana Toraja Telp. 0423-22264
33 RS Islam Faisal Jl AP Pettarani Makassar
Telp. 0411-871942
34 RS Akademis Jaury Jl Bulusaraung No 57 Makassar
Telp. 0411-317343
35 RSU Sinjai Jl Jend Sudirman No 47 Sinjai
Telp. 0482-21132
References

1 . Pedoman TataLaksana Klinis Infeksi Saluran Pernafasan Akut Berat Suspek Middle East Respiratory
Syndrome – Corona Virus (MERS Co-V)
http://www.depkes.go.id/downloads/merscov/Manajemen % 20Klinis % 20Mers_A5_Final120214 -1.pdf

2 . Diagnose of MERS Co-V http://www.ritm.gov.ph/Announcements/DIAGNOSIS % 20of % 20MERS %

20CoV.pdf

3 . WHO
http://www.who.int/csr/disease/coronavirus_infections/MERS_CoV_investigation_guideline_Jul13.pdf

4 . Laboratory testing for Middle East Respiratory Syndrome Corona Virus

http://www.who.int/csr/disease/coronavirus_infections/MERS_Lab_recos_16_Sept_2013.pdf?ua=1