Call Transcript: Interim Clinical Guidance and CDC Updates for Middle East Respiratory Syndrome Coronavirus (MERS-CoV)

Coordinator:
Welcome everyone and thank you for standing by, all participants have been placed on a listen-only mode until the question-and-answer session at the end of the presentation. At that time, to ask a question you may press Star 1 on your touchtone phone. Today's call is also being recorded, if you have any objections please disconnect at this time. I would now like to turn the conference over to Ibad Khan, you may begin.

Ibad Khan
Thank you, Wendy. Good afternoon, I'm Ibad Khan and I’m representing the Clinician Outreach and Communication Activity, COCA, with the Healthcare Preparedness Activity at the Centers for Disease Control and Prevention. I am delighted to welcome you to today’s COCA call, Interim clinical guidance and CDC updates for Middle East Respiratory Syndrome Coronavirus, MERS-CoV.

We are pleased to have with us today Dr. Sue Gerber, Dr. J. Todd Weber and Dr. Marty Cetron from CDC. They will discuss the latest situation, surveillance, traveler's health and updates to CDC clinical guidance for testing, patient evaluation and infection control.

There is no continuing education or slides provided for this call. Additional resources for clinicians are available on our COCA Web side and emergency.cdc.gov/coca under the Call Web page. At the end of the presentation, you will have the opportunity to ask the presenters questions. On the phone, dialing Star 1 will put you in the queue for questions. Questions will be limited to clinicians who would like information on clinical guidance related to MERS-CoV.

For those who have media questions, please contact CDC Media Relations at 404-639-3286 or send an email to media@cdc.gov.

Our first presenter today is Dr. Susan Gerber. She is the team lead for the respiratory viruses and the Picornavirus Team in the Division of Viral Diseases at CDC. She received her MD from Loyola University and completed a pediatric residency and pediatric infectious disease fellowship at the University of Chicago. She has over 13 years of experience in local public health with work on communicable diseases at the Cook County Department of Public Health and the Chicago Department of Public Health.

Our second presenter, Dr. J. Todd Weber is the Chief of the Prevention and Response Branch of the Division of Healthcare Quality Promotion at CDC. He received his MD from Columbia University, completed his residency in Internal Medicine at New York University Medical Center and joined CDC in 1990. He has worked in several different areas of infectious diseases at CDC. As part of his current role at CDC, Dr. Weber serves as a subject matter expert in infection control in response to outbreaks of healthcare associated infections.

Our final presenter is Dr. Marty Cetron; he is the Director for the Division of Global Migration and Quarantine who provides leadership for science, program, and policy development in global migration and health. Through his leadership, the Division works to prevent the introduction and spread of infectious diseases into the United States and to prevent morbidity and mortality among globally mobile populations. Dr. Cetron came to CDC in 1992 as an Epidemic Intelligence Service Officer. He has led several domestic and international outbreak investigations, conducted epidemiologic research, and was involved in domestic and international emergency responses. At this time please welcome Dr. Gerber.

Dr. Susan Gerber
Thank you. Today I'm going to present some updates and some recommendations for clinicians and public health departments on MERS-CoV.

I'm going to briefly discuss the worldwide epidemiology, a brief summary of two United States cases. I'll also discuss patients under investigation who should be tested for MERS-CoV and collection of specimen and types. I will also stress that it's important to communicate - for clinicians to communicate with state and local health departments if they actually - think that they have a suspect case of MERS-CoV.

And I'd also like to remind everybody that we are constantly updating our Web guidance and to please check the Web site for new information. As it becomes available it may change. First I'd like to start with worldwide epidemiology updates as of yesterday reports to the World Health Organization. The World Health Organization has reported 635 lab-confirmed cases as of yesterday, and again these numbers have - do change, with 193 deaths and the most recent symptom onset May 16 of this year.

There are still 34 cases that are announced by Ministries of Health that are pending WHO confirmation. Of the 635 reported cases, 227 are females, 391 are males, so there is a - remains a male predominance, and 17 patients with gender not reported. The median age of reported cases is 48 years with an age range of 9 months to 94 years with four cases of unknown ages.

A hundred and thirty-one cases have been reported to WHO as being asymptomatic or 21%. Thirty-two cases have been reported as having mild symptoms and not hospitalized or 5%. Sixteen have been reported as mild illness and not hospitalized and then 154were hospitalized and fatal or 25% and 288 were hospitalized and non-fatal, or 25%. Of the deaths the case fatality rate is 31%, 193 deaths.

