Call Transcript: Updated Information and Guidelines for Evaluation for MERS

Coordinator:
Good afternoon and thank you all for standing by. I’d like to inform all participants that your lines will be on the listen-only mode until the question and answers session of today’s conference.
Today’s call is being recorded. If you do have any objections, you may disconnect at this time.
I would now like to turn the call over to your first speaker, Mr. Ibad Khan. Sir, you may begin.

Ibad Khan:
Thank you, Sue. Good afternoon. I’m Ibad Khan and I’m representing the Clinician Outreach and Communication Activity -- COCA -- with the Emergency Risk Communications Branch at the Centers for Disease Control and Prevention.
I am delighted to welcome you to today’s COCA call, “ Updated Information and Guidelines for Evaluation for MERS.”

We are pleased to have with us today Dr. Susan Gerber and Dr. David Kuhar to provide an update on the status of the outbreak in Korea, updated guidance to healthcare providers and state and local health departments regarding who should be evaluated and tested for MERS infection, and further guidance on “Interim Infection Prevention and Control Recommendations for Hospitalized Patients with Possible MERS-CoV.”

There is no continuing education or slides provided for this call. Additional resources for clinicians are available on our COCA Web site at Emergency.cdc.gov/COCA. Again, that Web site is Emergency.cdc.gov/COCA. Once there, check under the MERS Call Web page.

Our First Presenter today is Dr. Susan Gerber. Dr. Gerber is team lead for the Respiratory Viruses and Picornavirus Team, Division of Viral Diseases, at the Centers for Disease Control and Prevention. She received her MD from Loyola University and completed a pediatric residency and pediatric infectious disease fellowship at the University of Chicago. Dr. Gerber later joined the University of Chicago faculty in the section of pediatric infectious disease. Dr. Gerber acquired over 14 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. David Kuhar is a medical officer in CDC’s Division of Healthcare Quality Promotion. Dr. Kuhar received his MD from Emory University, completed his residency in internal medicine at New York University Medical Center and completed a fellowship in infectious diseases at Mt. Sinai Medical Center in New York. Dr. Kuhar came to CDC in 2010. As part of his role at CDC, he serves as a subject matter expert on emerging pathogens, develops clinical guidelines regarding infection prevention in healthcare settings, and participates in investigations of infectious disease outbreaks in healthcare.

In addition to today’s presenters, Dr. Lisa Rotz from the Division of Global Migration and Quarantine will be available to answer questions during the Q & A section of today’s COCA Call.

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

That’s 404-639-3286 or send an email to media@cdc.gov.

At this time, please welcome Dr. Gerber.

Dr. Susan Gerber:
Thank you very much and thank you for the opportunity to speak today.

First, I’d like to start off with a little bit of background about MERS CoV starting with coronaviruses in general. Coronaviruses are envelope-positive strand RNA viruses and human coronaviruses were first isolated in the 1960s.

There are six human coronaviruses that have been identified to date, and there are four that are common human coronaviruses that are frequently identified, including 229E, OC43, NL63, and HKU1. And they most of the time cause relatively mild illness or upper respiratory tract infections.

SARS coronavirus was identified in 2003 and caused an outbreak; and more recently - going to talk about the Middle East Respiratory Syndrome coronavirus, or MERS CoV.

First, I would like to start about the first knowledge that we gained about MERS CoV which was in the fall of 2012. A sixty year old man in Saudi Arabia with acute respiratory distress syndrome and multi-organ dysfunction syndrome was - died in June of 2012. And tissue was saved from that particular patient.

And then late in September of 2012, a forty-nine year old Qatari National with respiratory failure and renal failure was admitted into a London intensive care unit in September of 2012.

Virus from the second case was compared to virus isolated from lung tissue of the first case, and over the region that was sequenced were nearly identical. And this was the first identification and recognition of the Middle East Respiratory Coronavirus Syndrome, which was named in May of 2013.

MERS CoV is a beta coronavirus and is separate and distinct - different than SARS-related coronavirus.

The MERS clinical - can cause a vast array of clinical presentations, and the spectrum includes asymptomatic infections, acute upper respiratory illnesses, rapidly progressive pneumonitis, respiratory failure, septic shock, multi-organ failure that may result in death.

Common signs and symptoms at admission include fever, chills and rigors, headache, nonproductive cough, dyspnea, and myalgia. Other symptoms may include sore throat, coriasis, sputum production, dizziness, nausea, vomiting, diarrhea, and abdominal pain.

Atypical presentations have been described as mild respiratory illnesses without fever and also diarrhea or illness preceding the development of pneumonia.

In other particular studies, most have shown that most patients who present to illness who become hospitalized present with fever and cough. And sometimes, it may be dry; and even though many times it’s nonproductive, in some cases it may be a productive cough with sputum production.

In patients who are very ill and admitted to the hospital, most have been found to have comorbidities. Comorbidities may include diabetes, chronic kidney disease, chronic heart disease, hypertension, and chronic lung disease.

