health security and emergencies mers coronavirus (as of 3 jun 2015) ariuntuya, to, esr, who,...

Health Security and Emergencies

MERS Coronavirus(as of 3 Jun 2015)

Ariuntuya, TO, ESR, WHO, Mongolia


Why are we concerned?

• MERS-CoV can cause severe disease and deaths in humans

• It can be transmitted from person to person– There have been outbreaks in healthcare facilities associated

with inadequate infection control • Critical information gaps (“unknown”)

– Reservoir, source of infection, routes of transmission, etc.• Ongoing largest cluster of MERS-CoV reported outside

the Middle East – To date, there are 30 cases reported in the Republic of Korea

and China following an imported case


Outline

• Basics about MERS• Current Situation

–Global–Regional

• Risk Assessment • WHO Response

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Basics about MERS

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What causes MERS?

MERS is caused by a CoronaVirus (CoV):– CoV’s look like a crown (corona in Latin)

under the microscope– CoV’s can be found in

humans and animals– A large family of viruses

causing a broad rangeof symptoms frommild to severe disease

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Coronavirus structureA decade after SARS: strategies for controlling emerging coronaviruses, Rachel L. Graham, Eric F. Donaldson & Ralph S. Baric, Nature Reviews Microbiology 11, 836–848 (2013)


Where does MERS-CoV come from?• It is related to CoV in bats • Previous epidemiologic investigations have

identified dromedary camels likely source of zoonotic transmission

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Potential zoonotic transmission of MERS-CoVEmergence of MERS-coronavirus, Raj et al., Current Opinion in Virology 2014(5):58-62


Where does MERS-CoV come from?• It is related to MERS-CoV

in bats • Previous epidemiologic

investigations have identified dromedary camels likely source of zoonotic transmission

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Potential zoonotic transmission of MERS-CoV, Emergence of MERS-coronavirus, Raj et al., Current Opinion in Virology 2014(5):58-62

http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRw&url=http://www.cidrap.umn.edu/news-perspective/2013/08/blood-study-suggests-camels-could-be-mers-cov-carriers&ei=jmNtVaJ6gfZSqpmDsAY&bvm=bv.94911696,d.d24&psig=AFQjCNEP2ifr3vZRLQka3Att3v4Sp9kN_w&ust=1433318399504878


Possible transmission routes• Primary cases: zoonotic

– Direct or indirect exposures? – Camel exposures?

(direct contact, droplet, raw camel milk)• Secondary cases (ie, contact to primary cases)

– Healthcare workers• Younger, lower number of deaths, high proportion of asymptomatic/mild

disease– Household, community

• Younger, lower number of deaths, high proportion of asymptomatic/mild disease

– Patients (nosocomial transmission)• Comorbidities, highest proportion of deaths

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• Incubation period: 2-14 days*• Asymptomatic cases occur • Initial symptoms include: fever, cough,

chills, sore throat, muscle and joint pain(=influenza like illness), diarrhea, vomiting

• Possibly progressing to severe acute lower respiratory illness

• The complete clinical spectrum remains unknown

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What are the symptoms?

Source: WHO MERS-CoV Research Group, PLOS, 2013 Nov 12* WHO Risk Assessment 24 April 2014


How is MERS treated?• Anti-viral therapy: Unavailable• Supportive care:

– treatment of complications and infection prevention & control remain the most important components of clinical case management

http://www.who.int/csr/disease/coronavirus_infections/en/

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How is MERS prevented and controlled?• Vaccine: Unavailable• Infection Prevention and Control in health care

settings: – Standard and droplet precaution – Airborne precautions needed when performing

aerosol-generating procedures (intubation etc)

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How is the virus detected?