The specific case number of 15 cases we currently don't have information for but this encompasses most of what we know. And of the 178 fatal cases which is 193 minus 15 with identifiable information, 127 are males, 50 are females and the median age of those reported dead is 60 and 123 were reported to have had comorbidities. Additionally reports to WHO have received 113 or 18% reports of healthcare workers as cases. And of these 77 are from Saudi Arabia, 31 from UAE, 4 from Jordan and 1 from Tunisia.

Among 112 healthcare worker reports to WHO from which there is information, 10 have died and 50 have been reported as being asymptomatic. In addition, using publicly available data from WHO we have been able to surmise that there have been approximately 28 clusters that we can connect patients to. The clusters that are reported to WHO have been associated with household settings and healthcare settings.

Countries tied to exposures or patients that have had exposures in - primarily in countries directly in the Arabian Peninsula include Saudi Arabia, UAE, Qatar, Oman, Jordan, Kuwait, Yemen, and Lebanon. Exportation of cases, or where there have been exposure to one of those countries and exported to other countries, include - cases have been identified in the United Kingdom, Tunisia, France, Malaysia, Italy, Netherlands, Greece, Egypt and the United States. And these have been exported from the countries I actually had said previously in the Arabian Peninsula.

A little bit about the two United States cases - the first case was a case in Indiana. A patient in their 60s who was a healthcare worker who traveled from Saudi Arabia, had onset with low grade fever, myalgia. No initial respiratory symptom in the middle of April, traveled to Chicago subsequently on April 24 and on April 27 developed shortness of breath, cough, fever and rhinorrhea.

On April 28 the patient was evaluated and admitted, was found to have a right lower lobe infiltrate on check x-ray, and chest CT revealed bilateral infiltrate. The patient required oxygen. And on May 9 the patient was no long symptomatic and tested negative by RT-PCR for two sets of specimens on different days that included sputum, nasopharyngeal and oropharyngeal specimen, serum, and those are specimens on different days and the patient was discharged.

For this case healthcare personnel and household contacts and a community contact monitored themselves twice daily for symptoms and fever for 14 days after exposure. Household contacts and exposed healthcare personnel were advised to wear a mask when going outside of the house or in contact with other household members while on voluntary home quarantine for 14 days after contact.

Healthcare personnel who had unprotected close contact with the patient returned to work 14 days after the last exposure and also had confirmed negative laboratory results for MERS and this consisted of nasopharyngeal and serum specimens from the household and healthcare personnel and the community contact, and they were tested by RT-PCR for MERS.

The Florida case was reported to CDC by Florida on May 11, was a traveler who also was a healthcare provider, aged in the 40s and resided and worked in Saudi Arabia. Importantly this case is not linked to the Indiana case. This patient began to feel unwell during a flight from Saudi Arabia to the United Kingdom and the symptom - initial symptoms included myalgia, fever, chills, and a slight cough.

The patient went on to have intermittent fevers, nausea, myalgia in Florida. May 9 went to the hospital emergency department and was admitted and notably at admission was afebrile. The management of this case was similar with respect to healthcare personnel and household contacts. Additionally initially an Illinois contact who was an Illinois resident who was a business associate was identified with extended face-to-face contact with the Indiana patient. That patient tested negative by PCR for MERS-CoV.

Preliminary information suggested a possibility of MERS antibodies - of this patient having MERS antibodies. But follow-up testing was - was done and we conclude that all - with the follow-up testing that this patient did not have any evidence of previous MERS-CoV infection. So we at this point do not believe this patient had had MERS-CoV.

In terms of patients under investigation, of those patients who have been tested for suspect MERS-CoV there have been 245 patients that have been tested and negative in the US. And the Indiana and Florida cases are the only two positive patients that we have identified.

In terms of evaluating suspect patients or patients under investigation our guidance is on the Web site and includes patients who meet the following criteria - fever and phenomena or acute respiratory distress syndrome based on clinical or radiologic evidence, and either history of travel from countries in or near the Arabian Peninsula within 14 days before symptom onset. Or close contact with a symptomatic traveler who developed fever and acute respiratory illness but not necessarily pneumonia within 14 days after they had traveled from countries in or near the Arabian Peninsula. And another suspect patient might be a close contact to a confirmed or a probable case of MERS.

Patients who are suspected to have MERS does not need to be - another etiology does not need to be ruled out. If a patient is suspected to have MERS it's important to call state and local health department officials to coordinate testing for MERS, often in state public health labs or we - our resource here at CDC.