In addition to that, for laboratory findings on admission - one recent study from the Annals of Internal Medicine showed that nine of twelve patients, or 75%, presented with lymphopenia on day one and eleven of twelve, or 92%, have lymphopenia during an ICU stay. In the same study, thrombocytopenia was noted in two patients on day one and in seven patients during their ICU stay.

With these twelve patients described in the study, all twelve patients presented with underlying comorbid conditions and presented with acute severe hypoxemic respiratory failure. Most patients -- 92% -- had extrapulmonary manifestations including shock, acute kidney injury, and thrombocytopenia. And five, or 42%, were alive at day ninety.

Common chest X-ray findings have included bilateral pulmonary infiltrates, ground-glass opacities, and have also included descriptions of bilateral subpleural and basilar air space changes.

In a recent study of seventy patients, the median age was sixty-two years and this is from the International Journal of Infectious Disease. Comorbid conditions in fifty-seven, or 81.4%. And acute lung injury, acute kidney injury, acute hepatic dysfunction were the most common complications.

And in this particular report, fifty-eight episodes of concomitant infection in thirty patients were also reported.

In addition, in this particular report, laboratory abnormalities at the time of diagnosis were described as low hemoglobin, lymphopenia, low albumin, and elevated aspartase aminotransferase. And then for several patients in many of these studies during intensive care unit stays, several lab abnormalities have been seen.

In children, a recent report by Namish, et al, from the Pediatric Infectious Disease Journal describes eleven pediatric laboratory-confirmed cases with a median age of thirteen years. And two symptomatic patients were described, and nine asymptomatic patients. And one two year old boy was described who had cystic fibrosis who had died and a fourteen year old girl with Down’s syndrome and was hospitalized.

Some background on the timeline of MERS CoV - I mentioned that it was first recognized in September of 2012. Retrospectively, diagnosed - was a cluster of respiratory illness associated with a hospital in Jordan. This occurred in April of 2012. Two safe specimens were both PCR-positive for MERS CoV, retrospectively, and this was the first known outbreak of MERS CoV that were recognized among people.

MERS CoV has subsequently been recognized to be transmitted in families, in healthcare facilities, and also originating in countries around Saudi Arabia and Qatar which I previously mentioned, including UAE, Aman, and Kuwait, and others in that vicinity. And Jordan.

In addition, a Qatar human cluster in December of 2013 was determined to be associated with PCR-positive camels; and in March and April of 2014, nosocomial outbreaks in Saudi Arabia were reported. Two cases were diagnosed in the United States; one in Indiana and one in Florida in May of 2014.

Since that point, in the fall of 2014 there have been some - a modest increases in cases reported in Saudi Arabia, which did subside. And then in January through March, another increase in cases reported in Saudi Arabia, along with sporadic cases reported from Aman, UAE, and Qatar. More recently, an outbreak in the republic of Korea has been reported.

In all, the MERS CoV overall epidemiology has shown - has - includes twelve, eighteen - or 1218 laboratory-confirmed cases according to the World health Organization. And this includes 449 deaths for a case fatality rate of thirty-seven percent.

Reported gender includes 791 males, 393 females, and thirty-four unknown gender. The median age -- fifty years with a range from zero to ninety-nine years. Approximately 17% of cases that have been reported have been identified as healthcare personnel. All cases have an epidemiologic link to nine countries. Those include Saudi Arabia, Qatar, United Arab Emirates, Jordan, Yemen, Oman, Lebanon, Iran, and Kuwait.

Transmission of MERS CoV has been known to occur person to person and has been well documented. Approximately fifty-nine spatial tempura clusters have bene reported and these clusters are known to occur among household settings and healthcare settings. The median incubation period seems to be between five to six days, with a range approximately two to fourteen days.

The rods of transmission are not fully know and there has been no clear evidence of sustained community transmission to date.

A few words about environmental sources -- MERS CoV neutralizing antibodies have been detected in dromedary camels and including countries -- Oman, United Arab Emirates, Egypt, Jordan, Saudi Arabia, Nigeria, Tunisia, Ethiopia, Kenya, Somalia, Sudan -- and in some of these places for several years.

MERS CoV sequences have been detected in dromedary camels in Saudi Arabia, Qatar, Egypt, Oman, and UAE. And virus has been obtained or MERS Co-V virus has been isolate from dromedary camels in Saudis Arabia and Qatar, and sequences have been linked to patients from camels to humans in Saudi Arabia and Qatar.

All in all, MERS CoV known exported cases total twenty-nine and have been exported to twenty-one countries. Some recent reports form the Republic of Korea include this particular country reporting -- as of today -- 122 reports of MERS CoV. And these include ten deaths.

Exportation of MERS CoV to the Republic of Korea - a description includes a sixty-eight year old male with history of travel to Bahrain, UAE, Saudi Arabia, and Qatar prior to returning to Korea on May 4. The onset of illness occurred on May 11 and the diagnosis with MERS CoV was made on May 20.

