EMERGING INFECTIONS

MERS-COV
EBOLA
AVIAN FLU

Department of Family and Community Medicine

De La Salle University Medical Center

Elmer R. Camarse, MD
MERS-CoV
Middle East Respiratory Syndrome
Coronavirus (MERS-CoV)

 What is MERS?
A viral respiratory illness first reported in
Saudi Arabia in 2012
It is caused by a virus that is different from
any other virus that has been previously
found in people
It is a betacoronavirus lineage C with
unknown origins
Symptoms of MERS include fever, cough,
and shortness of breath
Epidemiology
 CDC, the World Health Organization
(WHO) and other partners closely
monitor (MERS-CoV) infections globally

 This is to better understand the risks to

public health
 MERS-CoV was first identified and
reported to WHO in September 2012

 As of April 29, 2015, WHO has

confirmed:
 1110 laboratory-confirmed cases
 at least 422 deaths
 All reported cases have been directly or indirectly
linked through travel or residence to nine countries:
Saudi Arabia
the United Arab Emirates
Qatar
Jordan
Oman
Kuwait
Yemen
Lebanon
Iran
Number of cases of Middle East respiratory syndrome coronavirus
infection reported by the World Health Organization, by month of
illness onset — worldwide, 2012–2015
What can we do?
Early Recognition and
Management
 Patient Under Investigation
Acute respiratory infection

History of fever or measured fever (≥ 38 °C)

Cough

Suspicion of pulmonary parenchymal

disease (e.g. pneumonia or ARDS)
Residence in or history of travel to the
Arabian Peninsula or neighboring countries
within 14 days before onset of illness

Cannot be explained by any other infection

or etiology, including all clinically indicated
tests for community-acquired pneumonia
It is not necessary to wait for
test results for other
pathogens before testing for
novel coronavirus
Signs and Symptoms
 Fever  Sputum production
 Chills/rigors  Dizziness
 Headache  Nausea/ vomiting
 Non-productive  Diarrhea
cough  Abdominal pain
 Dyspnea  Atypical
 Myalgia presentations
 Sore throat include:
 mild respiratory illness
 Coryza
without fever
 diarrheal illness
preceding
development of
Clinical judgment should be
used to guide testing of
patients for MERS-CoV
infection
Person Under
Investigation
 Fever AND pneumonia or acute respiratory distress
syndrome
 AND EITHER:
History of travel from countries in or near the Arabian
Peninsula within 14 days before symptom onset

Close contact with a symptomatic traveler who developed

fever and acute respiratory illness within 14 days after
traveling from countries in or near the Arabian Peninsula

A member of a cluster of patients with severe acute

respiratory illness of unknown etiology in which MERS-CoV is
being evaluated
Person Under
Investigation
 Fever AND symptoms of respiratory
illness AND being in a healthcare facility
(as a patient, worker, or visitor) within 14
days before symptom onset in a country
or territory in or near the Arabian
Peninsula in which recent healthcare-
associated cases of MERS have been
identified.
Person Under
Investigation
 Fever OR symptoms of respiratory
illness AND close contact with a
confirmed MERS case while the case
was ill.
Evaluation and Management of Close Contacts

 A person who develops fever or

symptoms of respiratory illness within 14
days following close contact with a
confirmed case of MERS while the case
was ill
 Community contacts
 Contacts on conveyances (e.g.,
airplane, bus)
REMINDER:

The MERS-CoV infection

spectrum of illness is
incompletely defined. Although
most have severe acute lower
respiratory illness, mild
infections, and infections with
no apparent symptoms, have
been reported. Additionally, in
some cases, diarrhea preceded
respiratory symptoms.
 Close contacts who are ill and do not
require hospitalization for medical
reasons

Cared for and isolated in their home while

being evaluated for MERS-CoV infection.
 Close contacts of a PUI should be
taught to monitor themselves for FEVER
and RESPIRATORY ILLNESS

Seek medical attention if they become ill

within 14 days after contact
Healthcare providers
should IMMEDIATELY
report to their state or
local health department
any person being
evaluated for MERS-CoV
infection if they meet the
criteria for a patient
under investigation.
Laboratory Testing
 CDC MERS-CoV rRT-PCR assay
Lower respiratory specimen
○ Sputum
○ Broncheoalveolar lavage fluid
○ Tracheal aspirate
Nasopharygeal/oropharygeal swab
Serum
Laboratory Testing
 CDC MERS-CoV serologic assay

If symptom onset was more than 14 days

prior
Infection Control
 In PUIs and probable or confirmed
MERS cases

Appropriate infection-control measures

should be used

○ Managing patients

○ Specimen collection
 Person Corridor/ Patient Consultation Inside After Each Upon Leaving the
Concerned Nurse Waiting areaPPE FOR
Area Individual Patient Seen Area/At the End
Station (East 6) Rooms of shift
MERS_CoV (Admitted
Patients)