Importantly - important epidemiologic information to collect when trying - when thinking about whether or not a patient might have a diagnosis of MERS-CoV includes getting a travel history within 14 days of onset of symptoms. And also it is helpful to know if somebody may have been exposed to a person who may have had confirmed or probable MERS-CoV. And importantly if that patient for example may have any risk factors such as a healthcare worker in a country with reported cases of MERS-CoV.

In addition clusters of patients with severe acute respiratory illness - example fever and pneumonia requiring hospitalization without recognized links to a case of MERS-CoV infection or to travelers in or near the Arabian Peninsula should be considered and evaluated for common respiratory pathogens. But if the illnesses remain unexplained, providers should also consider testing for MERS-CoV in consultation with state and local health departments.

And it's important to note that close contact management and recommendations should be considered with state and local health department authorities.

In addition, in terms of testing, multiple specimens from different sites at different times from symptom onset are recommended for testing for MERS-CoV. Lower respiratory tract specimens such as sputum, broncheoalveolar lavage fluid, tracheal aspirate have been found to be more likely to be positive as compared to upper respiratory tract specimens such as nasopharyngeal swabs. But in addition to recommending as a priority lower respiratory tract specimen, it is still important to also collect nasopharyngeal and oropharyngeal swabs, serum specimens and stool and rectal swabs.

It's also important to add that while collecting these specimens to wear recommended PPE or personal protective equipment while collecting specimens. And again it is not necessary to wait or rule out other etiologies before testing for MERS, but it is important to contact state and local health departments when considering this diagnosis and considering testing. Thank you.

Dr. J. Todd Weber
Good afternoon this is Todd Weber, it's a pleasure to talk to you this afternoon. I'm going to focus my remarks on infection control in healthcare settings.

And really everything I'm going to discuss can be found on our Web site in greater detail, so I want to point you to the URL, that contains our interim infection prevention and control recommendations, which is found on the COCA announcement. I'd also point out that we have two checklists, one for healthcare provider preparedness and one for healthcare facility preparedness that you might find useful in terms of reviewing what resources you have and need for attending to infection and control procedures for suspected or confirmed MERS-CoV patients. The Interim Infection Prevention and Control Recommendations for Hospitalized Patients with MERS-CoV has eight key areas. And those include Patient Placement, Aerosol Generating Procedures, Personal Protective Equipment (or PPE) for Healthcare Personnel, Hand Hygiene, Environmental Infection Control, Duration of Infection Control Precautions, Monitoring and Management of Potentially Exposed Personnel, and, finally, Monitoring, Management, And Training Of Visitors. I'm not going to go through each one of those in detail but I'll focus on a few that I think are most important to highlight.

I'd also emphasize that this guidance is not intended to apply to persons outside of healthcare settings. Dr. Gerber mentioned a little bit of that and Dr. Cetron will also discuss that to some extent. But what I have to describe includes hospitals as well as other healthcare settings but not outside of that.

So for patient placement for known or suspected MERS-CoV patients the first issue is placing them in an airborne infection isolation room or what's called an AIIR. If that's not available the patient should be transferred as soon as feasible to a facility where an AIIR is available and pending transfer a face mask should be placed on the patient and they should be isolated in a single patient room with the door closed. The patient shouldn't be placed in any room where room exhaust is recirculated without HEPA filtration.

For aerosol generating procedures, although there are limited data available to definitively define a list of aerosol generating procedures, those that are typically included are those that are planned ahead of time such as bronchoscopy, sputum induction, elective intubation and extubation and some procedures that often occur in unplanned emergent settings and can be life-saving such as cardiopulmonary resuscitation, emergent intubation and open suctioning of airways.

Clearly what we're recommending is more easily implemented for those procedures that are planned. And we would not want to suggest that those need to be implemented when the choice is between getting that appropriate equipment and saving someone's life in an emergent procedure, so that's a judgment that has to be made at the bedside or in the institution.

For aerosol generating procedures we recommend using a combination of measures to reduce exposures from the procedure when performed on MERS-CoV patients, which includes limiting the number of healthcare personnel present during the procedure to only those essential for patient care and support, conducting the procedures in a private room and ideally in an AIIR when feasible. And room doors should be kept closed except when entering or leaving the room and entry and exits should be minimized during and shortly after the procedure.

Healthcare personnel should adhere to personal protective equipment precautions in this interim guidance - in other words gloves, gown, either a face shield that fully covers the front and sides of the face or goggles and respiratory protection that is as least as protective as a fit tested N95 filtering facepiece respirator.