Exportation of a secondary case to China on May 26 tested positive for MERS CoV in China on May 29. And as I mentioned, the Republic of Korea has been reporting 122 cases, including ten deaths.

Features of reports of MERS CoV in the Republic of Korea include the - all reported cases appear to be epidemiologically linked to the index case and are healthcare-associated. Secondary and tertiary transmission has been documented and read exposures have been upped through the end of May, at least at this time.

Cases include healthcare personnel, patients, and visitors in healthcare facilities where case patients have received care. And transmission has been reported to be associated with ward, clinic, and emergency department settings.

MERS CoV sequenced from a virus isolate from a Korean MERS CoV patient has been found to be closely related to recent viruses circulating in the Arabian peninsula. And no significant genetic changes have been observed in the sequence of this virus.

The patient under investigation guidance that CDC publishes on the MERS web site has been updated to include recommended testing for patients who are travelers from Korea, who have a history of being in a healthcare facility as a patient, worker, or a visitor in the Republic of Korea within fourteen days before onset; along with severe illness which includes fever and pneumonia, or acute respiratory distress syndrome. And pneumonia can be based on clinical or radiological evidence.

In addition, the recommendation is not to wait for other etiologies before testing for MERS in these circumstances. There’s no need to wait to diagnose another infection. Also, coinfections have occasionally been identified along with MERS CoV infection. A couple of examples have bene influenza and parainfluenza infections.

In terms of recommendations for collecting ad testing clinical specimens, testing patients under investigation is important to do promptly; and also, consider the timing of collection in terms of reference to onset of illness and current symptoms. Collecting multiple specimens and lower respiratory tract specimens are preferred and those include sputum, tracheal aspirates, broncoalveolar lavage fluid.

Also, nasopharyngeal and oropharyngeal specimens are recommended to be collected as well, and serum for both PCR and -- if appropriate -- serologies. And serum for serologies would be appropriately collected at least ten days or fourteen days after onset of illness.

Now, the PCR kits have been distributed from CDC to the LRN labs, which are often state public health labs. And these include a kit for diagnosis of MERS CoV and assays for three gene targets -- two against the nucelocapsid and one from the upstream gene.

A summary of MERS CoV US patients under investigation -- there have been two US patients who have tested positive for MERS CoV in Indiana and Florida in May of 2014. In addition, negative 582 patients as of June fifth have tested negative for MERS in the United States, and these include submitted specimens to CDC or performed by LRM labs from forty-five states.

In addition, MERS CoV RNA detection over time has been described in two patients from a paper written by Poissy, et al, that MERS CoV RNA was detected in lower respiratory tract specimens approximately a month after onset of illness. This does not give us information about live virus, but about PCR detection.

In addition, MERS CoV RNA was detected in whole blood and urine several days after onset of illness, but not so for rectal swabs. So there is the possibility of detection of MERS CoV RNA over time in respiratory tract specimens.

Identification of MERS CoV states - a summary include the patients under or persons under investigation guidance which I just went over. And along with the updated guidance is that the - a form has also been posted that can be fillable with information on PUI’s.

In addition, the most important pieces of identification of a potential MERS CoV patient include obtaining a travel history with dates, asking about healthcare exposure, checking the date of onset of illness, and remembering that multiple specimens -- including lower respiratory tract, upper respiratory tract, and sera acutely for PCR -- are important to collect. And note the timing with respect to onset of illness.

And most importantly, for people who think that - who may actually think that they may be diagnosing a potential patient with MERS CoV, please call local and state health department authorities immediately. These are decisions that have to be made with local and state health departments and it’s very important to add that. One of the first steps upon thinking about a potential MERS CoV identification is calling local and state public health authorities

I would like to turn this over to Dr. David Kuhar.

Dr. David Kuhar:
Thank you. So there is current infection control guidance for US hospitals that’s posted on the CDC’s Web site, and this guidance is correct. We will be releasing expanded infection control guidance shortly. CDC’s going to continue to recommend standard contract and airborne precautions for management of these hospitalized patients.

In addition, the new guidance will emphasize additional elements of infection prevention and control programs that should be in place to prevent transmission of any infections agents, including respiratory pathogens such as MERS CoV in healthcare settings.

The recommendations, again, will be based on available information and considerations such as a possible higher rate of morbidity and mortality among infected patients, incompletely defined modes of transmission of MERS CoV, and the current lack of a safe and effective vaccine and chemophophylaxis.

And I’m now going to summarize some main points in the current and upcoming guidance.

So the guidance is going to emphasize minimizing the chance for exposure before and upon patient arrival to a healthcare facility and during care. When scheduling patient appointments, instructing patients and those who accompany them to call ahead or inform personnel on arrival if they have respiratory symptoms. And to take appropriate action such as wearing a face mask upon entry and following triage procedures.

Posting visual alerts in check-in areas could encourage respiratory hygiene, cough etiquette, and hand hygiene among patients. Space could be provided for patients with respiratory symptoms to sit away from other patients.