• Molecular test– Yes, detection by PCR and sequencing

• Serology test– ELISA developed, validation ongoing

• Rapid diagnostic test available– Not yet

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Knowledge gaps (1)

• Exact routes and modes of transmission– Primary cases (→ risk factors, e.g. zoonotic exposures)– Secondary cases (→ risk factors, e.g. health care

workers)

• Viral shedding (→ Infectivity)– Length of shedding (start of shedding)– Viral load dynamic

(also in asymptomatic persons)

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Knowledge gaps (2)

• Clinical– Spectrum of clinical picture (→ case definition)– Best therapy for patients – Risk factors for poor outcome - comorbidities

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Global situation update

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Global update (as of 31 May 2015)

• Globally reported to WHO– 1174 laboratory confirmed cases – 431 deaths (crude CFR 36.7%)

• The reported number of cases has decreased sharply since large nosocomial outbreaks occurred in KSA and UAE (April-May 2014)

• > 85% cases are from KSA • 25 countries have been affected, including China, the

Republic of Korea, Malaysia and the Philippines• Median age= 48 years (range=9mo-99 years; n=964);

63.5% male as of 5 Feb 2015

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Health Security and Emergencies 17


Regional update

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MERS-CoV in the Region• Since 20 May 2015, 30 MERS cases have been reported by the

Republic of Korea (n=29 and China (n=1) as of 3 Jun 2015 • All cases are linked to one chain of transmission from an imported

case that became ill in the Republic of Korea following travel to the Middle East

• This is the first cluster of MERS cases in the Western Pacific Region • This is the first time MERS cases have been reported in the Republic

of Korea and China.• Previously, Malaysia and the Philippines were the only Member

States in the Region to have reported laboratory confirmed cases of MERS-CoV (one case each).

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Epicurve of MERS cases reported in the Republic of Korea and China*

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Index case isolated

*4 confirmed cases without clear date of onset

Isolation of index case

Median age=55.5 years (range=28-79 ) 63% of cases (19/30) are male


Timeline of exposures in healthcare settings

21Symptom onset Hospital D Monitoring

Clinic A Hospital E Diagnosis

Hospital B Hospital F Deceased

Clinic C Designated Hospital

KEY

24 linked to Hospital B

2 linked to Hospital F

1 linked to Clinic A

1 linked to Clinic C

2 linked to Hospital E


Transmission chain of MERS cluster

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The index case• Travelled to Bahrain, the Kingdom of Saudi Arabia, Qatar

and the United Arab Emirates between 18 April to 3 May• Returned to Republic of Korea on 4 May• There has been no reported history of exposure to known

risk factors such as contact with camels or MERS patients• Source of infection is still under investigation• Notified to WHO on 20 May 2015• Presented to 4 healthcare facilities prior to suspicion of

MERS

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The case reported in China• Contact to index case• Became symptomatic 19 May 2015• Travelled to Guangdong, China via Hong Kong SAR on 26

May 2015• Travel occurred despite advice by authorities of home-

monitoring• Isolated on 27 May 2015 in China• Tested positive and notified to WHO on 29 May 2015

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Country Response• Republic of Korea

– As of 29 May, 1364 contacts have been identified • 1261 under self-monitoring• 103 under self-monitoring

– Contact tracing and extensive epidemiological investigation is ongoing

• China– Mainland China: As of 3 June, 78 close contacts have been identified and 69

have been located and are being monitored at home or in a hotel. To date, all cases are asymptomatic. Actively strengthening hospital infection control measures and strengthening surveillance.

– Hong Kong SAR: As of 31 May, 42 contacts are under monitoring including 19 close contacts are under quarantine in a quarantine centre and remain asymptomatic and 23 other contacts are under medical surveillance and remain asymptomatic.

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Risk Assessment

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Risk of further cases in our Region• The occurrence of such a large outbreak outside the Middle East

is a new development, as is exportation of the disease to a third country.

• Further cases are expected among initial contacts– First case visited four healthcare facilities before MERS-CoV was suspected

(before the index case was isolated)• The ongoing cluster is similar to health setting outbreaks in other

countries. Adequate IPC measures have ended transmission in previous outbreaks.– Human-to-human transmission has occurred in close family contacts,

patients (or their visitors) who shared a room/ward with the index case, and to healthcare workers caring for the patient.