For personal protective equipment I would add in addition to the list that I just gave you that if a respirator is unavailable a facemask should be worn. And in this situation respirators should be made available as quickly as possible. The recommended personal protective equipment should be worn by healthcare personnel upon entry into patient rooms or care areas for any reason, for example clinical care, specimen collection and environmental cleaning. And upon exit from the patient room or care areas, the equipment should be removed and either discarded or, for reusable PPE, cleaned and disinfected according to the manufacturer’s reprocessing instructions.

And hand hygiene should be performed after removal of the personal protective equipment.

For the duration of infection control precautions at this time we don't have the information to definitively determine the recommended duration for keeping patients in isolation precautions.

The duration of precautions should be determined on a case-by-case basis in conjunction with local, state, and federal authorities. The presence - the factors that should be considered include the presence of symptoms related to MERS, the date symptoms resolve, other conditions that require specific precautions such as tuberculosis, and available laboratory information.

For monitoring and management of potentially exposed personnel, healthcare personnel who care for patients with MERS-CoV should be advised to monitor and immediately report any signs or symptoms of acute illness to their supervisor or facility-designated person, in other words, for example, occupational health services, for a period of 14 days after the last known contact with the sick patient.

Personnel who develop respiratory symptoms or fever after an unprotected exposure, in other words not wearing recommended PPE at the time of contact to a patient with MERS-CoV should not report to work or immediately stop working, should notify their supervisor, should implement respiratory hygiene and cough etiquette, seek prompt medical evaluation and comply with work exclusion until they are deemed no longer infectious to others.

For asymptomatic healthcare personnel who have had an unprotected exposure, consider exclusion from work for 14 days to monitor for signs and symptoms of respiratory illness and fever. And, if necessary to ensure adequate staffing of the facility, the asymptomatic provider could be considered for continuing work if they wear a facemask for source control. The facemask should be worn at all times while in the healthcare facility for 14 days from the last unprotected exposure.

The healthcare personnel continuing to work while wearing a facemask should be reminded that if caring for patients under airborne precautions to change the facemask to respiratory protection that is at least as protective as a fit-tested NIOSH-certified disposable N95 filtering face piece respirator without an exhalation valve. In other words the healthcare personnel should not wear both a facemask and respirator at the same time. When respirator use is no longer needed the healthcare personnel should put a facemask back on for source control.

I will stop my remarks there and after Dr. Cetron has given his presentation I'll be happy to take questions on infection control issues.

Dr. Marty Cetron
Thanks Todd, this is Marty Cetron from Global Migration and Quarantine, just a few comments and we'll take your questions. One, just to give you an update since our last call and a few activities.

We still just have the two imported cases but we should not be surprised if there are additional importations until the epidemic at the source is under control. And so it's for this reason that I think this call and having you all really aware of how to think of MERS, respond to MERS and seek help in testing and reporting and closing the public health loop between clinicians, health departments and CDC, is absolutely critical.

We're entering into a heightened travel season. Over the summer typically over three million visitors will visit Saudi Arabia and other areas in the Arabian Peninsula. And notable events coming up as Ramadan begins at the end of June, around June 28 through July 27. And this is typically a time we see increased religious pilgrims traveling to the area which is another reason to sort of maintain the vigilance that we have so far.

As far as what we know from the existing contact investigations on conveyances - I think Sue has updated you on the contact investigations for households and in healthcare settings - the news is equally good so far in our conveyance investigations with over 500 airline passengers associated with the first two introductions. We've notified more than 98% of them and none so far has had evidence of an acute infection compatible with MERS. And those who have had any minor illnesses all have been aggressively interviewed and tested, and tested negative by the acute PCR.

We're now entering the second phase of this vigilant testing in order to inform our response and understand transmission, and that is beginning a serosurvey where they'll be I hope several hundred participants on a voluntary basis providing a convalescent blood sample in order to give us any indication whether inapparent infection had occurred potentially associated with this airline travel.

We're very excited, this contact investigation will span over 30 states and more than a half a dozen countries. We think that the information gleaned from this first-of-its-kind full airline-based contact investigation could be informative in looking at, one, the ease of transmission, and two, whether or not there's a necessity to continue these types of conveyance investigations as cases are exported. So stay tuned for those results, it will take a while to reach out at the local level in your states and in your communities. If you're asked to help and participate in this we sure appreciate your support. A lot of this is being coordinated through state health departments.

In addition as Sue Gerber highlighted there's a series of testing that goes on from a screening ELISA followed by an immunofluorescence assay and then finally a confirmative neutralization antibody test. That whole process in sequence probably can take us more than a week or two just once the specimens arrive here. So we're not really expecting the results of this serosurvey until sometime later next month, but I think they'll be very informative.