Rapid triage and isolation of patients at risk of infection with MERS CoV is critical. Ensuring that patients are asked about the presence of respiratory symptoms, travel history, and possible contact including occupational risk with those infected with MERS CoV prior to or upon arrival to facilities is important.

Those identified at risk should be rapidly isolated in an airborne infection isolation room. It’s important to ensure all who enter the patient care area adhere to standard contact and airborne precautions. Hand hygiene should be performed before and after all patient contact, contact with potentially infectious materials, and before putting on and removal of personal protective equipment -- or PPE.

Attention should be paid to proper donning, doffing, and disposal of PPE. Healthcare personnel should wear appropriate PPE when entering the patient care area, including gloves, gowns, respiratory protection at least as protective as a Niosh certified N-95 respirator, and eye protection.

I mentioned earlier that patients should be placed in an airborne infection isolation room when hospitalized. Patient movement outside of the airborne isolation room should be limited to medically essential purposes, and only healthcare personnel essential for care should enter. When transported outside of an airborne infection isolation room, that patient should wear a face mask for source control.

The healthcare personnel should use caution when performing aerosol-generating procedures that might create higher concentrations of infections respiratory aerosols -- coughing, sneezing, or talking. Although not quantified, procedures that might pose such a risk include cough-generating procedures, bronchoscopy, sputum induction, intubation and extubation, cardiopulmonary resuscitation, and open suctioning of airways.

Ideally, a combination of measures should be used to reduce risk, including only performing the procedures if medically necessary and they cannot be postponed, limiting personnel present to those essential for patient care and support, conducting procedures in an AIIR when possible -- the airborne infection isolation room, having personnel wear appropriate PPE as previously described, and conducting environmental cleaning after the procedure.

Information to determine the necessary duration for infection control precautions is still limited, and the duration for precautions is still to be determined on a case by case basis in conjunction with local state and federal health authorities.

The guidance will recommend establishing procedures for monitoring, managing and training visitors. Visitors should be restricted from entering a MERS CoV patient’s room, but exceptions could be considered for those essential for the patient’s emotional well-being and care. Visits should be scheduled and controlled for logging all visitors; screening a visitor for acute respiratory illness before entering the hospital; evaluating the risks for the visitor; providing instructions on hand hygiene, limiting touching surfaces, use of PPE, and limiting their movement in other parts of the facility.

Monitoring and management of ill and exposed personnel continues to be emphasized, and will continue to be emphasized in upcoming guidance. Personnel who care for MERS patients should be monitored and instructed to immediately report signs or symptoms of acute illness to their supervisor or a facility-designated person for fourteen days after their last known contact with a MERS patient.

Personnel who develop respiratory symptoms after an unprotected exposure such as not wearing recommended personal protective equipment at the time of contact should not report to work or stop working immediately. Notify the appropriate designated person, seek medical attention, and comply with work restrictions until no longer infectious to others.

For asymptomatic healthcare workers who have unprotected exposures to a MERS patient, they should be excluded from work for fourteen days after the last contact to monitor for signs and symptoms of illness and fever.

Healthcare personnel should be provided job- and task-specific education and training in preventing transmission of infectious agents, including refresher training. They should be medically cleared, fit-tested, and trained for respiratory protection device use. They should be educated, trained and practiced in the use of PPE prior to caring for a patient, including preventing contamination of clothing, skin, and the environment during the process of removing equipment. For environmental infection control, standard cleaning and disinfection procedures are appropriate for MERS CoV.

And finally, the importance of establishing case reporting processes to public health authorities is emphasized in the upcoming guidance.

As we learn more about the transmission of MERS CoV, guidance updates may be posted. And I’m going to stop there.

Ibad Khan:
Thank you Dr. Gerber and Dr. Kuhar for providing our COCA audience with such a wealth of information. As a reminder, Dr. Lisa Rotz from CDC is also available during the question and answer portion of today’s COCA call.

Please note that questions are limited to clinicians who would like information on clinical guidance related to MERS. For those who may have media questions, please contact CDC Media Relations at 404-639-3286, or send an email to media@cdc.gov.

We will now open the lines for the question and answer session, please.

Coordinator:
Thank you. At this time we’ll begin the question and answer session. If you would like to ask a question, please press star one on your touchtone phone. Please record your first and last name when prompted. To withdraw your request, press star two.

One moment, please, for the first question.

Our first question comes from Dr. Susan Donelon. You may go ahead with your question.

Dr. Susan Donelon:
Yes. My question is regarding the N-95. Am I to assume that the N-95’s are going to be a use-once and throw away as opposed to how we utilize them when caring for patients with tuberculosis?

Dr. David Kuhar:
This is David Kuhar speaking. You’re - so essentially you are correct hat because contact precautions are in effect that reuse of disposable N-95 respirators is not recommended. They should be used in accordance with manufacturer’s instructions. If it’s a single use respirator, it should be disposed of after use. If you are using a reusable product such as a powered air purifying respirator or another, they should be appropriately reprocessed -- cleaned and disinfected according to manufacturing instructions.