• Sustainable transmission is unlikely– To date, appears to be one generation of spread

• Viral sequencing from external laboratories is pending• Countries have to revise their risk assessment accordingly based

on their own country context

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WHO Response

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Health Security and Emergencies29

WHO’s response to MERS-CoV • Globally, guided by:

– International Health Regulations or IHR (2005)

– WHO Emergency Response Framework

• In WPR through:– Implementation of the

Asia Pacific Strategy for Emerging Diseases or APSED(2010)


WHO Response for this event (1)

• Leadership and coordination– MERS event is ERF grade 2

– Establishment of a WPRO Event Management Team (EMT)

– Dedicated resources for leadership and coordination; epidemiology and information; technical expertise; risk communication; and core services

• Epidemiology and Information– Risk assessment ongoing and will be posted online.

– EIS and DON posting

– Working and communicating closely with health officials in the Republic of Korea and China

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WHO Response for this event (2)

• Technical expertise– Providing technical support, as needed in areas of epidemiology, laboratory

and risk communications

• Risk communication– Talking points will be distributed daily

• Core services– Activated EOC

– Mobilization of staff from other units/division in WPRO for additional support to EMT

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Event Management Team for MERS-CoV in the Region


Preparedness in the RegionWhy a framework for action?

• Translates APSED 2010 Focus Areas and IHR core capacities into operational planning

• Provides a checklist of what needs to be in place to respond effectively

• MERS-CoV infection in the Region highlights the importance of APSED/IHR implementation as part of emergency preparedness planning 33

Checklist Keeping up-to-date Leadership and

coordination Preparing to respond

Surveillance, risk assessment and response

Laboratory functions IPC Risk communications Public health emergency

preparedness Monitoring &Evaluation


WHO Recommendations to Member States

• Enhance their surveillance for severe acute respiratory infections (SARI)

• Review any unusual patterns of SARI or pneumonia cases. • Notify or verify any probable or confirmed case of

infection with MERS CoV with WHO. ‐• Raise awareness of MERS

– Alert practitioners and facilities to the possibility of MERS CoV ‐infection in returning travellers from the Middle East

– Provide information to travellers

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WHO Recommendations to Member States

• Enhance their surveillance for severe acute respiratory infections (SARI)

• Review any unusual patterns of SARI or pneumonia cases. • Notify or verify any probable or confirmed case of

infection with MERS CoV with WHO. ‐• Raise awareness of MERS

– Alert practitioners and facilities to the possibility of MERS CoV ‐infection in returning travellers from the Middle East

– Provide information to travellers

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Advice to general public• People at higher risk

– Health care workers, travellers to the ME exposed to animals or human cases

• Travellers to the Middle East– Take precautions when visiting farms or other places with

camels, particularly if you have underlying diseases– Avoid contact with sick animals / camels– Practice good hand hygiene– Practice food hygiene: Avoid drinking raw milk or eating

potentially contaminated food• Travellers from the Middle East

– See the doctor and report travel history if you have acute respiratory symptoms after returning from the Middle East

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WHO recommendations for travellers

• WHO does not recommend travel restrictions or closure of borders in response to MERS-CoV

• Screening of passengers at POEs (arrivals or departures) is not recommended

• All countries should advise people in high risk groups (medical risk factors, elderly, pregnant women, parents of young children) to:X seek travel medicine advice before travelling, especially

to mass gatherings (e.g. pilgrimage)

X avoid contact with live birds/other animals


WPRO and MERS-CoV

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Website: http://www.wpro.who.int/outbreaks_emergencies/wpro_coronavirus/en/


Conclusions It is certain that health security threats and

emergencies will continue to occur…

We must Prepare for a rapid response to outbreaks

We need greater investment during peaceful time


Thank you !

FAQs: http://www.who.int/csr/disease/coronavirus_infections/faq/en/

http://www.who.int/csr/disease/coronavirus_infections/faq/en/

health security and emergencies mers coronavirus (as of 3 jun 2015) ariuntuya, to, esr, who,...

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