What else is going on in order to heighten the vigilance is to basically increase surveillance and awareness for the ability to detect and respond rapidly and early with the isolation and contact tracing and quarantine precautions that have been laid out. And so some of the efforts in doing this are targeted at conveyances and ports of entry. We've got a heightened amount of messaging going off at airports around the country. We're developing special content messaging for outbound travelers as well and inbound travelers, both while they're still on the ground before they board, and in addition some targeted messaging with the intent to run while people are actually traveling en route or in return.

In addition we're having special outreach and educational programs for airline crew to heighten their ability to recognize potential cases and report early for port workers at CBP and TSA that can serve as the eyes and ears at almost 400 international points of arrival. And particularly through our Web site (emergency.cdc.gov/coca/calls/2014/callinfo_052814.asp) and other types of targeted outreach toward travelers. And these travelers fall into a variety of categories, one might be the casual visiting traveler or tourist traveler, another may be the special religious pilgrim traveler. And another would be the sort of high-risk populations for whom either high risk of becoming infected with MERS because of their exposures or high risk in becoming severely ill with MERS because of underlying health conditions or vulnerability.

All these types of recommendations and guidance are on our Web site. I think the only thing that's changed in our traveler notice in this regard, it still remains at a Level 2 which is special precautions indicated in various settings was the addition of some precautions about camel exposure in addition to the general recommendations around hand hygiene and visiting animal facilities. And this is based on still incomplete but I think important evidence that the sequencing of some of the human viruses is closely matched to sequences that have been coming from some of the camel viruses in - on the Peninsula and in KSA.

Specifically the Florida patient sequence is very well matched to a sequence reported from camels in the Jeddah outbreak and so we've had - we've put on there some special precautions about that exposure. But it's important to highlight that although increasing evidence is coming in about the potential role of camels as a reservoir, the means at which camels or other animals are infecting humans is still not known and the transmission characteristics are not known.

Some of the hypothesis that are out there that you will see have to do with consumption of raw camel products, raw camel milk or other cultural practices related to raw camel meats and so on. So more to follow as that story begins to unfold.

A number of people have asked about issues regarding healthcare workers and this arises from the fact that Saudi Arabia relies very heavily on foreign-born expatriate workers in their workforce - in some estimates up to 75%.

And there are many different countries and regions of the world represented in this workforce in addition to the United States. And I think it's particularly important that we have a very high level of targeted education, either you who may be involved in providing care in KSA or others: colleagues of yours or friends of yours, really to take special notes of the specific advice for healthcare workers.

In addition I think several training videos are being prepared along the lines that Todd had mentioned before people do a tour of duty for healthcare service in the area. And also for what to be alert for if you're leaving healthcare working facilities - healthcare facilities in KSA. Some countries are recommending voluntarily – we learned for example the Philippines which has more than 100,000 estimated healthcare workers in Saudi Arabia is voluntarily recommending a 14-day deferral from return travel after that type of exposure, especially if it's in facilities that have had outbreaks.

So we're evaluating all these other types of strategies. I mentioned it mostly for your awareness, you may hear about this from colleagues or others. And the point of this is to be able to have good health monitoring of high-risk situations that don't put others at risk by someone who may inadvertently develop an illness during their journey home.

I think the last area that we've been having some questions about from clinicians working in hospitals that either have satellite programs in KSA or are receiving patients as medical evacuations in transfer from healthcare facilities in Saudi Arabia. I mentioned this on our last call, the emerging area of medical tourism and the importance of understanding the amount of exchange that goes on between healthcare facilities.

Somebody asked whether there was special recommendations for state medical evacuation, and those are under development. They will be derived from the SARS model that - where we had some specific guidance, and state tuned for that to follow. But I think it's very wise to say that if you get contacted to be involved in a facility to facility transfer of a patient, even if that patient doesn't come with a preexisting diagnosis of MERS, given the potential for undiagnosed cases in facilities that are experiencing outbreaks, putting it into place infection control precautions or asking those questions, finding out whether people have been tested or what the clinical picture looks like is reasonable precautionary advice in that setting. When we become aware at CDC of air ambulance request for country-to-country transfers we will try to due diligence in that process as well make sure those questions get asked and any information regarding the potential risk or diagnosis of MERS gets addressed and shared with their receiving healthcare facility.

With that I think I'll end my remarks and let the lines be opened for questions, thank you very much.

Ibad Khan
Thank you Drs. Gerber, Weber and Cetron for providing our COCA audience with such a wealth of information.

We will now open up the lines for the question-and-answer session. Please remember questions will be limited to clinicians who would like information on clinical guidance related to MERS-CoV. For those who have media questions, please contact CDC Media Relations at 404-639-3286 or send an email to media@cdc.gov.