Health Worker Not Indicated Surgical mask Surgical mask N95/P100 Change: Discard all PPE
(Doctors, Gloves Gown respirator Gown
Gloves Gown Gloves
Nurses, IW,
Gloves  
RA)

Medical Not Indicated Surgical mask Surgical mask N95/P100 Change: Discard all PPE
Technologist Gloves (*N95/P100 respirator Gown
respirator) Gown Gloves  
Gown Gloves
Gloves Goggles/face
*Goggles/face shield shield
 

Radiology Not Indicated N/A N/A N95/P100 Change: Discard all PPE
Technician respirator Gown  
Gown Gloves
 
Gloves
Goggles/face
shield

Janitor Not Indicated Surgical mask Surgical mask Entry Restricted N/A Discard all PPE
Gloves Gloves
 

Security Not Indicated N/A N/A Entry Restricted N/A N/A

Guard
 Standard precautions

Hand hygiene

Personal protective equipment (PPE)

 Droplet precautions

Any patient known or suspected to have an

acute respiratory infection

Patients in the triage with symptoms of

acute febrile respiratory illness
 Patients in the triage with symptoms of
acute febrile respiratory illness
Spatial separation (at least 1 meter) between
each patient with acute respiratory infections
and other individuals not wearing PPE
Triage and waiting areas adequately ventilated
Respiratory hygiene (i.e. covering the mouth
and nose during coughing or sneezing)
Hand hygiene.
 Airborne precautions

For aerosol-generating procedures which have

been consistently associated with an increased
risk of pathogen transmission (i.e. tracheal
intubation)
PPEs
○ Gloves
○ Long-sleeved gowns
○ Eye protection
○ Particulate respirators (N95, etc.)
Patients Placement
 Airborne Infection Isolation Room
(AIIR)
• A single-patient room in which environmental
conditions are controlled to minimize the
possibility of airborne transmission of infectious
agents.
• specified number of required air exchanges per hour (ACH)
• monitored negative pressure relative to hallways
• air exhausted directly to the outside preferably or
passed through a high-efficiency purifying air (HEPA)
filter if recirculated
Management
 Oxygen therapy

Patients with signs of severe respiratory

distress, hypoxaemia (i.e. SpO2 < 90%) or
shock

Initiate: 5 L/min

Titrate: SpO2 ≥ 90% in non-pregnant adults

SpO2 ≥ 92–95 % in pregnant patient
Antibiotics
 Give empiric antimicrobials to treat
suspected pathogens, including
community- acquired pathogens
Fluid Therapy
 Use conservative fluid management in
patients when there is no evidence of
shock
EBOLA VIRUS DISEASE
Ebola Virus Disease
 The 2014 Ebola epidemic is the largest
in history, affecting multiple countries in
West Africa.

 There were a small number of cases

reported in Nigeria and Mali and a single
case reported in Senegal
Ebola Virus Disease
 According to the latest World Health
Organization update on January 28,
2015
22,092 confirmed, probable, and suspected
cases of Ebola
8,810 deaths had been reported as of
January 25 from the three West African
countries (Guinea, Liberia, and Sierra
Leone) where transmission has been
widespread and intense.
Areas with widespread
transmission as of May 5, 2015
Total Cases
(Suspected, Laboratory-
Probable, and Confirmed Total
Country Confirmed) Cases Deaths
Guinea 3589 3167 2386

Liberia* 10507 3151 4691

Sierra Leone 12440 8595 3903

Total 26536 14913 10980

Previously affected
countries
Total Cases
(Suspected, Laboratory-
Probable, and Confirmed Total
Country Confirmed) Cases Deaths
Guinea 3589 3167 2386

Liberia* 10507 3151 4691

Sierra Leone 12440 8595 3903

Total 26536 14913 10980

Ebola Virus
 Ebola virus enters the patient through
Mucous membranes
Breaks in the skin
Parenterally
 Healthcare personnel must prevent direct
contact or splashes with
Blood
Body fluids
Contaminated equipment
Soiled environmental surfaces.
 Healthcare personnel must prevent
direct contact or splashes with
Blood
Body fluids
Contaminated equipment
Soiled environmental surfaces.
Clinical Course
 Abrupt onset of fever and symptoms (2 to
21 days after exposure but usually at 8-12
days)
 Initial signs and symptoms are
nonspecific
Elevated body temperature or subjective fever
Chills
Myalgias
Malaise
 Because of nonspecific symptoms early
in the course of the disease, EVD often
can be confused with other more
common infectious diseases such as
Malaria
Typhoid fever
Meningococcemia
Other bacterial infections (i.e. pneumonia)
 The most common signs and symptoms
reported from West Africa during the
current outbreak from symptom-onset to
the time the case was detected include:
Fever (87%)
Fatigue (76%)
Vomiting (68%)
Diarrhea (66%)
Loss of appetite (65%).
 Five days after nonspecific symptoms:

Gastrointestinal symptoms
○ Watery diarrhea
○ Nausea
○ Vomiting
○ Abdominal pain
Other symptoms
○ Chest pain
○ Shortness of breath
○ Headache
○ Confusion
○ Conjunctival injection
○ Seizures
○ Cerebral edema
 Bleeding is not universally present but can
manifest as:
 Petechiae
 Ecchymosis/bruising
 Oozing from venipuncture sites
 Mucosal hemorrhage
 Frank hemorrhage is less common
 In the current outbreak:
 Unexplained bleeding: 18%
 Blood in the stool (about 6%)

 Diffuse erythematous maculopapular rash

 Day 5 to 7 (usually involving the neck, trunk,
and arms)

 Pregnant women may experience spontaneous

miscarriages
Pathogenesis
 Ebola virus appears to trigger pro-inflammatory
cytokines with subsequent vascular leak and impairment
of clotting ultimately resulting in multiorgan failure and
shock

 Ebola virus migrates from the initial infection site to

regional lymph nodes and subsequently to the liver, spleen,
and adrenal gland

 Although not infected by Ebola virus, lymphocytes undergo

apoptosis resulting in decreased lymphocyte counts.
 Hepatocellular necrosis
Dysregulation of clotting factors
Subsequent coagulopathy

 Adrenocortical necrosis
Associated with hypotension
Impaired steroid synthesis.
Laboratory Findings
 Leukopenia frequently with lymphopenia
 Elevated neutrophils
 Platelet counts often decreased (50,000 – 100,000)
 Amylase may be elevated (pancreatic involvement)
 Hepatic transaminases are elevated with AST
exceeding ALT (liver involvement)
 Proteinuria
 Prothrombin (PT) and partial thromboplastin times
(PTT) are prolonged and fibrin degradation
products are elevated (DIC)
Safety for the
Healthworker
 Wear appropriate personal protective equipment
(PPE).
 Practice proper infection control and sterilization
measures
 Isolate patients with Ebola from other patients.
 Avoid direct, unprotected contact with the bodies
of people who have died from Ebola.
 Notify health officials if you have had direct
contact with the blood or body fluids, such as but
not limited to, feces, saliva, urine, vomit, and
semen of a person who is sick with Ebola
Common symptoms
 Fever
 Severe headache
 Muscle pain
 Weakness
 Fatigue
 Diarrhea
 Vomiting
 Abdominal pain
 Unexplained hemorrhage (bleeding or bruising)
 Symptoms may appear anywhere from 2 to 21 days
after exposure to Ebola, but the average is 8 to 10 days.
 Recovery from Ebola depends on good
supportive clinical care and the patient’s
immune response

 People who recover from Ebola infection

develop antibodies that last for at least
10 years
Avian Flu (H7N9)
Avian Flu (H7N9)
 Human infections were first reported in
China in March 2013

 Most are believed to result from

exposure to infected poultry or
contaminated environments
 Most patients have had severe
respiratory illness, with about one-third
resulting in death
 No evidence of sustained person-to-
person spread of H7N9 has been found
Though some evidence points to limited
person-to-person spread in rare
circumstances.
 A(H7N9) viruses
Can cause severe disease in humans
Do not transmit easily from person to person
Primarily linked to exposure to infected poultry or
contaminated environments
 However A(H7N9)
Circulates in poultry without the typical HPAI-
associated morbidity and mortality therefore may
spread undetected
This makes A(H7N9) passive surveillance and
control in poultry species challenging
 The global total for H7N9 cases stands
at 660 at present.

 Since H7N9 is not spreading easily from

person to person at this time, CDC
advises the public to take some
common sense precautions, like not
touching birds or other animals and
washing hands often
Monitoring of Exposed Persons

 Exposed persons should monitor

themselves for new illness for
10 days after the last known exposure
Fever and respiratory symptoms (e.g.,
cough, sore throat, shortness of breath,
difficulty breathing)
Treatment
 Chemoprophylaxis with influenza antiviral
medications can be considered for all exposed persons

 Based on clinical judgment, with consideration given to

the type of exposure and to whether the exposed person
is at high risk for complications from influenza

 If antiviral chemoprophylaxis is initiated, treatment

dosing for the neuraminidase inhibitors oseltamivir or
zanamivir (one dose twice daily) is recommended in
these instances instead of the typical antiviral
chemoprophylaxis regimen (once daily).
The Best Prevention is to Avoid Sources of
Exposure

 People who work with poultry or who

respond to avian influenza outbreaks
Use of appropriate personal protective
equipment
Careful attention to hand hygiene.
 Highly pathogenic avian influenza (HPAI)
poultry outbreak responders
Receive seasonal influenza vaccination annually
Prophylactic antiviral medication during response
Monitored for illness during and after responding
to HPAI outbreaks among poultry

Seasonal influenza vaccination will not prevent infection with avian

influenza A viruses, but can reduce the risk of co-infection with
human and avian influenza A viruses.
Thank you…