Dr. Susan Donelon:
Thank you.

Coordinator:
Thank you. The next question comes from Gina Fleming. You may go ahead with your question.

Gina Fleming:
Hi, thank you. I’m representing the student health centers at the University of California and I’m looking at your travel guidance Web sites. And currently it looks like there’s no real travel restrictions. I’m wondering if there’s going to be any changes to that, or any additional guidance or recommendations you could provide for us regarding how to monitor our students traveling to and from Korea.

Dr. Sue Gerber:
Dr. Lisa Roth. Would you like to answer this question, please??

Dr. Lisa Roth:
Please email COCA and our Division of Global Migration and Quarantine representative will be happy to answer that question.

Gina Fleming:
Alright. Thank you.

Coordinator:
Thank you. The next question comes from Dr. Barry Rosenthal. You may go ahead with your question.

Dr. Barry Rosenthal:
You mentioned the testing modalities, one of them being nasopharyngeal swab, the other being a serum PCR. So we’re here in New York State. What study would we be doing from the emergency department?

Dr. Sue Gerber:
This is Sue Gerber. I actually - our recommendation right now for acute infection is to collect multiple specimens and, if available, lower respiratory tract stuff. They’re still the preferred specimens to detect MERS CoV; but in addition, we do request nasopharyngeal/oropharyngeal swabs plus serum for acute PCR. And serum has been shown to be positive by PCR for MERS CoV in the acute infection, and can be helpful in diagnosis of MERS CoV patients.

So really what we are asking for to diagnose these infections are actually multiple specimens in the acute phase of illness.

Dr. Barry Rosenthal:
You can’t get lower respiratory tract specimens - so basically you can swab the nasopharynx from the emergency department fairly readily and you can draw blood. That would be sufficient?

Dr. Sue Gerber:
Right now this is really our guidance; but in terms of what is possible, that hopefully could be worked out between you and, actually, local and state public health authorities in terms of feeling that the best specimens in a situation were obtained under the circumstances.

Dr. Barry Rosenthal:
Okay, thank you.

Coordinator:
Thank you. The next question comes from Anna O’Donnell. You may go ahead with your question.

Anna O’Donnell:
Hi. My question is related to persons under investigation. And it was mentioned on the call that travelers from the Republic of Korea were included in that. However, when I look at the CDC guidelines, the only criteria for people from Republic of Korea have to do with history of being in a healthcare facility. Is this going to be changing to include travelers or contacts of travelers from that country? Because this isn’t reflected on the Web site currently.

Dr. Sue Gerber:
Right now it’s actually - all that’s been added to the recommendations right now, and I have to say these recommendations are fluid. And as we learn more information we may also be updating or changing recommendations over time if we learn more about this outbreak. But at this time, what has been added is for persons who have severe respiratory illness and a history of having traveled to Korea, plus any type of healthcare exposure to be tested.

And again, this is guidance. And I just want to add that this is also meant to help guide decisions. And sometimes there may be - it may be unclear if there is a healthcare facility exposure or if this is pneumonia or upper respiratory tract disease. In an abundance of caution, I would recommend at this time to call public health authorities and also we have cast a wide net of testing as well.

In fact, many of the 582 negatively - the patients who were negative for MERS CoV may not have precisely fit this kind of definition or case definition. But as I said, this is mostly about guidance and about thinking through the issues, and trying to determine if there is a possibility.

So, as I said, I think the best way to use this patients under investigation Web page is to help guide decision-making in terms of who should be tested. And we also still have travel in or near the Arabian Peninsula, and also include symptomatic travelers who developed fever or acute respiratory illness. That’s unchanged.

So we still have our previous recommendations for the Arabian Peninsula, including the milder illness with an exposure to healthcare facility for someone who had traveled to the Arabian Peninsula -- in or near -- and also being alert to patients who think they may have been in close contact with a MERS CoV patient, or clusters of severe respiratory illness for which there is no clear etiology.

Anna O’Donnell:
I guess I was trying to point out that on the Web page it only lists the Arabian Peninsula for travel. It doesn’t say anything about the Republic of Korea.

Dr. Sue Gerber:
We’re happy to send the link. And I think that if you could email COCA, we can actually respond and make sure that we have solved that.

Anna O’Donnell:
Great, thanks.

Coordinator:
Thank you. The next question comes from Richard Leeman. You may go ahead with your question.

Richard Leeman:
Thanks. I actually found the answer on the CDC Web site. Thanks so much.

Coordinator:
Thank you. The next question comes from Marisia De’Angelay. You may go ahead with your question.

Marisia De’Angelay:
Hello, yes. I’m actually with state public health in Washington and I want to thank Drs. Gerber and Kuhar for the informative presentations. Mine’s more of a comment, and I actually just wanted to stress the importance for providers of testing for other causes of community-acquired pneumonia because the experience we’ve had is, often, we’re just requested to do the MERS test and no other testing has been done.

And the importance if you’re testing for flue to do a PCR; not just rely on a negative rapid test.
That was just a comment I wanted to make. Thank you.