Coordinator
Thank you, as a reminder if you would like to ask a question please press Star 1 on your touchtone phone. Please ensure your line is un-muted and record your name when prompted. The first question today is from Michael Cooper, your line is open.

Michael Cooper
Hi and thank you for those presentations. It appears as though a fever and pneumonia or acute respiratory distress syndrome are required in order for a patient tested. And I was hoping that maybe the guidance would be made a little more liberal given that as I understand it the second patient in Florida didn't meet those criteria and it might be that the first patient didn't meet those criteria. My question will be is there any chance in the near future that those criteria will be broadened? And I ask this because we are restricted by the EUA to test pretty much by CDC guidance. And that's my question, thank you.

Dr. Susan Gerber
Thank you for that question, you bring up very good points because we are constantly evaluating how to evaluate potential patients. And we do - we do actually have in our guidance close contacts of confirmed or probable cases who have acute respiratory illness being tested. And we have used our tests for evaluating close contacts in our investigations already. Right now clinical judgment is also very important in determining epi-risk factors. And the possibility right now of a patient maybe having an unrecognized exposure to a confirmed MERS case, especially when putting together a travel history. And perhaps more epidemiologic information, an example would be a healthcare worker who works in a hospital in countries where there are reported cases, especially if the healthcare worker is aware that that hospital may have had MERS-CoV patients. We are constantly updating our Web site and our recommendations. And right now I can tell you that it is important to have clinical judgment. It is important to actually identify or recognize if a patient could have had exposure to a MERS-CoV patient and to cast a wide net.

Not every patient under investigation that has been tested by states or at CDC - not every patient has had definitive evidence of lower respiratory tract disease such as pneumonia or ARDS. So right now - and we can, it is allowable in cases where there is clinical judgment that with the epi-risk factors and clinical facts and putting all the pieces together that it can be considered. And we are always evaluating our web site and guidance and this is always something that we will be changing and updating regularly, so...

Dr. Marty Cetron
And just one comment to add to that, I mean for folks that remember the SARS experience, there is a risk at limiting your diagnostic inquiry to people that are, you know, too tightly meet a case definition.

Whether it's at that time a WHO case definition for SARS that require bilateral pneumonia or infiltrates. And when you have a typical presentation that don't get tested and are missed and that languish sort of unprotected on an orthopedic ward or somewhere else, that's exactly how the second wave of cases happened in Toronto. It's far better to have a low threshold with an Epi-link for investigating and testing and having a lot of negative results.

But knowing that you have an early ability to intervene, isolate, check on family and so on than it is to be overly restrictive about who you work up. And I think being very aggressive with a looser set of definitions with a strong Epi-link makes a lot of sense.

Michael Cooper
Thank you and I agree 100% with what you said, but my understanding is the EUA...

Dr. Marty Cetron
But that's not the case to our understanding, it's either in process - Sue can address this.

Dr. Susan Gerber
Yes this is Dr. Gerber, we - it is allowable, we - and we have actually had testing. Many of these patients under investigation have not completely fit our case definition. And it is allowable to have testing of symptomatic patients.

Coordinator:
Thank you, the next question is from Dr. Kim Miller.

Dr. Kim Miller
Hi, I'm a college health physician and I'm wondering if you could provide some guidance for college campuses where there are groups of Saudi Arabian students arriving on a regular basis. It sounds like we should be quarantining them until test results are available and I was wondering what the turnaround time on testing is.

Dr. J. Todd Weber:
So let me just clarify your question and maybe just clarify some definitions. So when we use the term isolation we're referring to people that are ill with a suspected quarantinable illness.

And when we use the term quarantine we're talking about restricting the movement in some fashion of exposed persons who presumably are either in the incubation period or not yet ill with the suspected illness. So when I hear your question I hear you asking whether simply being a student from KSA who arrives on a college campus is a reason to implement a quarantine. And the answer to that is no, that is not necessarily warranted.

If you're asking about students who arrive from Saudi Arabia and develop a clinically compatible illness, should that person be isolated and tested and investigated for MERS-CoV, the answer would be yes. But I just want to make the distinction in your question which of those scenarios you were describing.

Dr. Kim Miller
The latter.

Dr. J. Todd Weber:
Yes, so an ill individual with a compatible exposure deserves a full inquiry, you know, diagnostic, questioning, testing, isolation, and there will be - you will find the ability to get a turnaround at a state or local level of a test result in a fairly short period of time using PCR for, you know, the acute viremic phase from qualified specimens - OP, NP, sputum as indicated and so on. The serologic results which really aren't going to be helpful in that acute diagnostic setting because they're really meant to be sort of convalescent or serial titers that will take some time to get back will not necessarily be as useful in managing the acute scenario as these PCR-based assays which have been distributed widely to states.

Dr. Kim Miller:
And when you say a short time, do you mean days or weeks?

Dr. J. Todd Weber:
No we're talking about from the time the specimens arrive until a result is in hours. Sometimes the greatest delay is actually getting the person in, getting the specimen and getting the specimen to a qualified laboratory. That often will take longer than it does to run the assay.

Dr. Kim Miller
Great, thank you.

Coordinator:
Thank you, the next question is from Dr. Tucker Wood.

Dr. Tucker Wood:
Hi, I just had a question regarding sending specimens. We have Pneumatic Tube System and I'm sure other hospitals do also. I was just wondering if we send specimens through our Pneumatic Tube System to the lab, could the jostling of those specimens in the Pneumatic Tube System release any particles and, you know, results in spread of disease potentially via that route? And should we, you know, not use our Pneumatic Tube Systems?

Dr. Marty Cetron:
We're all looking at each other a bit puzzled because we haven't gotten a question like that before and probably we're not capable of giving you a definitive answer. But most of the specimens that are collected are properly enclosed and encased in some fashion I would presume...

Dr. J. Todd Weber:
Yes I - this is Todd Weber, I think right if we're talking about a swab that has in and of itself pretty limited ability to aerosolize. That's presumably going to be in some kind of sort of test tube or other kind of screw-top container and within - and that would be placed within your Pneumatic Tube instrument that goes through the tube. So, you know, I can't cite evidence but I think that the risk is probably fairly low. And at the same time I think the risk is probably - where one should focus your concern for infection control is the - obtaining the specimen and making sure the person who does that is properly protected. And that after they've placed the swab - or whatever the sample is - appropriately in the container, you know, disposing of the equipment that they were wearing appropriately so that the spread isn't from those items, more so than the swab or sample itself. I think at that - and at the other end the laboratory should be fully aware that that's what they're receiving so that they take the appropriate precautions as well.

So I think you're question's a good one because it's thought-provoking, but I suspect that the highest risk is at one end of that tube and at the other.

Dr. Susan Gerber:
Yes and this is Sue Gerber, just to add that we do not recommend virus isolation fir MERS-CoV in a laboratory. We're talking about sending specimens for Reverse Transcripted PCR, and that's serum, upper and lower respiratory tract, and stool and/or rectal swab. So the laboratory risk theoretically could be related to virus isolation and we do not recommend virus isolation in microbiology labs.

Dr. Tucker Wood:
Thank you.

Coordinator:
Thank you, the next question is from (Dr. Robert Goldstein).

Dr. Robert Goldstein
Good afternoon and thank you very much for the presentation. If I might, two quick questions, the first is relative to influenza, what is the propensity of this coronavirus to resort or experience other generic shifts such that we might anticipate increased virulence in the future?

The second question is though we have concern about the upcoming Hajj, are there special public health aspects to it that might change our approach to employees who are either heading over or returning to the pilgrimage?

Dr. Susan Gerber:
Hi this is Susan Gerber, there are approximately 65 partial and complete genome sequences that have been posted to Gen Bank, and there are some differences between them, but no great differences between them. And because MERS-CoV is a completely different virus, it's even different from SARS, but there have not been identified as of yet a large change that would be immediately concerning for a change in potential - transmission potential. That said, these small changes between different genome sequences, it is not completely clear if they may be relevant.

And more work needs to be done to model these changes and to really understand these little - these maybe point mutations or slight differences between these different sequence - these different sequences from virus isolates from people or genetic sequences directly taken from specimens. So there haven't been wide differences, but again we're still learning about MERS-CoV and it is a beta-coronavirus and it's even different than SARS.

So it, you know, and certainly different than flu. So what, you know, I think is important that every new case-patient has specimens or virus that is completely sequenced. And it's very important that this - these investigations continue.

Dr. Marty Cetron:
Yes I'll take the Hajj...

Dr. Susan Gerber:
Would you like to take the Hajj?

Dr. Marty Cetron:
The Hajj question, so for those who may recall last year the Saudi Arabian Ministry both the Ministry of Hajj as well as the Ministry of Health issued particular new health recommendations discouraging pilgrims from coming to Hajj that met the high-risk category.