Dr. Lisa Roth:
Thank you very much.

Coordinator:
Thank you. Does that conclude your comment, ma’am?

Marisia De’Angelay:
Yes, thank you.

Coordinator:
Okay, thank you. The next question comes from Elizabeth Dufort. You may go ahead with your question.

Elizabeth Dufort:
Hi, yes. I was wondering if you could please comment on the recommendation for eye protection -- either goggles or face shield -- in the routine care for PUI or confirmed MERS CoV patients.
And if there’s any data or case report data - if not, more detailed rationale behind that.

Dr. David Kuhar:
So for eye protection, a disposable face shield can be used that should be discarded immediately upon leaving the patient area. Reusable eye protection, such as googles, are also going to be listed in the upcoming guidelines, and also acceptable. They just have to be cleaned and disinfected according to manufacturer’s reprocessing instructions after use.

I’m not sure I quite understood the point about a case report or case reporting. Could you clarify?

Elizabeth Dufort:
Yes, sure. I guess I was just wondering the rationale. I’m not familiar with eye goggles as usually being part of standard contact airborne. So this seems like an additional element of protection for the healthcare worker, unless I’m not correct here. So I was wondering if there was data to support that or theory, or rationale, or overabundance of caution.

Dr. David Kuhar:
First, that’s a great question, and you’re right. Eye protection is certainly not - I think it’s considered an unresolved issue when it comes to droplet precautions. The idea here is that droplets when someone is coughing could hit your eyes. There’s a lacrimal duct that could allow potentially infectious materials to be just pretty much quickly deposited into your mucous membranes.

And the eye protection recommended here is an added measure of safety to ensure - to really just to try to make sure we’re doing everything we can to minimize the chances of transmission.

There are no case reports that I’m aware of, for example, documenting that transmission has happened because of a lack of eye protection. This is just a measure recommended to err on the side of safety.

Coordinator:
Does that conclude your question, ma’am?

Elizabeth Durfort:
That’s absolutely perfect. Thank you.

Coordinator:
Thank you. The next question comes from Jan Estelle. You may go ahead with your question.

Jan Estelle:
Yes. My question is in regard to disinfecting patient care surfaces. Are there recommendations on products? Which ones kill the virus more effectively than others? I’m looking for how to disinfect those goggles, disinfect the surfaces.

Dr. David Kuhar:
No, that’s also a great question and - this is (David Kuhar) speaking. Standard cleaning and disinfection procedures are appropriate for MERS CoV, which I already said. I don’t believe there are any EPA registered products that have a label claim for MERS CoV; and if there aren’t, any with label claims against human coronaviruses should be used according to label instructions.

Jan Estelle:
Thank you.

Coordinator:
Thank you. The next question comes from (Henry Lu). You may go ahead with your question.

Henry Lu:
Hi. Thanks Dr. Gerber and Kuhar for the presentation. Just a question specifically about the outpatient ambulatory setting -- has there been evidence of transmission of MERS in clinic settings either in Arabia or in South Korea? And do you have specific advice for outpatient clinics in the US? And really, the challenge would be the need for airborne isolation, which is obviously not standard in most outpatient clinics. Is this an immediate priority in someone who may be a PUI or is interim isolation in a room sufficient during the workup?

Dr. David Kuhar:
This is David Kuhar speaking. Good question. I can address part of what you asked.

For outpatient settings, you’re correct. I think many don’t have airborne infection isolation rooms. I think one of the most important points is identifying the patients in the first place who may be at risk for having MERS CoV. Again, that importance for travel history and identifying the epidemiologic links that put them at risk.

If you do identify someone, placing them - and you do not have an airborne infection isolation room, placing them in a standard patient room with a face mask on for source control and with the door closed could be a sufficient temporizing measure. After that, they should be transferred to a facility with an airborne infection isolation room as soon as possible. And that’s actually going to be mentioned in the updated guidance.

Dr. Sue Gerber:
This is Dr. Gerber. That was a very important question, and certainly, most of the person to person spread has been identified within healthcare facilities and some may have involved emergency departments, which can be similar to clinics. They’re - and so I think that it is certainly possible that there could be transmission in an outpatient setting. It is important to be cognizant of that.

Henry Lu:
Great, thank you.

Coordinator:
Thank you. The next question comes from Andrew Pavia. You may go ahead with your question.

Andrew Pavia:
Yes. Thanks for the presentation. My question has to do with evaluating children with travel to either of the high risk areas. And you may have answered this with your emphasis on using clinical discretion and erring on the side of caution, but given that the limited experience with children suggests that they may present with milder symptoms. Would you use the same criteria for PUI in evaluating a child who has been in a healthcare facility in the Republic of Korea?

Dr. Sue Gerber:
Thank you for that question. This is Sue Gerber. It is true that the median age cases for where many cases have been reported in the Arabian Peninsula have been older adults. Although, I mentioned that children who have had more severe illness have seemed to be children who have had underlying disease, including chronic lung disease or underlying kidney disease.

So, again - and as you mentioned, and abundance of caution. What has been published has been guidance, and I think that right now we actually are recommending severe respiratory illness and a history of travel to Korea and healthcare facility exposure. But this is guidance, and to be used in the real world with many considerations. So I think that most of the identified cases still have bene older adults, but certainly children who have underlying diseases may become more severely ill, too.

And so right now, I think using the recommendations - using the patient under investigation guidance as something to think by would probably be the best way to approach it.

Andrew Pavia:
And as you said, it should probably - decisions that should be made in consultation with the health department?

Dr. Sue Gerber:
Yes. I can’t emphasize that enough, that state and local public health departments need to be part of the process and decision-making, and certainly considerations about patient movement and circumstances. And often state public health laboratories are actually performing the MERS CoV testing and working together with the clinical community and state and local health departments.
It’s very important to have that engagement in potentially diagnosing a patient with MERS CoV.

Andrew Pavia:
Thanks.

Coordinator:
Thank you. The next question comes from Donna Curry. You may go ahead with your question.

Donna Curry:
Hi. Thank you very much for the presentation. It’s been great. I do have one question. When you were speaking about the PPE, the contact precautions, and airborne and all of that, you also made a comment in there and maybe I misunderstood it’s to cover all (unintelligible). So, are we talking about PPE similar to what we used with Ebola? Or are we talking about gown, mask, and gloves, and caps and everything?

Dr. David Kuhar:
This is David Kuhar speaking. I did not intend to make any comment about covering all-exposed skin. We’re recommending personal protective equipment that’s used as a part of routine care – gloves, gown, eye protection, and respiratory protection.

Donna Curry:
Okay, good. Thank you.

Coordinator:
Thank you. The next question comes from Jennifer Eastman. You may go ahead with your question.

Jennifer Eastman:
Hi. Thanks for the personation. Actually, all three of my questions were answered, but I was more concerned with the screening of possible; but that was answered, as well as the infection control measures. So thank you.

Coordinator:
Thank you. The next question comes from Russ Olmstead. You may go ahead with your question.

Russ Olmstead:
Great, thanks. Appreciate the faculty for today’s presentation. A couple of questions. One is -- do we have any evidence that applying the precautions that we do around the Ebola virus disease and, specifically, the partner monitoring the doffing technique - does that lesson risk of transmission or contamination of the healthcare provider who’s gone in to care for the patient?

Dr. David Kuhar:
Could you please clarify the question? Are you asking with regards to MERS?

Russ Olmstead:
Yes. In other words, for this particular virus, MERS CoV, is there evidence that that level of partner buddy system lessens the probability that healthcare provider will be contaminated or, certainly the most important, less the risk of transmission? I’m looking at an adaptation of that model to this particular virus.

Dr. David Kuhar:
I understand the question. No, there is no direct evidence for MERS CoV.

Russ Olmstead:
Okay. Great. Yes, that’s what I suspected.

And then any plans by CDC to develop a draft notice or warning notification like we do have for
Ebola virus for screening people who may be returning travelers?

Dr. Lisa Roth:
Hi. This is Lisa Roth from the Division of Global Migration and Quarantine. Sorry, I couldn’t get my phone off of mute earlier for the earlier question. Currently we do have a travel health notice for travelers that are travelling to Korea; again, encouraging them to practice good respiratory and hand hygiene as a primary means for avoiding respiratory infection.

And then for returning travelers there are messages that are playing in airports currently highlighting the current outbreaks of MERS in the Arabian Peninsula as well as in Korea, and reminding individuals to monitor their health and, if they develop respiratory symptoms, to make sure they let their doctor know of their recent travel history.

Russ Olmstead:
Great, thanks. Thanks all very much.

Coordinator:
Thank you. The next question comes from Jim Cazbrezek. You may go ahead with your question.

Jim Cazbrezek:
Thank you. It was mentioned earlier in the presentation that health care workers who have had unprotected contact with a MERS patient should be furloughed for two weeks, not be at work. I was wondering whether you foresee similar recommendation to quarantine others like household members who may have had unprotected contact with the patient.

Dr. Sue Gerber:
Hi, this is Sue Gerber. Currently, right now, we do have on the CDC Web site some guidance about home isolation for patients who actually may be returning home who have - do not need hospitalization but may be suspected to have MERS while their MERS test is pending. And right now we have home isolation or separation in the home guidance for people who are awaiting tests.

And in terms of contacts of patients who are confirmed of having had MERS, that would be worked out with state and local health department authorities and we would definitely be providing recommendations such that we did with the Indiana and Florida patients.

Dr. Lisa Roth:
This is Lisa. To address another component of your question, I think, in general if we are talking about family members of a contact or a contact of a contact type of situation, there would not be any anticipated restrictions on those contacts of the contacts unless that individual actually ultimately developed symptoms and they became contacts.

Jim Cazbrezek:
Actually, I was referring to contacts of a confirmed case who are also contacts asymptomatic that have had unprotected contact with the confirmed case of MERS.