I can go over the list, it's fairly long but it is the elderly, those with chronic renal disease, underlying significant immunocompromising states, use of immunocompromising medications and so on - severe heart disease, other chronic cardio- you know, cardiovascular conditions. If you look among the, you know, as Dr. Gerber pointed out there's - the overall case fatality rate, but if you sort of divide that out by those with health conditions - serious health conditions and those without, you see a really bimodel case fatality distribution rather than the aggregate at 30%. You're seeing maybe 60% in some of these very high-risk groups and 10% to 15% in the, you know, younger more healthy folks. Those are just rough, you know, sort of rough breakdowns. And I think that was the basis of the concerns.

In addition last year the Saudi Arabian government actually reduced in total the number of Hajj pilgrim visas that were issued by somewhere between 20% and 30%. It varied a little bit by country but they have a, you know, a pretty good handle on who's applied for a visa to do Hajj and what the allocation is by different countries of origin. And they reduced that number for a variety of reasons which included construction sites and their ability - the capability of the country to receive the volume.

It is our understanding that similar recommendations would be forthcoming this year, probably no less. Whether they will go further than that I don't know. They do also have a pretty aggressive health system for setting up provisional care during the Hajj. That is a lot of healthcare facilities in tents, a lot of surveillance systems. They are some of the globe's leaders in managing mass gathering - health events associated with mass gatherings.

And CDC and other governments have participated in providing consultation as well as in learning from the structure with which they set those things in place. That said we've all seen the pictures, these are very, very crowded environments and there's lots of risk. They have taken precautions in the past when meningitis outbreaks have been associated with the Hajj both in incoming and in distribution, as well as outbreaks during the pandemic influenza of H1N1, and so they have vaccine requirements as a criteria for being issued at Hajj pilgrimage visa. And I would stay tuned as we get sort of in closer to that time which is in the fall generally to see what types of recommendations they will or won't formally issue this year. There are systems in place, nonetheless aside from healthcare workers, religious pilgrims tend to make up the other large category of risk for the exported cases.

Coordinator
Thank you, the next question is from Dan Abstra.

Ibad Khan
Wendy, this would be our last question.

Wendy
Okay thank you.

Dan Abstra:
Hi, Dan Abstra, I'm an emergency physician that works in a large healthcare system near an airport. I just wanted to confirm with you folks that an asymptomatic patient that presents to the emergency department with concerns that they were on a flight with someone that was an identified case is not someone that we should be currently testing?

Dr. J. Todd Weber:
So actually, you know, as we indicated before both out of an abundance of caution and respect for this virus as well as acknowledging the gap of information, we are offering anyone who had that type of contact in the first - around the first two cases, the opportunity to have a blood test.

And that is a - in this date, you know, those travel dates were very remote, so we're well past the incubation period. But yes those people who wish to get a blood test for a convalescent serology to see whether they had any evidence of MERS infect- MERS-CoV infection in the past – we are offering that opportunity.

And if they come to your emergency room and ask for it you can call either your nearest quarantine station or us directly in the EOC and we'll tell you how to do that at no cost to the patient. We're very interested in having that result.

Dan Abstra
That's wonderful, I'm very appreciative of that. Obviously if there's a lot of potential for people that have had cross-flights with somebody that then is identified as a case and what to do with the worried well is always a concern from the emergency department's standpoint.

Dr. J. Todd Weber
Understand. And that's why we're gathering this data so we can better understand whether there's any significant reason for the well to be worried. And we need to answer that question as best we can.

Dan Abstra
Wonderful, I appreciate the time, thank you.

Ibad Khan
On behalf of COCA I would like to thank everyone for joining us today with a special thank you to Dr. Gerber, Dr. Weber and Dr. Cetron.

We invite you to communicate to our presenters after the call. If you have additional questions for today's presenters please email us at coca@cdc.gov. Put May 28 COCA Call in the subject line of your email and we will ensure that your questions are forwarded to them for a response. Again that email address is coca@cdc.gov. The recording of this call and the transcript will be posted to the COCA Web site at emergency.cdc.gov/coca within the next few days.

There are no continuing education credits for this call. MERS-CoV resources for clinicians are available on the COCA call Web page. Go to emergency.cdc.gov/coca, click COCA calls and then follow the links for the 2014 MERS-CoV call. To receive information on upcoming COCA calls subscribe to COCA by sending an email to coca@cdc.gov and write subscribe in the subject line.

Also CDC launched a Facebook page for health partners. “Like” our page at facebook.com/cdchealthpartnersoutreach to receive COCA updates. Thank you again for being a part of today's COCA call, have a great day.

Coordinator:
Thank you, this does conclude today's conference. Thank you for joining, you may disconnect at this time.

END