Dr. Sue Gerber:
This is Sue Gerber again. No, that’s a great question. I think that in former experience of the
United States, household contacts of confirmed cases did limit their activities and were at home.
So there would be recommendations and, certainly, very importantly monitoring for symptoms of illness and evaluation for MERS CoV, especially if contacts of confirmed cases developed any illness symptoms. So this would be worked out with state and local public health authorities.

Jim Cazbrezek:
Thank you.

Coordinator:
Thank you. The next question comes from Catherine Meyer. You may go ahead with your question.

Catherine Meyer:
Thank you. In regards to high risk procedures, sputum induction, and open suctioning and such, would you recommend wearing a PAPR rather than just an N-95 respirator?

Dr. David Kuhar:
The guidelines indicate just wearing an N-95 - respiratory protection at least as protective as a
Niosh-certified N-95 respirator. A PAPR.

Catherine Meyer:
Okay. I’m sorry?

Dr. David Kuhar:
A PAPR is also acceptable. We’re not recommending one over the other.

Catherine Meyer:
Okay, thank you.

Coordinator:
Thank you. The next question comes from John Hamrin. You may go ahead with your question.

John Hamrin:
Yes, I believe my question was answered by Dr. Kuhar. It was related to infection prevention and I did follow up and see that on the infection prevention control there is a section that talks about EPA registered disinfectants for coronavirus and a link to the Web site. So my question is answered. Thank you.

Coordinator:
Thank you. The next question comes from Dr. Paul Pappanick. You may go ahead with your question.

Dr. Paul Pappanick:
Yes. Thanks for a great presentation. With regard to the period of infectivity, do we know if
MERS is infective before the patient becomes symptomatic? And then at the other end, when does the patient stop being symptomatic? So when can you stop the infection control precautions?

Dr. Sue Gerber:
Hi. This is Sue Gerber. Thank you for that question. The first part is about period of infectivity and potential for transmissibility in patients who have MERS CoV infection. We are missing some important data about natural history of infection of MERS CoV and so we are - we do not have precise data to guide decision-making.
That said, it is known that patients may go on to have detections of MERS CoV by PCR or evidence of MERS CoV RNA in respiratory tract specimens that could go on for weeks. But is this important for transmission or not is not known; and it is also not known if this represents live virus or not.
And in terms of remaining positive, I don’t know if you would like to add anything.

Dr. David Kuhar:
This is David Kuhar speaking. The duration of precautions really, as you said, is at this time information is lacking to really definitively determine a recommended duration or a set recommended duration. I think you all know that we currently have no cases in the United States.
As it stands currently, the duration is going to be determined on a case by case basis. Discussions between the facility, local, state, and federal health authorities.

And I think many factors are going to be considered, including presence of symptoms related to
MERS CoV, date the symptoms resolved, available laboratory information. And we always have to consider other conditions that might require specific precautions such as if they have C diff or tuberculosis or another reason to be in isolation precautions.

Ibad Khan:
Operator, we have time for one last question.

Coordinator:
Okay. Our last question comes from Bill Ludthem. You may go ahead with your question.

Bill Ludthem:
Hi. I think the previous question probably reflects a bit on mine. With regard to getting serum for PCR, I was curious as to whether or not you know anything about the range of viremia and when it might peak.

Dr. Sue Gerber:
Thank you for that question. This is Sue Gerber. And again, we don’t have hard, good, or adequate data on natural history of infection to really talk about the peak of viremia that’s evident in the serum of patients. I do know that PCR of serum in the acute phase of MERS CoV infection can be helpful for diagnosis of MERS CoV infection, and that PCR’s are positive sometimes in some patients in the serum in the acute phase of infection.

In terms of overtime and detections over time, we don’t have any data to really tell us about peaks and the range of positivity in different types of patients. And again, this natural history of infection data is lacking at this time.

Bill Ludthem:
Great. 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. Kuhar, and Dr. Rotz. 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 MERS COCA Call in the subject line of your email and we will ensure that your question is forwarded to them for a response. Again that email address is C-O-C-A – at- C-D-C-dot-G-O-V.

The recording of this call and the transcript will be posted to the coca website at Emergency–dot-C-D-C –dot-G-O-V – forward slash C-O-C-A within the next few days. There are no continuing education credits for this call. Resources for clinicians related to MERS are available on the COCA Call web page. Go to Emergency – dot-C-D-C-dot G-O-V-forward slash-C-O-C- A, click COCA Calls and then follow the links for the June 2015 MERS call.
I would like to announce that we are planning an Ebola COCA Call for next week. This call will provide our audience updates on the status of the outbreak as well as the latest guidance and recommendations from CDC. Date and time for the Ebola COCA Call will be announced shortly via email and on our webpage at emergency.cdc.gov/COCA.

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.

Thank you again for participating in today’s COCA call. Have a great day.

Coordinator:
Thank you. That concludes today’s conference. All lines may disconnect. Thank you for your participation.

END